June 2014 – March 2019

USAID Advocacy for Better Health: End of Project Report (June 2014 – March 2019)

Submission Date: April 30th 2019 Cooperative Agreement Number: AID-617-A-14-00004 Project Start Date/End Date: June 01, 2014 to March 31, 2019 COR/AOR Name: Dr. Nobert Mubiru

Submitted by: Dr. Emmanuel Mugisha, Chief of Party, ABH Project, PATH Plot 17 Golf Course Road, Kololo Tel: +256 312 393200 Email: [email protected]

This document was produced by PATH for the United States Agency for International Development Uganda Mission (USAID/Uganda). The views expressed in this document are the responsibility of the author and do not necessarily represent those of USAID or the American People.

Table of Content

Acronyms/Abbreviations ...... 3 EXECUTIVE SUMMARY ...... 6 1.0 Background ...... 8 1.1 Project Goal and Result Areas ...... 8 1.2 Theory of change ...... 8 1. 3 The Advocacy for Better Health model ...... 9 1.4 Rationale for the four advocacy priority areas ...... 10 2.0 Project Start-up Activities ...... 11 3.0 Project Result Areas ...... 17 3.1 Result Area 1: Citizens demand improved quality services...... 17 3.2 Result Area 2: CSOs effectively advocate for issues of citizen’s concern in health and social sectors ...... 26 3.3 Sub R3: Institutional capacity of CSOs strengthened ...... 45 4.0 Responsiveness to the CDCS 2.0 (2017-2021) development objectives ...... 51 5.0 Lessons Learnt ...... 56 6.0 Recommendations for sustainability ...... 58

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Acronyms/Abbreviations AAG Advocacy advisory group AIDS Acquired Immune Deficiency Syndrome ABH Advocacy for Better Health ACODEV Action for Community Development ACT Health Accountability Can Transform Health AMELP Activity Monitoring, Evaluation and Learning Plan ARUWE Action for Rural Women Empowerment ADI Addis Declaration on Immunization AIC Aids Information Centre ARV Antiretroviral AWAC Alliance of Women Advocating for Change ART Antiretroviral Therapy ADS Automated Directives System BCC Behavior Change Communication CFR Code of Federal Regulations CDFU Communication for Development Foundation Uganda CHC Communication for Healthy Communities CEHURD Center for Health, Human Rights and Development COP Chief of Party CSO Civil Society Organization CAAT Consortium of Advocates on Access to Treatment CAO Chief Administrative Officer CSW Commercial Sex Work CPHL Central Public Health Laboratory CIDI Community Integrated Development Initiatives DO Development Objective DCDO District Community Development Officer DSDM Differentiated Service Delivery Model DLF District Linkage Facilitator DCOP Deputy Chief of Party DFID UK Department for International Development DMC District Management Committee DHO District Health Officer DNCC District Nutrition Coordination Committee DNAP District Nutrition Action Plan FANTA Food and Nutrition Technical Assistance FAA Fixed Amount Award FLEP Family Life Education Program FP Family Planning FY Financial Year FDG Focus Group Discussion GOU Government of Uganda GBV Gender Based Violence GMC Grant Management Collaborative HUMC Health Unit Management Committee HC Health Centre HIV Human Immunodeficiency Virus Page 3 of 59

HRH Human Resources for Health HEPS Coalition for Health Promotion and Social Development IEC Information, Education and Communication IP Implementing partner IDO Integrated Development Options ICWEA International Community of Women Living with HIV in East Africa JIACOFE Jinja Area Communities Federation KACSOA Kapchorwa Civil Society Organizations Alliance KADINGO Kalangala District NGO Forum KRC Kabarole Research Centre KPP Key and Priority Population LADA Literacy Action and Development Agency LG Local Government LSC Life Saving Commodity M&E Monitoring and Evaluation MARPs Most-at-risk populations MOH Ministry of Health MSM Men who have Sex with Men MoLG Ministry of Local Government MUCOBADI Multi-Community Based Development Initiative MAAM Mass Action Against Malaria MCP Malaria Control Program MoFPED Ministry of Finance, Planning and Economic Development MDA Ministries, Departments, and Agencies MP Member of Parliament MoJC Ministry of Justice and Constitutional Affairs MRDT Malaria Rapid Diagnostic Test MCH Maternal and Child Health MAFOC Mbale Area Federation of Communities NNF National Nutrition Forum NCD Non Communicable Disease NUPAS Non-U.S. Organizations Pre-Award Survey NACS Nutrition Advocacy and Communications Strategy NMS National Medical Stores NHIS National health Insurance Scheme NTLP National TB and Leprosy program NAHP National Adolescent Health Policy NDA National Drug Authority NAFOPHANU National Forum of People Having HIV/ AIDS Networks in Uganda OPM Office of Prime Minister OVC Orphans and Vulnerable Children OACA Organizational and Advocacy Capacity Assessment OD Organizational Development PHC Primary Health Care PEPFAR Presidential Emergency Plan For AIDS Relief PDSA Plan Do Study Act PFN Parliamentary Forum on Nutrition RFA Request for Applications

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RMNCAH Reproductive Maternal Newborn Child and Adolescent Health RDC Resident District Commissioner RHITES Regional Health Integration to Enhance Health Services RHU Reproductive Health Uganda RACOBA Rural Action Community-Based Organization SHRH Strengthening Human Resources for Health SCORE Sustainable Comprehensive Responses (SCORE) for Vulnerable Children and their families SOP Standard Operating procedure SNCC Sub county Nutrition Coordinating Committee STI Sexually Transmitted Infection SWANET South Western Advocacy Network SMS Short Message Service STF Straight Talk Foundation TA Technical Assistance TB Tuberculosis ToT Training of Trainers UAC Uganda AIDS Commission UNAP Uganda Nutrition Action Plan USAID United States Agency for International Development UDHS Uganda Demographic and health Survey UPE Universal Primary Education URA Uganda Revenue Authority USG United States Government USTP Uganda Stop TB Partnership UKAID United Kingdom AID UNEPI Uganda National Expanded Program for Immunization UDN Uganda Debt Network URCS Uganda Red Cross Society UNASO Uganda Network of AIDS Service Organizations VHT Village Health Team WHO World Health organization WRA White Ribbon Alliance Uganda

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EXECUTIVE SUMMARY

Introduction

USAID Advocacy for Better Health (ABH) was a five-year, approximately US$20 million-funded project that was awarded to PATH in June 2014. The project’s goal was to improve the availability, accessibility, and quality of health services in Uganda. Implemented by PATH and Initiative’s Inc., the project aspired to support citizens to demand for their rights and more fully engage communities in the planning and monitoring of health services. The project enhanced the ability of civil society organizations (CSOs) to effectively advocate for issues of citizens’ concern while growing their institutional capacity to be able to attract more funding and implement large-scale policy advocacy. The project operated for nearly five years, from June 2014 to March 2019. Procured through a competitive process, PATH supported 22 local sub-awardees to implement the project while leading implementation of some of the advocacy activities at the district and at national level. The project covered 35 districts (12 Western, 11 Central and 12 Eastern), although this number had increased to 39 by the end of the project. The project developed, at the start, an activity monitoring, evaluation and learning plan (AMELP) that guided implementation, performance monitoring and quality assurance.

Implementation Model PATH, with guidance from USAID and in consultation with Initiatives and local CSO partners, developed an implementation model of working through CSO partners at national and district level, and community groups at community level. The model emphasized three distinct but interrelated strategies: 1) citizen mobilization and empowerment, 2) social accountability, and 3) policy advocacy. Capacity-building of CSOs was the foundation for this model, responsible for accelerating project outcomes and leaving behind a legacy of powerful, high-performing partners who are able to sustain a locally-led health advocacy movement leading to measurable and meaningful change. In total, ABH worked with 479 existing community groups across 35 districts, each with different goals and objectives—from women’s groups, to environmental associations, farmer groups, and youth groups, self-help groups for people living with HIV, and savings and credit associations. After training and continuous support from ABH partners, the groups demonstrated capacity and willingness to embrace advocacy and integrate activities into their existing work. By the time the project ended, many groups indicated they would continue identifying gaps in service delivery and engaging their leaders to address them.

Learnings

The success of ABH relied on identifying and capacitating the right partners, as well as establishing a reputation in districts as a trusted partner. This required district entry meetings, community group mapping, action planning training, and skills building for CSOs—all of which took time.

Initially, some project stakeholders were anxious that the government would perceive advocacy interventions as combative and accuse the project of stirring political opposition, especially because ABH focused on government inefficiencies, lack of transparency and accountability, and

Page 6 of 59 poor political will. Instead of using accusatory tones and jumping to conclusions based upon single examples, the project captured and presented meaningful evidence, and emphasized approaches rooted in dialogue, and problem solving. ABH became a trusted partner that could effectively hold cross-sectoral dialogues and meaningfully engage civil society, health workers, and policymakers at all levels.

Rather than focus on health issue areas alone (e.g. HIV/TB, RMNCAH, and malaria), the project strategically selected cross-cutting themes (human resources, health financing and health commodity security) to drive system-wide change. This enabled ABH to engage in advocacy holistically and gave the project convening power to host dialogues focused on quality and availability of health services more broadly. Through community mobilization, social accountability, and policy advocacy, ABH was able to improve human resources for health, increase domestic health financing, and reduce stock outs of lifesaving medicines especially for HIV/AIDS and TB.

Since 2014, the project highly influenced government budget allocation to the health sector. Together with other health advocates, ABH was able to avert a 30 percent cut to the health budget for financial year 2017/2018 and compelled the MOH to be more proactive in prioritizing and ring-fencing money for PHC, MNCH, HIV/AIDS and TB. As a result of advocacy and community demand, districts also started prioritizing health-related interventions in their annual budget allocations. This is a key lesson for donors: rather than rely solely on direct funds for health services, investing in advocacy can unlock a country’s own resources for health.

Combining policy advocacy and social accountability approaches achieves both quick wins and longer-term results. The project and its sub-grantee CSOs had to sustain policy advocacy engagements for months or years, often changing tactics or approach. This was mainly because the advocacy asks required structured decision-making, involved different players and sometimes budgets had to be allocated in line with the government’s fiscal years.

Partnerships with media can catalyze action and responsiveness from duty-bearers. ABH engaged journalists to profile major challenges affecting the health sector, resulting in decisions by national and district leaders to renovate or expand health facilities, deliver critical medicines to avert stock outs, or deploy more health workers to facilities with acute shortages.

Recommendations for sustainability • USAID implementing partners need to absorb the trained community groups to support their programs and have a platform to continue with citizen-led advocacy. • USAID IPs could adopt and integrate in their programming proven project approaches and models such as institutional capacity strengthening, Grant Management Collaborative (GMCs), advocacy forums, and government participatory planning processes, and the annual presidential dialogue on health care. • Based on the successes that were realized in the 35 districts where the project operated, the same project model should be scale up to cover other districts in the country so that they equally benefit. This can be done by way of integrating citizen-led advocacy into all service delivery programs

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1.0 Background

1.1 Project Goal and Result Areas

1.2 Theory of change The project’s theory of change stipulated that; IF citizens’ knowledge and awareness of their rights and responsibilities were increased (to stimulate collective consciousness); and IF the capacity of CSOs was built to effectively empower and represent communities, THEN, citizens would have the confidence to hold their leaders accountable and influence them to change health and social policies in their favor.

This empowerment and confidence would motivate citizens to get organized; reach consensus on their priorities and plans of action; and demand for better health and social services from their duty bearers. The persistent collective voice and actions from citizens and CSOs would compel leaders and duty bearers to respond by changing the necessary policies and taking actions to improve the availability, accessibility, and quality of health and social services.

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1. 3 The Advocacy for Better Health model The Advocacy for Better Health model was developed by PATH, with guidance from USAID and in consultation with Initiatives and local CSO partners. The model emphasized three distinct but interrelated strategies: 1) citizen mobilization and empowerment, 2) social accountability, and 3) policy advocacy. Capacity-building of CSOs was the foundation of this model, responsible for accelerating project outcomes and leaving behind a legacy of powerful, high-performing partners who are able to sustain a locally led health movement leading to measurable and meaningful change. For effective advocacy, the project adopted priority thematic areas: HIV/AIDS; TB; malaria; nutrition; family planning; and reproductive, maternal, newborn, adolescent, and child health (RMNCAH). This was done through the lens of four priority advocacy areas: health commodity security, human resources for health (HRH), domestic health financing, and orphans and vulnerable children (OVC) as matrixed below; THEMATIC Domestic Health Human OVC AREAS Health Commodity Resources for Financing Security Health MCH X X X X HIV/AIDS X X X X Malaria X X X X OVC X X X X TB X X X Family planning X X X Nutrition X X X

Consolidated synergy between district and national level sub awardees was also created, to ensure that systemic impediments to health service delivery are appropriately championed from district to national level.

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1.4 Rationale for the four advocacy priority areas

1.4.1 Domestic health financing At the time the project was launched in June 2014, the government of Uganda (GoU) was increasingly abdicating its health financing obligations to development partners. USAID in particular expressed concern about the health sector budget that was continuously dwindling against the 2001 Abuja declaration by Africa Union that urged all member states to dedicate 15 percent of their national budgets to health financing. There was also growing overdependence on donors for funding HIV/AIDS prevention and treatment programs. Funding for primary health care (PHC) was equally limited, yet PHC funding was critical to financing key health prevention programs. This domestic financing situation justified the project’s continuous focus on budget advocacy to ensure the government realizes its funding obligations and considers increasing the percentage of the national budget going toward the health sector. 1.4.2 Human resources for health (HRH) Health worker absenteeism was a perpetual phenomenon crippling health service delivery in Uganda. A study conducted by IntraHealth in 2015 1reported that health workers were absent from their posts for up to as much as 50% of the time. The Uganda National Household Survey findings also showed that health worker absenteeism was at 30% in 2009/10, 30% in 2010/11, and 46% in 2011/12, depicting a worsening trend. Uganda also continued to experience a shortage of staff in the health sector due to government failure to commit to filling the gap. For instance, in 2012/13 only 63% of the approved posts in government health facilities were filled, a slight improvement from 2011/12 where the percentage of posts filled was 56% (MOH Annual Performance Review report 2013/2014). Health worker motivation had frequently been cited as a critical barrier to effective health service delivery and contributor to the shortage of health care workers. Therefore, the project heavily engaged in advocacy to ensure improved recruitment, deployment, retention, supervision, and motivation of health workers, especially at lower-level health facilities where the majority of Ugandans access health services from.

1.4.3 Health commodities security Uganda’s public health facilities often experience stock-outs of essential medicines and medical supplies. For instance, the 2013/14 Annual Health Sector Performance Review reported that 40% of health facilities continued to experience persistent drug stock-outs. Poor management of the drug supply chain regularly caused insufficiency of essential medicines. Lack of compliance with standard operating procedures (SOPs) further aggravated the situation and lead to stock-outs and expiry of essential medicines. Drug stock-outs in public health facilities directly contribute to increased drug resistance in the population as patients fail to get the required regimens in time or resort to self-prescribed, over-the-counter medicines that may be harmful to their lives. Moreover, interruption of HIV or TB treatment can lead to the development of resistant strains of these diseases, which are much more difficult to treat and require costly second-line drugs. Against this background, the project invested heavily in advocacy to detect and prevent stock- out of critical health commodities, both at the community and national level.

1 Strengthening Human Resources For Health: End of Year One Assessment Report by IntraHealth (January 2016)

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1.4.4 Plight of orphans and vulnerable children (OVCs) According to the Uganda Demographic and Health Survey (UDHS 2011), teenage pregnancy rates were reportedly at 24% in 2011, 25% in 2006, 31% in 2000, and 43% in 1995. A 2014 UNICEF report showed that 10% of Ugandan girls were married by age 14 and 40% by age 18. In light of this evidence, the project undertook advocacy on OVC issues.

The project engaged in advocacy aimed at increasing school retention, reducing teacher absenteeism, and improving primary school performance. Other OVC issues undertaken were child abuse, teenage pregnancy, and child/early marriage. At the time, the evidence that informed advocacy in this area was quite overwhelming. For example, according to a Universal Primary Education (UPE) situational analysis report by UNICEF (2014), 33% of children who enrolled in primary school did not complete their seventh year. In 2012, UNESCO reported a 71% drop-out rate of primary school students who enrolled under the UPE.

2.0 Project Start-up Activities

2.1 Staff recruitment, office set up, and procurement of project equipment Staff Recruitment The project employed technical staff who were responsible for the implementation of the project activities across the 35 districts during the 5 years. National-level staff included Chief of Party (CoP), Deputy Chief of Party (DCoP), M&E Specialist, M&E Officer, National Advocacy Officer, Communication and Empowerment Officer, Finance and Grants Manager, three Grants Officers, Project Accountant, and Program Support Assistant. At the regional level, the project recruited three Regional Coordinators, three Advocacy and Empowerment Officers (who later served fully at the national level) and three drivers.

Establishment of Offices In order to enhance effective coordination of project activities in the 35 districts, the project successfully established regional offices in Mbale (for Eastern Region), Mbarara (for Western Region) and Kampala (for Central Region). These regional offices were able to coordinate partner project activities in the districts and established tangible networks with USAID implementing partners (IPs) and districts.

Procurement of Equipment Advocacy for Better Health Procured 4 vehicles and 20 motorcycles to support project activities across the 35 districts. These vehicles have since been passed on to USAID IPs and the motorcycles allocated to high performing sub-awardees to continue supporting health ctivities.

2.2 Development of the project’s activity monitoring, evaluation, and learning plan (AMELP) through a consultative process Upon award, USAID Advocacy for Better Health initiated the process of developing its AMELP. The project solicited input from partners to understand the expectations of key stakeholders, set reasonable expectations for what could be achieved, and identify relevant information on similar programs that had been implemented under comparable conditions. The key stakeholders involved were the USAID/Uganda M&E team, USAID Communication for Healthy Communities, Page 11 of 59

Strengthening Decentralization for Sustainability, USAID Learning Contract, Governance Accountability and Participation Program, Advocacy and Public Policy team at PATH, local government representatives, Ministry of Health, Accountability for Health—a project supported by DFID under Goal Uganda—and the ABH project team. The stakeholders supported the re- alignment of the results framework, identification and designing of the indicators, and identification of preliminary areas of advocacy focusing on HIV/AIDS, TB, OVC, malaria, maternal and child health, family planning, sexual and reproductive health, and nutrition. This process also helped align the project results framework and indicators with the goals and relevant indicators for the USAID/Uganda Country Development Cooperation Strategy, President’s Malaria Initiative, Global Health Initiative, and PEPFAR.

2.3 Baseline survey With the AMELP in place, the project conducted a baseline survey to establish pre-intervention conditions to inform the development of tailored interventions and provide a basis for monitoring and evaluating activity results and impacts. The purpose of the baseline was therefore to gather comprehensive data at the starting point of the project with regard to its core performance indicators in order to make it possible to evaluate the project outcomes mid-way and at the end of its implementation.

The baseline study objectives were to:  Establish the extent to which citizens were empowered to demand for improved health and social services in their communities.  Determine the extent to which citizens were involved in decision-making concerning delivery of quality health and social services in their communities.  Identify key advocacy forums and groups that enable citizens to engage with duty bearers.  Establish the extent to which sub-grantee civil society organizations (CSOs) have effectively advocated for citizens’ concerns in the health and social sectors.  Establish the current organizational and advocacy capacity of sub-grantee CSOs.

The baseline study (full report available on request) used a mixed method design and collected the required data using quantitative and qualitative methods including community assessments in a sample of 14 districts, policy mapping, and organizational and advocacy capacity assessment with 17 sub-grantee organizations. The baseline also included a household survey covering 1,844 respondents. Average organizational and advocacy scores reflected inadequate capacities. Analysis of findings indicated that 54.7% of all respondents reported that in the past year, health service delivery in public health facilities had improved; 29.6% of citizens reported having participated in an activity to demand for improved health and social services; while 24% of citizens said they understood their rights related to health and social services. Furthermore, baseline findings indicated that citizens were inadequately empowered to demand improved health and social services in their communities and that there is limited citizen involvement in decision-making concerning delivery of quality health and social services in their communities. From the qualitative data, the baseline survey report identified potential advocacy forums and groups that may enable citizens to engage with duty bearers; information on CSO involvement

Page 12 of 59 in advocacy in the health and social sectors; and current organizational and advocacy capacity of sub-grantee CSOs. 2.4 Selection of sub-awardees through a Request for Applications (RFA) process As part of the startup process, the project undertook a competitive process in selecting sub- grantees. A request for applications (RFA) was released calling for local CSOs to apply for the implementation of the Advocacy for Better Health project. An overwhelming number of CSOs (179) responded to the RFA. All applicants were subjected to administrative review, and those that met the requirements were recommended for technical review. Forty-five organizations passed the technical review and were recommended for pre-award assessments conducted by the project team. Results of the technical review, pre-award assessments, and recommendations from previous and existing partners were used to select 21 sub-grantees that were approved by USAID. Below is a summary of the sub-grantees disaggregated by their areas of coverage.

Table 01: Approved Advocacy for Better Health sub-grantees (Nov 25.2014) CSO Cluster # of sub-counties Family Life Education Program (FLEP) Kaliro and Iganga 22 Action for Rural Women's Empowerment (ARUWE) Mpigi 7 Reproductive Health Uganda (RHU) Kabale, Kisoro 39 Literacy Action and Development Agency (LADA) Rukungiri, Kanungu 29 Integrated Development Options (I-DO) Isingiro 43 Action for Community Development (ACD) Kasese 29 Kabarole Research and Resource Center (KRC) Kyenjojo, Kamwenge 30 URCS Ntungamo, Bushenyi 30 Rural Action Community-Based Organization Ssembabule, Mityana 20 (RACBO) Community Integrated Development Initiative (CIDI) Luwero, Nakasongola, Kayunga 31 Kalangala NGO Forum Kalangala 7 Jinja Area Communities Federation Kamuli, Mayuge 26 Straight Talk Foundation (STF) Bugiri, Busia, Namutumba 32 Mbale Area Communities Federation Mbale, Sironko 40 UDN Pallisa, Kumi 26 Multi-Community Based Development Initiative Budaka, Butaleja, Bududa 41 (MUCOBADI) Kapchorwa Civil Society Alliance Bukwo, Kapchorwa 27 Health Promotion and Social Development (HEPS) Ibanda, Kiruhura, 30 National Forum for PHA Networks in Uganda National level (NAFOPHANU) Communication for Development Foundation National level Uganda (CDFU) Center for Health Human Rights and Development National Level (CEHURD)

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2.5 Formative research to inform development of advocacy communication strategy Based on the need to ground all advocacy communications in strategic communication principles, a formative study was conducted in the districts of Sembabule, Kiruhura, and Mityana. The formative research selected the three districts based on their uniqueness to the project’s thematic areas. The selection took into consideration unique population characteristics such as presence of fishing communities in Mityana and pastoralist communities in Kiruhura and Sembabule. The formative research also built upon the community mapping exercise that was done in 15 districts. The purpose of the study was to:  Identify patterns of citizen behavior that affect access and utilization of health and social services.  Determine barriers, enablers, and influencers of citizen engagement in demanding for quality health and social services.  Explore ways in which citizens’ participation and demand for better health and social services could be enhanced within the community.

The formative study findings found that the majority of respondents perceived their quality of health services to be very poor. Complaints ranged from poor attitudes and absenteeism of health center staff to persistent stock-outs of drugs and other commodities. Community members expressed that they would like to engage with duty bearers, but such opportunities for engagement are limited. For instance, a respondent in Nkungu FGD said: “You cannot meet a leader and begin asking him things when he has never called for a meeting. I have been a resident of Kataraza for 14 years but I have never seen our leaders calling for meetings, it’s just a title that someone is a chairman but we do not see what they really do.”

2.6 Mapping of existing assets for community empowerment and advocacy The project conducted a community mapping exercise in 15 districts to identify existing assets, tools, and resources to form a strong foundation for community empowerment and advocacy efforts at all levels. The exercise identified and documented existing platforms where citizens engage with duty bearers, as well as communication channels that national level CSOs utilize to mobilize communities for health and social services-related advocacy. The mapping exercise (full report available on request) also identified critical knowledge gaps on a number of health issues such as insufficient mechanisms to address OVC issues and gaps in messages related to health advocacy—some were not strategically designed and disseminated, like the Government of Uganda Patients’ Charter for instance.

2.7 Development of an advocacy communication strategy The project developed a communication strategy to guide all communication interventions that would raise citizens’ awareness of their rights and responsibilities but also ground their advocacy communications in strategic communication principles. The project communication strategy (full report available on request) was customized by all sub-grantee CSOs to suit their contextual and communication needs. CSOs were supported in customizing the communication strategies through technical workshops organized by CDFU, a national level CSO that provided communication-related technical assistance to the project. During the process, emphasis was put on harmonizing CSO advocacy issues to the project’s four broad priority advocacy issues, namely

Page 14 of 59 human resources for health, health commodity security, domestic health financing, and OVC. The workshops also provided an opportunity for the CSOs to learn how to improve their organizational communication strategies.

2.8 Advocacy strategy development During the first year, ABH staff were trained in policy advocacy strategy development using PATH’s 10-part approach to policy advocacy (see figure 01 below). During the same training, staff were oriented to community mobilization techniques using PATH’s Community Mobilization and Advocacy Action Planning curriculum. All these trainings were later flowed down to CSO staff as `they developed their individual advocacy and community mobilization strategies. Through this process, ABH staff and project partners identified health and social sector policies and guidelines, identified decision-makers and influencers, and developed tactics to influence through advocacy. Sub-grantee CSOs utilized these strategies to guide their advancement of evidence-based advocacy issues of citizens’ concern to the duty bearers.

Figure 01: PATH’s 10- part plan for policy advocacy strategy development

2.9 The Advocacy Advisory Group The project formed and operationalized the Advocacy Advisory Group (AAG) to support and advise the implementation team to bolster project outcomes. The process of selecting members involved developing terms of reference to outline objectives, their functions, and membership categories. Priority was given to personalities who had a track record of exemplary performance and demonstrable experience in influencing health and social sector policies. These included national and district-level decision-makers, CSO and private sector representatives, media, and

Page 15 of 59 other health and social service-delivery projects in Uganda. Members of the AAG played a big role in shaping the advocacy priorities of the project and proposing strategies to increase citizen and duty bearer engagement on issues related to public accountability and good governance systems. Some of the members of the AAG were positioned as Advocacy Champions, passing on call-to-action advocacy messages through different channels, especially print and electronic media.

The objectives that drove the agenda for the AAG were as follows:

 Identify and recommend critical stakeholders and diverse project participants in the USAID Advocacy for Better Health project.  Advise on strategies for fostering communication and collaboration across relevant health and policy advocacy initiatives.  Review and recommend tools and provide evidence to inform the effective design and implementation of project activities.  Provide a forum for sharing lessons learned, innovations, and best practices to enhance civic engagement in social accountability and strategic policy advocacy.  Provide technical assistance to the project leadership relative to the groups’ areas of expertise.  Advocate for project goals and objectives.

PATH Country Director in Uganda, Dr. Emmanuel Mugisha addresses members of the Advocacy Advisory Group at a quarterly review meeting in Kampala.

The AAG members were also involved in project related activities such as meetings to review the status of health commodities (ARVs and TB drugs) in the country together with USG implementing partners, Ministry of Health, and the national medical stores. The AAG meetings also provided an opportunity for the project to learn from sister social accountability programs

Page 16 of 59 such as the DFID-funded Accountability Can Transform (ACT) Health project being implemented by GOAL.

Some AAG members became strong advocates and actively participated in advocacy engagements at the national and district level, including participating in People’s Parliament, giving media interviews, and attending meetings with National Medical Stores and radio talk shows, among others. Their voice added value to ensure the project achieved its advocacy objectives, especially those related to health commodity security and human resources for health.

3.0 Project Result Areas

3.1 Result Area 1: Citizens demand improved quality services This result area sought to create a critical mass of empowered citizens in the 35 districts who could demand improved quality, availability and accessibility of health and other social services. In order to attain this, the project translated and disseminated the Patients’ Charter and other tools for community empowerment, created awareness for citizens’ rights and responsibilities through media and forum theatre (interactive drama), engaged media, empowered communities to organize community group meetings, and ensured the functionality of advocacy forums at the sub- county level. Below is the detailed account of the achievements registered under Result Area.

3.1.1 Intermediate Result 1.1: Increased citizens’ awareness of rights and responsibilities related to health and social services

Performance indicator: percentage of citizens who demonstrate understanding of their rights and responsibilities related to health services (disaggregated by gender, age group, and health thematic area).

ABH empowered citizens to amplify their voices as agents of change in their respective communities. This was done through multiple integrated interventions and communication strategies. The general citizenry, community leaders, and targeted groups engaged in advocacy and social accountability activities with duty bearers and service providers. Central to these efforts was increasing citizen knowledge and awareness of their rights and responsibilities related to health and social services and developing their ability to identify, articulate, and take advocacy actions relative to their needs. Empowerment was measured using different parameters such as citizens’ ability to speak out on issues affecting health care and engage their leaders and service providers, and the responses/actions taken by duty bearers on the same issues affecting health and social service delivery.

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3.1.1(i) Identification of advocacy and media champions As a step toward soliciting support for the realization of its objectives, the project identified 94 journalists from major media houses situated in Eastern, Central and Western Uganda, and 10 national level ones as advocacy champions. All the media houses received an orientation focusing on their expected roles, understanding of the project, responsible reporting, and the project’s priority advocacy issues. A press kit was also launched and distributed to the media champions to aid their reporting. Most of these champions have been influential in reporting advocacy related stories.

Media advocacy quick win! Security guard stops treating patients at Gisozi Health Centre II. In Muramba sub-county, Kisoro district, a community group held a meeting on 9th September 2015 facilitated by a team from RHU, a sub-grantee CSO partner who at the time was in charge of Kisoro and Kabale. The objective of the meeting was to support the group in identifying social issues affecting the citizens and supporting the group to prioritize the issues and develop an advocacy action plan.

In this meeting, an issue came up about a security guard (Askari) for Gisozi Health Centre II who was allegedly administering treatment to patients whenever health workers were be absent from duty. Since a radio journalist was present and recording the meeting, the issue was brought to the attention of duty bearers through the media (local radio). The story was aired the next day with a sound bite of community members voicing their concerns. The District Health Department was shocked about the revelation and did not take it lightly. The Kisoro DHO summoned the RHU staff for a meeting to substantiate the claims by the community members.

Given the overwhelming evidence to support the claim, the DHO went on air on 14th September to respond to the issues the community members were raising. An interface meeting was also organized on 22nd September by RHU between the duty bearers and community members to discuss the same challenges. In this meeting, resolutions were passed, and among them were commitments to open the health center on time, for treatment to be administered by qualified staff, and that Askari be guided further on his roles and responsibilities by the in-charge of Gisozi Health Centre II and involve the health unit management committee in the operations of the health center, especially in witnessing the drugs received. The situation has since changed for the better and there have been no more complaints from the community. Narrated by Josephine Kiconco, former District Advocacy officer under RHU.

3.1.1(ii) Media analysis and action As part of the process to position the project to effectively harness the power of the media in achieving its objectives, ABH, through one of the sub-grantee CSOs (CEHURD), conducted an analysis for coverage of health issues in the Uganda’s mass media from a human rights perspective. The purpose of the analysis was to map health issues highlighted by leading media houses in Uganda, identify opportunities and challenges in the media coverage of thematic health issues; and identify core health-related human rights issues that are often missed by journalists reporting on health. Findings from the analysis indicated that often while reporting on health issues, whether deliberately or unknowingly, reporters were not sensitive to the rights of the subjects at the center of their reporting. Some human rights, like the right to privacy, appeared to be violated. The findings from the analysis were used to orient 24 journalists on responsible media advocacy and appeal to them to take into consideration human rights while reporting on health issues.

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3.1.1(iii) Broadcasts and placements of advocacy messages on radio, TV, newspapers, and social media The project and its sub-grantee CSOs used a variety of media platforms to broadcast advocacy messages and increase awareness on citizen rights and responsibilities. Some platforms included live call-in radio talk shows where citizens could raise concerns to duty-bearers, TV guest appearances, radio and TV spots delivering key health messages, radio drama series, and newspaper supplements. All messages went were approved by the project’s technical teams and management or USAID before going on air. The messages were developed across all the thematic areas and some were specific to citizen rights and responsibilities derived from the Uganda patient’s charter

3.1.1(iv) Media articles referencing Advocacy for Better Health ABH received a lot of media coverage for its various events happening at national and sub-national levels. The project ran a series of 28 advocacy strip messages in Uganda’s two leading dailies (New Vision and Monitor newspapers). The messages focused on priority advocacy issues for the project, namely drug stock-outs, health worker absenteeism, school drop outs, and citizen rights and responsibilities. The messages were endorsed by the national advocacy champions who were members of the project’s Advocacy Advisory Group. The project also garnered earned media coverage as some media houses found health-related coverage increased their listenership.

Similarly, some sub-grantee CSOs featured a number of articles and advertorials in the same newspapers and other regional papers. This augmented the project’s visibility and its emphasis on priority advocacy issues. Some project events, such as the Presidential Dialogue on Health, received live media coverage from both NTV and NBS television stations. Subsequently, a number of stories and articles were filed featuring ABH staff, partners, and beneficiaries at the community level. Some of these stories can be accessed online through the links below:

 TV talk show on domestic financing for health and HIV in particular: https://www.youtube.com/watch?v=Tx6O7eAzmxI&feature=youtu.be)  Monitor Story on Presidential dialogue at Colline Hotel, Mukono: http://www.monitor.co.ug/News/National/health-services-to-donors--activists-tell- government/688334-4120472-9jdwap/index.html  Feature story on community empowerment tactics in Kalangala district: http://www.monitor.co.ug/SpecialReports/-drama-fight-HIV-Kalangala/688342-3473924- 10jxe5c/index.html  Feature story on stock out of TB drugs: https://www.newvision.co.ug/new_vision/news/1460297/treating-tuberculosis-districts-hit- isoniazid-stockout

3.1.1(v) Social media engagement The project utilized social media platforms such as Facebook, Twitter, YouTube, and SMS to popularize policy advocacy results and all emerging advocacy issues related to the public health sector. High-level project events like the Sing4Change2 campaign launch, were also promoted via social media.

2 Sing4Change was an ABH campaign that leveraged local celebrity artistes to sing edutainment songs that were utilized to champion community empowerment and advocacy messages on HIV/AIDS, TB, nutrition, malaria, and RMNCAH. Page 19 of 59

The use of social media led to increased advocacy engagement as the discussions continued through the digital platforms. The social sites were also an ideal avenue for citizens to report stock-out cases and the state of health care services in their communities. Some of the high-visibility activities that More men (67%) participated in social media triggered discussion over social media discussions compared to women (33%). By the end of the project, Facebook had a total audience channels included: 16 Days of Activism reach of 47,027 while Twitter impressions clocked against Gender Based Violence, the “Sing out at 213,057. for Change” campaign launch, and the National Presidential Dialogue.

3.1.1(vi) People’s Parliament on NTV to discuss MCH and HIV/AIDS-related issues The project utilized NTV people’s parliament as an innovative TV platform for citizens to interact with their respective duty bearers and discuss systemic impediments to quality health service delivery in the country. Over the years, the project organized eight sessions of the people’s parliament in the districts of Bududa, Butaleja Pallisa, Ntungamo, Kisoro, Nakosongola, Mityana, and Kampala.

Topical issues included at these sessions included the provision of HIV services for at-risk populations like fishing communities; the need to address teenage pregnancy, child marriages, and gender- based violence; maternal deaths; breakdown of referral systems and lack of ambulances; limited community sensitization on nutrition; water shortages in health facilities; and stock-outs of essential drugs and other lifesaving commodities. In The Speaker of People’s Parliament, Agnes Nandutu (extreme left) attendance were community walks out after a session that debated gender-based violence in group members affiliated to Pallisa district. the project, curious citizens, CSOs involved in HIV/AIDS advocacy including Young Positives and Positive Men’s Union, and other HIV constituents. Other attendees included national level partners and government agency representatives such as the Uganda AIDS Commission. The shows extensively discussed MCH and HIV financing and the need for advocates to call on government to consider long term sustainable strategies to support its MCH and HIV response instead of relying heavily on external funding from development partners.

For instance, in Nakasongola district, the People’s Parliament session focused on accessibility of HIV AIDS services in the district. The discussion involved the top district leaders, both political

Page 20 of 59 and technical, including the DHO who gave vital information about HIV/AIDS service delivery. In response, citizens specifically people living with HIV responded by asking the district to consider having routine outreach services to hard-to-reach areas, since distances to health facilities offering such services were quite long and were causing poor adherence and lost to follow-ups.

3.1.1(vii) Performance of educative drama shows at community level Drama (forum theatre) was embraced as an edutainment approach that the project used to create awareness of citizens’ rights and responsibilities and other advocacy issues through modeling desired behaviors using characters in the drama. The project, through its sub-grantee CSOs, conducted A drama group of people living with HIV making a presentation on citizen dramas shows on awareness on rights and responsibilities in Ibanda district. about the Patients’ Charter with the objective of empowering citizens to know their health rights and responsibilities. The drama shows attracted large audiences of community members, service providers, and duty bearers. Increased awareness of citizen rights and responsibilities through drama contributed largely to community members holding their leaders accountable to explain gaps in service delivery or make commitments toward addressing such gaps as was seen in the majority of the advocacy forums at sub-county and district level.

3.1.1(viii) Development and Production of IEC and promotional materials The project, through its sub-grantee CSOs, developed and disseminated a number information, education and communication (IEC) materials with various messages about the advocacy issues the project pursued. The materials included posters, fact sheets, stickers, booklets, banners, t-shirts and caps. All the materials were properly branded with the project and partner logos, accordingly. All advocacy communication interventions and materials utilized the project tagline: Where Everyone is Accountable, Everyone Wins.

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Furthermore, the project also translated, printed and disseminated 88,650 copies of the Patients’ Charter in eight local languages, namely: Luganda, Runyakitara (4Rs), Lukhonzo, Lumasaba, Rufumbira, Kupsabiny, Lusoga and Ateso. The tool, which was reviewed and approved by the Ministry of Health and USAID, was critical for empowering communities within the 35 districts. ABH also utilized opportunities such as community group meetings and advocacy forums to disseminate the Patients’ Charter.

Copies of the Patients’ Charter were also posted strategically in places such as health facilities, sub county halls, and schools, all places that are widely visible for citizens. The Patients’ Charter was also disseminated at commemorative events such as the World AIDS Day and World Contraceptive Day. During the World Contraceptive Day event in Pallisa district, the Minister of State for Health in charge of Primary Health Care, Dr. Joyce Moriku, was excited by the version developed by PATH as she inspected the PATH exhibition stall. She remarked, “this is what we want…” upon seeing the Patients’ Charter.

3.1.2 Intermediate Result 1.2: Community groups advance priorities for improved health and social services

Key performance indicator: percentage of community groups whose action plans advance into implementation phase.

3.1.2(i) Selection and orientation of 479 community groups to engage in citizen-led advocacy

The ABH project worked through existing community structures, specifically community-based organizations/groups, health unit management committees, and drama groups. Using findings from the community mapping exercise that was done at the start of the project, 479 community groups were selected to represent all 479 sub counties in the 35 districts where the project was implemented. The prioritized All this effort resulted into a more effective and groups were those that had an edge over coordinated process of evidence collection that others in doing community mobilization informed advocacy engagements between citizens and engagement work, but also those with and duty bearers at community, district and greater potential to grasp the concept of national level. citizen-led advocacy and take it to scale. Priority was also given to community groups composed of people living with HIV, youth, and women, as a strategy to promote equity and gender inclusiveness. The groups, through a training cascade led by PATH and the CSOs, were oriented to the project using the standard community mobilization and advocacy action planning curriculum developed by PATH. The groups were also trained in principles of group cohesion, minutes writing, evidence generation and packaging, decision-maker engagement, action Page 22 of 59 planning, and follow up. They were introduced to critical tools to be used in their citizen empowerment activities. The tools included the advocacy action planning tool, Patients’ Charter, health facility assessment tool, and advocacy forum minutes template. The groups supported the project in socialization of the 90’90’90 HIV treatment targets, Test and START policy, and Differentiated Service Delivery Model across the 35 districts. On a monthly basis, the groups tracked and monitored availability of health workers and drugs for HIV/TB, MCH, and malaria, particularly at health center IIIs and IVs.

3.1.2(ii) Supporting community groups with community empowerment materials for mobilization and advancement of their advocacy agenda The ABH project identified challenges faced by community groups in reaching the wider community members. As a way of ensuring that the groups undertook effective advocacy within their respective communities, the project supported them with hardware, tools, and materials to facilitate their work at community level and sustain citizen-led advocacy after the project’s closing. Such The Advocacy Champion for Nakasongola town council, Nakafero materials included Jenipher (in red t-shirt) receives a bicycle from a district official at bicycles to ease mobility Nakasongola district headquarters. to distant communities; chairs and tents to host monthly community meetings; umbrellas, gumboots, and raincoats to be used during rainy seasons, especially in districts with difficult terrain; and branded t-shirts for visibility in the communities. The community group members expressed appreciation to the project for this level of support, saying that it helped them overcome visibility issues and allowed them to host community meetings all year long, regardless of the weather.

3.1.2(iii) Piloting of the community scorecard for social accountability The project developed a “hybrid version” of the community score card that suited the project’s design and was used by sub-grantee CSOs in enhancing the community empowerment processes and identification of critical issues needing to be addressed in the community. For example, working with one CSO (KADINGO) in Kalangala district, the project successfully piloted the community score card in seven fishing communities in the district. During the score card adaptation process, the community members were able to better articulate health service delivery gaps such as: poor transport and communication services, non-functionality of Health Unit Management Committees (HUMCs), and limited working time for laboratories. KADINGO and the participating communities used these issues to form their advocacy objectives and agendas. However, this approach was not rolled out to scale because the project realized the

Page 23 of 59 groups were already getting similar results through regular health facility assessments and community action planning.

3.1.2 (iv) Health Facility Assessments The ABH model promoted health facility assessments (HFA) as a method through which the community could gather evidence for social accountability efforts. Using the standard tool, advocacy champions and community members visited their local health facilities every month to collect information on the quality and availability of health services. Routine monitoring enabled communities to identify a range of problems—such as staff absenteeism and stock-outs of medicines and supplies—that they can present to their duty-bearers with supporting data. The evidence collected by the groups was used to develop advocacy action plans based on what the group members, led by their champions, discussed with their duty bearers at social accountability platforms (advocacy forums).

3.1.3 Intermediate Result 1.3: Improved engagement between citizens and duty bearers

Key performance indicator: Number of functional advocacy forums at sub county level.

3.1.3(i) Advocacy forums at sub county and district level

In the context of the ABH project, advocacy forums were used as platforms “The advocacy forums have helped to improve or interface meetings where citizens the client-provider relationships. Staff and clients could engaged with decision-makers (duty are happy with the services offered. We have bearers) to present and discuss issues also improved on health workers’ attendance to affecting the quality of health and social duty since all the midwives are accommodated at services. The issues presented and the facility and all departments have updated discussed had to be based on factual duty rosters.” Dr. Chebet Benjamin, In-charge evidence collected from reliable sources Budadiri HCIV, Sironko district. like at health facilities. The advocacy forums were critical social accountability platforms that citizens utilized to raise issues affecting the quality, accessibility, and availability of health services in their communities to the different duty bearers. Througout the lifespan of the project, CSO partners, together with community groups, mobilized citizens and duty bearers to participate in such quarterly forums, some at the sub county and others at district level. Most of the evidence presented by the citizens to duty bearers at these forums was collected during routine tracking and monotoring of service delivery. In Sironko district, the in-charge for Budadiri HCIV, Dr. Chebet Benjamin, after participating in a number of forums that were organized at his health facility, commended the use of advocacy forums in the search for solutions to challenges crippling service delivery.

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The District Health Officer for Kanungu, Dr. Ssebudde Stephen (left), addressing participants at a district advocacy forum in Kanungu district.

“During a public hearing that took place in Bugangari subcounty, Rukungiri district, one community member raised the issue of a non-functional theatre at Bugangari HCIV. After the Sub-County Chief and project staff followed up the issue with the office of the DHO, within a month, the district had mobilized funds to operationalize the theatre at Bugangari Health facility. The health facility has been given a new doctor in an attempt to fix the complaints at the facility.” Buhara Benon, Advocacy Champion, Bugangari Community Group.

Below is a summary of some of the outcomes of the sub county-based advocacy forums:  In Kitayunjwa sub county, Kamuli district, citizens tasked the District Health Officer to explain why drug stock- outs remained widespread in their facilities (See online story on http://www.monitor.co.ug/News/National/Residents-grill-health-boss-over-missing-).  In Kisoro district at Rubuguri HCIV, an advocacy forum unearthed a “corrupt” in-charge who had for long been misusing PHC funds. The district took action and interdicted him. He was also made to refund the money and transferred after to another duty station.  In Isingiro district, one community group called Rwendezi Functional Adult Literacy Group petitioned the district health department and the District Health Inspector committed to following up the issue of composition and orientation of new HUMCs in all health centers in the district.  In Keihangara sub-county, Ibanda district, community-led advocacy efforts culminated into a health centre securing an emergency room where critically ill patients can rest from as they await to be attended to by health workers.  In Busia district, citizens demanded for monitoring of health workers at Masafu hospital because of high absenteeism. As a result, a duty roster and an attendance register were introduced and these are shared with the CAO on monthly basis.  At Bumadanda HC III in Bubyangu sub-county, Mbale District, community members accused health workers of refusing to reside at the facility staff quarters. During an advocacy forum, the health workers expressed their challenges as to why they do not prefer to reside at the health facility quarters. They cited insecurity, where thieves would steal their household items, as the reason they were not comfortable staying at the facility. At the same forum, the community members resolved that they were going to erect a fence around the facility using their local resources. This was done and the health workers have already started staying at the health facility.

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3.2 Result Area 2: CSOs effectively advocate for issues of citizen’s concern in health and social sectors

This Result Area was largely aimed at empowering sub awardees to capture citizens’ concerns related to health and social services, gather evidence around these issues, and engage duty bearers to take actions in forms of policy change, formation, or implementation, allocation of budgets, and putting programs in place to address citizens’ concerns. During the period, the project supported sub awardees to gather and package advocacy evidence, engage with duty bearers, participate in appropriate advocacy forums as a way of representing community interests before duty bearers, and coalescing with other like-minded CSOs to influence policy change and accountability in both the public and private spheres. Detailed achievements are highlighted below.

3.2.1 Intermediate Result 2.1: Increased utilization of evidence by CSOs to inform advocacy

Key performance indicator: percentage of CSO advocacy initiatives which are supported by evidence

3.2.1(i) Gathering and packaging evidence The project, through its sub-grantee CSOs, gathered and packaged evidence to support its advocacy efforts. A number of rapid assessments, desk reviews, fact finding missions, and health facility assessments were undertaken to establish more information and facts about the issues the project was advocating for. The sub awardees packaged this evidence into dossiers, factsheets, issue papers, and policy briefs that were disseminated during one-on-one engagements and dialogue meetings with duty bearers.

In Mayuge district for example, one of the project’s implementing partners, Jinja Area Because of this advocacy, communities are now Communities’ Federation (JIACOFE), providing greater oversight, especially on issues of unearthed a number of anomalies in supply staffing and drug stock-outs. As a result we now chain management that were causing have a system in place to meet unexpected stock- sporadic stock-outs of drugs. Some of the outs. If a community alerts us that there is a stock- findings included inadequate capacity of out, we place an emergency order to the National health facilities/workers to quantify and Medical Stores. Likewise, if community members forecast their health commodity needs, and report issues of staff absenteeism, we can take the delayed deliveries by the National corrective action. Dr. Nabangi Charles, DHO, Medical Stores. These findings were Mayuge District packaged and presented to the District Health Office for action.

At the national level, one of the project’s implementing partners focusing on HIV/AIDS-related advocacy, the National Forum for People Living with HIV/AIDS Networks in Uganda (NAFOPHANU), sustained its work with District Linkage Facilitators (DLFs) to compile and share information on the number and functionality of accredited public health facilities providing antiretroviral treatment (ART) in the respective project focus districts. This data enabled NAFOPHANU to identify gaps in HIV/TB service delivery, which was instrumental in informing the advocacy at national level especially with regard to stock-out of drugs and absenteeism of health workers. As a result, more facilities were considered for accreditation and upgrading by

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Ministry of Health to offer static HIV/AIDS services or operate outreach HIV/AIDS clinics for hard-to-reach areas.

In an attempt to address challenges of stock-outs of HIV/AIDS commodities in health facilities, NAFOPHANU supported by PATH, held series of meetings between its Consortium of Advocates on Access to Treatment (CAATs) and duty bearers in the Mid-West, East Central and Western regions and national level, including the Ministry of Finance, Economic Planning and Development, the Ministry of Health, Speaker of Parliament, and the National Medical Stores. The key issues that came out from the discussions included: limited access to CD4 and viral load services; orders from health facilities not honored as per requisition; shortages/ stock outs of ARVs for children; stock outs of rapid testing kits; single source supplier/monopoly of supply which compromises quality of rapid testing kits; poor quantification and failure to make orders on time; inadequate storage Whereas the issue of stock out still remains, the facilities and management of expired drugs; magnitude has greatly reduced. That is where we expiry of anti-TB drugs mainly due to talk of sporadic stock outs. It is not something that delivering drugs that have a short shelf-life; is consistent, like you go to a district and you find and the standard operating procedures for drugs a stocked out for three months, six months supply chain management not being well or a year. You will not find all regimens missing. disseminated and therefore not well Stella Kentutsi, Executive Director, NAFOPHANU. known by all health workers. All these efforts have resulted in a general reduction of cases of stock-outs of HIV and TB drugs at health facilities.

In Kabale and Kisoro, Reproductive Health Uganda (RHU), supported by PATH captured community voices and photographs depicting status of health services in the two districts. This evidence was aired on selected radio stations and generated a lot of debate amongst the general population and concerned duty bearers. Further evidence was also collected through a media tour conducted in Kabale district, where journalists interfaced with most at risk populations (MARPs), whose plight in terms of access to health services was documented in the media (including one national television-Uganda Broadcasting Services, and the New Vision Newspaper) see links https://youtu.be/c7nDS1zcSzI and http://www.newvision.co.ug/news/673557-truck- drivers-fuelling-hiv-spread-in-kabale-kisoro.html.

In Kisoro, during the media tours, sex workers pointed out a number of issues affecting their health which included; limited services for sexually transmitted infections (STIs), lengthy travel to receive antiretroviral (ART) services at Kabale Regional Referral hospital, unfavorable working hours of health As a result of such advocacy, a number of facilities, and the need for alternative improvements have been registered at health income generating projects. These issues facilities serving these populations where were presented to the duty bearers (the “moonlight” services have been introduced. They Deputy Chief Administrative Officer, the can access counseling and testing services, and District Health Officer-DHO, the supplies such as condoms and other family Secretary for Health, and the Vice planning methods. chairperson for the district local council) who pledged to; earmark some health centres to offer STI and ART services beyond the normal working hours. RHU and a sister

Page 27 of 59 implementing partner- Katuna MARPs were asked to support sex workers by linking them to the Government of Uganda Youth Livelihood Program fund as an avenue for seeking alternative source of income.

3.2.2 Intermediate Result 2.2: Effective participation of CSOs in LG planning, monitoring & accountability of health and social services

Key performance indicator: percentage of CSOs actively involved in public sector planning processes

The project, through its regional team members and the respective sub-grantee CSOs, sustained participation in district planning meetings. Notably amongst these were the District Management Committee (DMC), Extended Technical Planning Committee meetings, district health sector committees, regional Performance management and Review meetings, District Health Management Team meetings and budget conferences. These meetings were attended by a mix of participants (such as the Chief Administrative Officers, district political leadership, implementing partners, district heads of department, technical staff, health facility in-charges, and sub county chiefs). These provided the project an opportunity to share the project purpose as well as ensure that issues of citizen’s concern related to health and social services were championed and incorporated in the district planning processes.

Mr. Willy Kawanguzi representing ARUWE (ABH sub-grantee) during an outdoor district planning meeting for health sector involving leaders and citizens at Mpigi district headquarters.

These meetings were not limited at district level but also at national level. At national level for example, PATH and its national-level sub awardee (HEPS) continued to participate in the monthly Maternal, and Child Health working group meetings. In one of the meetings and while discussing the situation analysis on community supply chain system of Family Planning commodities, HEPS Page 28 of 59 championed the issue of women not exercising their Family Planning choice due to stock-outs, especially of contraceptive pills. This was based on experiences adduced from communities within Kamuli, Kiboga, Mbarara and Isingiro districts, with whom the advocacy champions interacted.

3.2.3 Intermediate Result 2.3: Enhanced co-ordination & collaboration among CSOs

Key performance indicator: Number of CSOs that are involved in joint advocacy initiatives

In order to ensure the effectiveness and amplification of its advocacy efforts, the project actively supported coordination and collaboration among its sub-grantee CSOs to undertake joint advocacy activities with other CSOs both at district and national levels. For example, the South- Western Advocacy for Better Health CSO Network (SWANET) established by one of the sub- grantee CSOs (Literacy and Development Agency- LADA), and comprising 31 like-minded CSOs in the region, is an example of a district level joint advocacy initiative that the project registered during the period. This network is an example of how the advocacy for better project will remain self-sustaining even when the project closes. It is a platform to champion health and social service advocacy issues affecting citizens, amplify their voices before the responsible duty bearers.

3.2.4 National level policy advocacy tailored to specific Policy ASKs From its onset, and through protracted advocacy engagements, the project sought to influence a number of policies in the health sector aligned to its overarching goal of improved accessibility, availability and quality of health and social services. Based on PATH’s 10-part advocacy framework, the project employed different strategies and tactics in its advocacy engagements to ensure unfavorable polices were reviewed or changed, and non-existent policies were formulated or introduced in the service delivery continuum. The project organized press conferences, published press releases and held media tours to document HIV drug stock-out and HRH issues. All these culminated into high level media-orchestrated advocacy campaigns that yielded tangible results for the project, both for short and long term, including reactions from legislators over the state of health care in the country. Working across the three priority advocacy areas of HRH, commodity security and domestic health financing and the thematic/disease areas of HIV/AIDS/TB, Malaria, RMNCAH, Nutrition and OVC, the project made significant progress in the last five years on certain policy issues/advocacy asks, as highlighted below;

A. HIV/AIDS (i) Policy ASK: Government to develop and pass a separate Anti- HIV Stigma and Discriminatory Policy The Advocacy for Better Health Project, working through its sub awardee the National Forum for People Living with HIV Networks in Uganda (NAFOPHANU), advocated to the Uganda AIDS Commission (UAC) to develop the Anti-HIV Stigma and Discriminatory Policy. UAC, through its HIV Prevention Technical Working Group, convened meetings and developed a road map for writing this policy. UNAIDS became interested and availed funds for a consultant to lead the policy development process. The draft policy document was presented to the government Solicitor General for legal interpretation. USAID could consider incorporating advocacy for this policy into existing USAID projects, to ensure it is completed, passed, and implemented.

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(ii) Policy ASK: MoH to implement and roll out the Differentiated Service Delivery Model (DSDM) The project through its sub awardee, the International Community of Women Living with HIV in Eastern Africa (ICWEA), oriented all project sub awardees and other CSOs. This process was facilitated by the Ministry of Health Technical Advisor on DSDM. It was aimed at empowering the sub awardees with knowledge on DSDM and promoting evidence-based advocacy. Through ICWEA, the project also sustained its advocacy on the roll-out of DSDM in the MoH Technical Working Group meetings. Through the increased popularization and advocacy efforts by the ABH project, Ministry of Health was able to work with District Health Offices and US government funded implementing partners to roll out the DSDM guidelines in the respective regions.

With the launch of the Consolidated Guidelines for HIV Prevention and Treatment by the Ministry of Health in December 2016, the project continued to work on socialization of the policy, guidelines, and the provisions thereof, especially among PLHIV and key populations such as sex workers. Working with the Alliance of Women Advocating for Change (AWAC)—an umbrella organization for female sex workers—to organize a one-day national meeting under the theme: The Effective involvement of sex workers in the fight against HIV/AIDS towards achieving 90-90-90 treatment targets by 2020 in Uganda. This meeting was attended by 114 Participants from 23 districts across the country. Participants at the meeting committed to spending more time to i) mobilizing their peers to seek and access HIV testing and treatment services, ii) advocating for scale up of optimum friendly HIV Testing and Treatment services, iii) advocating for attitude change and promotion of a rights-based approach to quality health care services for key populations. The project worked with key populations, as a critical mass to the attainment of the 90-90-90 goals, demand for services but also to educate others about their rights.

(iii) Policy ASK: Government to ensure adequate last mile supply of HIV/AIDS drugs and related supplies A successful anti-HIV drug stock out campaign was held in 2015 that resulted in frontloading of funds by the Global Fund to avert a national stock out crisis. Since then, quarterly engagement meetings between civil society and the National Medical Stores (NMS) on security of HIV commodities have been held where updates on stock statuses are provided. Regular health facility assessments were also conducted by community-based groups at the local level to detect drug stock outs and report them through NAFOPHANU structures.

(iv) Policy ASK: Government to increase funding for HIV/AIDS and TB program in the national budget The project, working with other coalition CSOs on health advocacy, presented a position paper urging the government of Uganda to allocate/ring fence Uganda funding for HIV and anti TB commodities. This advocacy yielded 80 billion and 6.5 billion shillings for antiretroviral and TB drugs respectively, for the FY 17/18. (v) Policy ASK: MoH and its departments especially National Medical Stores (NMS), to ensure adequate supply of HIV medicines for successful implementation of Test and Start Policy Through community-led health facility assessments (HFA), and the monthly HIV commodities stock status tracking, evidence was generated and shared with different stakeholders to drive advocacy efforts aimed at stemming the chronic drug supply outages. This evidence was also triangulated with the periodic summaries shared by the USAID Uganda Health Supply Chain

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Project Technical Advisor based at the Ministry of Health. In partnership with NAFOPHANU the project convened various meetings on health commodities stock status, with the leadership of NMS and MOH. Although stock levels of HIV commodities continue to fluctuate, these engagements proved fruitful for providing critical evidence and sustaining pressure on persons responsible for taking appropriate action.

(vi) Policy ASK: Government to implement innovative financing mechanisms such as the National AIDS Trust Fund and the National Health Insurance Scheme which would increase domestic funding for the health sector and reduce overreliance on donor funding The desire to establish the National AIDS Trust Fund is being fast-tracked under the 2017 Presidential Fast-Track Initiative on Ending AIDS in Uganda by 2030. On the other hand, for the National Health Insurance Scheme (NHIS), the Chairperson of the Health Committee in Parliament, Dr. Micheal Bukenya, is currently undertaking the drafting of a Private Member’s Bill on NHIS to be presented to Parliament. For over a decade, Cabinet has persistently failed to pronounce its position on the already existing NHI Bill and present it to Parliament for passing into law. In 2017, the project facilitated Dr. Bukenya, together with a team of fellow legislators, to go on a bench-marking tour to Rwanda which is already implementing a national insurance scheme for its citizens. Since then, the bill has not been presented to Parliament by Cabinet and because of this delay, Dr. Bukenya was granted leave by Parliament to develop a private member’s bill for the NHIS.

(vii) Policy ASK: MoH to absorb PEPFAR-contracted staff at the national and district levels Recognizing the need for a national-level dialogue to advocate for government to absorb health workers on contract with support from PEPFAR, ABH partnered with the USAID Strengthening Human Resources for Health project (implemented by IntraHealth) to convene a high-level

Extreme left: Dr. Vincent Oketcho, Chief of Party USAID Strengthening Human Resources for Health project implemented by IntraHealth presents on status of HRH at a national dialogue in Kampala.

Page 31 of 59 meeting. Stakeholders included government ministries, departments, and agencies, parliamentarians, district health officials, hospital directors, donors, and CSOs. They developed a roadmap for absorbing the nearly 2,000 PEPFAR-funded staff working in various locations of the MoH. A multi-sectoral task force was formed, chaired by the MoH. This Task force developed a two-year roadmap, which was embraced by all stakeholders. From the most recent statistics (up until June 30, 2018) shared by IntraHealth, 805 staff out of the targeted 1,965 had been absorbed thus far.

(viii) Policy ASK: Districts to include in their annual budgets introduction or scale up outreach activities to extend to hard-to-reach areas HIV/AIDS treatment services and upgrade the majority of health facilities to level III where maternal and child health services can be provided

The MoH is currently implementing a phased upgrade of HCIIs to level III. The choice of facilities in phase 1 this financial year (2018/2019) was largely informed by the evidence and demand from the citizens under the ABH project. Kasese district is fast-tracking accreditation of a number of HCIIs to offer static HIV/AIDS services. In Busia district, the CAO received a directive from the MoH requesting information on sub counties that have HCIIs needing to be upgraded to HCIII. The district also recruited critical health cadres moving from 52% to 57% of staffing levels. Four health facilities at level III in Mbale (Jeewa, Bukasakya, Bumasikye, and Bukiende) received drug supplies for the first time since the facilities’ doors opened to the public, after the district intervened to address citizen demands regarding persistent stock-outs of medicines.

B. Tuberculosis (TB) (i) Policy ASK: MoH to finalize development of the TB desk guide The National Tuberculosis and Leprosy Program (NTLP) is mandated to produce and revise TB Desk Guides. However, the project noted that the most current version produced in 2010 was extremely outdated. For example, it did not address the emergence of drug-resistant TB, need for improved and/or new interventions in TB infection control, new developments in diagnostics, policy changes regarding TB treatment (including the emergence of new drugs and new treatment regimens), need for skills to communicate to patients and caretakers more effectively, or the realization of new TB key affected populations. The project, in partnership with NAFOPHANU and NTLP, collaborated to ensure that a draft TB Desk Guide was developed. Given the rising numbers of TB cases, this new guide will be instrumental as a reference tool for health workers in TB case detection and diagnosis.

(ii) Policy ASK: Increase domestic funding for TB activities in the country from current 4% funding to 25% to avoid relying heavily on donor-driven financing

ABH worked with champions from Parliament to establish the Parliament TB Caucus (Uganda Chapter) whose mandate is to steer future legislation on TB issues and create a platform to highlight issues affecting TB services. The project held a half-day meeting to orient members of this caucus, raise awareness of TB issues, and highlight existing TB policy gaps. Furthermore, the meeting was aimed at strengthening partnership and collaboration with other TB key players. It was attended by 14 Members of Parliament, USAID TRACK TB project, Uganda Cares, Ministry of Health (National TB and Leprosy Program), AIDS Information Centre (AIC), Uganda Stop TB Partnership (USTP), and Welfare Development Network (WEDNET) Africa. Follow on projects should continue working with this caucus to discuss and champion policy issues regarding TB.

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Hon. Joel Ssebikali was facilitated by the project to attend the United Nations High-Level Meeting on Tuberculosis in New York and he has since turned into a passionate advocate working closely with the Ministry of Health technical team to advance policies and programs aimed at ending TB.

C. RMNCAH (i) Policy ASK: Government to sustain the availability of the UN Lifesaving Commodities (LSC) for mothers and babies in health facilities Through CSOs and community groups, ABH tracked the stock status of lifesaving commodities (oxytocin, magnesium sulfate, misoprostol, contraceptive implants, female condoms, chlorhexidine, ORS, zinc, and Amoxicillin), ABH continued to work with the Ministry of Health MCH Technical Working Group to improve stocks of LSCs in the health facilities. As part of its advocacy on the availability of high-quality oxytocin, ABH presented evidence to the MoH MCH cluster working group about its use and storage, sustained media advocacy (largely through TV and radio), and held multiple face-to-face meetings with the MoH Permanent Secretary. These activities resulted in a directive by the PS to District Health Officers to ensure the use and storage of oxytocin in the UNEPI cold chain fridges (see the directive herewith). Furthermore, project sub awardees (i.e. Coalition for Health Promotion and Social Development (HEPS) Uganda, and White Ribbon Alliance) were nominated to work with the Samasha Foundation to conduct regular and periodic follow-ups on the stock status of lifesaving commodities.

(ii) Policy ASK: MoH to develop guidelines for integration of oxytocin into the vaccine cold chain Pursuant to the Ministry of Health Permanent Secretary’s Directive on oxytocin, the project turned to developing guidelines for integration of oxytocin in the cold chain with the MOH MCH Technical Working Group. The response received from the MoH was that there was no need to develop new guidelines since the existing guidelines on the storage of health commodities stipulate, among others, the storage of oxytocin. The Ministry of Health plans to procure fridges for maternity wards that should improve oxytocin storage. They also expressed interest in stocking alternative products when they become available.

(iii) Policy ASK: MoH to recruit, motivate, and retain midwives ABH worked with IntraHealth (SHRH project) to develop a position paper on the status of midwives in the country which was used to inform discussions at MoH MCH Technical Working Group. After sustained engagements with the MoH, the latter presented the recruitment, motivation, and retention of midwives as a priority at the inter-ministerial meeting held at the Ministry of Finance, Planning and Economic Development (MoFPED). There has been reassurance that the recruitment of midwives is a key priority in the GFF investment case.

(iv) Policy ASK: Government of Uganda to establish an immunization fund in line with the Immunization Act of 2017 Parliament of Uganda passed the Immunization Act in 2016, which was later signed by the President.

The Act aims to: 1. Encourage and enforce immunization as a cost-effective and efficacious public health measure against diseases of public health importance. 2. Increase domestic financing for immunization services through establishment of an immunization fund.

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As a step toward the establishment of the Immunization Fund and as requested by the PS MoH, ABH, in collaboration with PATH’s Anchor Advocacy Partnership (funded by the Bill and Melinda Gates Foundation) supported MoH to gazette the Act. The Advocacy Partnership and ABH project held a high-level meeting to pursue commitments in the Addis Declaration on Immunization (ADI), to which Uganda is signatory and contains the need to increase and sustain domestic investments and funding allocations, including innovative financing mechanisms. The meeting included Members of Parliament, Minister of Health, implementing partners, and CSOs, and was officiated by the Minister of Health Dr. Jane Ruth Aceng. Participants committed to pursue the establishment of the Immunization Fund. PATH-ABH worked with the MoH and a team of legal experts to develop regulations for the Immunization Fund. In order to fully incorporate key issues in the regulations, PATH worked with Ministry of Justice & Constitutional Affairs and MoH to conduct focused district consultative meetings in Mbale, Sironko, and Budaka. This meeting was a follow on to an earlier one that ABH convened to educate parliamentarians on the Immunization Act and its provisions, including the need to establish an immunization fund.

D. FAMILY PLANNING (i) Policy ASK: Government to increase the budget of Family planning (FP) For the Fiscal Year18/19, UGX16 billion has been allocated in the Ministry of Health’s Vote 116, toward the procurement of reproductive health commodities. The project pursued this ask with the MoH to ensure equitable appropriation to family planning commodities and to reach commitments signed by the president following the 2012 London FP 2020 Summit, which commits to allocating US$5 million for FP commodities every year for five years.

E. MALARIA (i) Policy ASK: Government should increase budget for rolling back malaria The project partnered with the MoH Malaria Control Program (MCP) to establish the Uganda Parliamentary Forum on Malaria (UPFM) which worked with MCP and other stakeholders to launch the Mass Action Against Malaria (MAAM) campaign that was presided over by the president on May 5, 2018. The UPFM provided a platform for advocating for increased domestic funding for anti-malarial commodities, and other related interventions. In partnership with MoH and HEPS (a sub awardee), the project focused its efforts on generating evidence that informed advocacy for the implementation of the 2012 WHO Malaria Test, Track and Treat policy and the Uganda Malaria Strategic plan 2014-2020.

(ii) Policy ASK: Government to regulate the quality Malaria Rapid Diagnostic Tests (mRDTs) A key project breakthrough on malaria was achieved through advocacy to ban the importation of unregulated mRDTs and bring to light how taxation of mRDTs was being done illegally at custom points. Through national level engagements, the Director General (DG) MoH wrote to URA instructing them to ensure that no mRDTs should be cleared for import without express clearance from National Drug Authority (NDA). URA obliged by sending written communication to all its boarder control offices.

This came about after the project had identified and publicized the problems surrounding affordability and quality of mRDT kits in the country. It had been noted that mRDTs only attracted a 2% tax to be cleared as medical supplies and this was the standard practice through the NDA. However, importers tended to opt to clear them as ordinary merchandise, attracting a tax of 18%. This practice meant that importers were compromising on the quality of the mRDTs Page 34 of 59 imported but also made the kits expensive since this extra cost was being passed on to the consumers. Armed with evidence, ABH and the MoH organized a national multi-stakeholder dialogue on malaria response. The dialogue brought together over 100 participants from MoH, NDA, Central Public Health Laboratory (CPHL), Members of Parliament, development partners, CSOs, and media. From the multi-stakeholder dialogue, the following resolutions were decided on: NDA to increase its efforts on post-market surveillance; MPs to ensure that there is more funding for malaria programs; and government to subsidize mRDTs to improve their affordability.

(iii) Policy ASK: DHOs to prioritize and allocate a budget to revitalize village health team (VHT) structures to ensure increased community education on malaria prevention and management programs by September 2018 In Kamuli district, the DHO allocated budget for VHT facilitation, training, and IEC material dissemination, though some of these were included as unfunded priorities in the health sector workplan. In Mayuge district, Buwaiswa and Malongo HCIIIs and Kityerera HCIV allocated part of PHC funds to VHT in the quarterly work plans.

Moses Dombo (center), former ABH Chief of Party gives remarks at a national multi- stakeholder dialogue on malaria in Kampala.

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F. NUTRITION (i) Policy ASK: Government of Uganda to prioritize nutrition in national and local government development plans and budgets

The Uganda National Nutrition Advocacy Platform

The ABH project led the process of establishing the Uganda National Nutrition Advocacy platform to champion nutrition advocacy. The platform is comprised of 15 organizations and implementing partners including UNICEF, FHI360 (FANTA and CHC projects), AVSI (SCORE project), JSI (SPRING Project), and World Vision. As a product from this partnership, a joint Multi-Stakeholder Nutrition Advocacy Action Plan was developed, in alignment with the Uganda National Nutrition and Communication Strategy 2015- 2019. Through this platform, the OPM organized regional advocacy and experience sharing meetings on nutrition with the aim of prioritizing budgetary allocation for nutrition interventions in the respective districts. Districts revived both District Nutrition Coordination Committees (DNCCs) and Sub County Nutrition Coordination Committees (SCNCCs) as avenues for ensuring nutrition interventions are planned for and implemented at district and sub county levels.

Regional Nutrition Advocacy events in Eastern and Central Uganda

To support the implementation of the National Nutrition Advocacy and Communication Strategy, the ABH project worked closely with the Nutrition Secretariat at Office of Prime Minister (OPM), to organize regional meetings on the implementation of District Nutrition Action Plans (DNAPs). The meetings were attended by a cross section of district and national leaders including members of parliament, RDCs, CAOs, DHOs and District Planners. From these meetings, district governments developed Nutrition Action Plans and formed part of performance indicators for Chief Administrative Officers and districts at large.

Right: Mr. Boaz Musiimenta from Office of Prime Minister opening the regional nutrition stakeholder meeting in Mbale, Eastern Uganda.

While opening the regional meeting in eastern Uganda, the Coordinator for Nutrition programming at the OPM, Boaz Musiimenta, emphasized diet diversification in eliminating malnutrition. He criticized the practice these days, saying the population is becoming too dependent on government to distribute food aid to them. He said, “when we bring you food, you will have eaten a road.” He thanked the ABH project for its efforts to support the OPM in rolling Page 36 of 59 out the Nutrition Advocacy and Communications Strategy (NACS), saying “We are glad to have Advocacy for Better Health on board as a partner to help implement this NACS, giving the right messages to the people.” He also emphasized the need to invest heavily in the first 1,000 days of life.

Formation, orientation and launch of the Parliamentary Forum on Nutrition (PFN)

In order to strengthen high level nutrition advocacy and legislation in Uganda, the project was at the forefront of the formation, orientation, and the launch of the Parliamentary Forum on Nutrition (PFN). The launch was presided over by The Rt. Hon. Speaker of Parliament (Rebecca Alitwala Kadaga) and The Rt. Hon. Prime Minister (Dr. Ruhakana Rugunda). Attendees included district leaders; members of parliament; government ministers; heads of ministries, departments, and agencies; CSOs; USAID; and implementing partners. Both the Rt. Hon. Speaker of Parliament and the Rt. Hon. Prime Minister pledged to ensure that nutrition interventions are prioritized and coordinated by the OPM.

The Speaker of Parliament, Rt. Hon. Rebecca Kadaga (left) and Rt. Hon. Prime Minister Dr. Ruhakana Rugunda (right) officially launch the Parliamentary Forum on Nutrition (PFN) in Mukono District.

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3.2.5 Other national level advocacy campaigns and engagements

3.2.5(i) Leveraging the 2016 presidential elections to advocate for increased health financing

The project coalesced with like-minded CSOs and steered the process of developing and launching the citizens’ health manifesto, which called upon candidates to prioritize increased financing for the health sector if elected into office. The launch was held on 15th September, 2015 and was well attended by CSO representatives, the media, and UN agencies. While presiding over the launch, Ms. Hanifah Kasule, on behalf of the WHO Uganda Country Representative, appreciated the role of CSOs in the timely and well calculated move to champion health concerns. She underscored the need for a stable and sustainable financing for health from domestic and international resources.

In addition to health financing, the manifesto called upon all candidates and all parties to prioritize other health concerns in their platforms. These include calls to improve human resources for health; end the HIV epidemic through universal access to treatment; stop violence against women, tackle maternal and newborn mortality; end malaria, TB, and emerging viral hepatitis; oppose discriminatory laws and policies, end theft of public resources in the health sector; address non communicable diseases; and WHO Representative, Hanifah Kasule (center) officially launches strengthen community the Civil Society Health Manifesto at UNASO offices in Kampala. engagement in health programing and accountability.

The launch of the manifesto was highly publicized in both electronic and print media, and copies were hand delivered to all political party offices at the national level. It is believed the President’s focus on health after winning the 2016 elections where he declared “Kisanja Hakuna Mchezo” [translated as term of office with no jokes] was largely informed by the citizen concerns well- articulated in the health manifesto. Since then, the President has also reinvigorated the fight Page 38 of 59 against HIV/AIDS where he launched the Presidential Fast-Track Initiatives to Eliminate HIV/AIDS as a public threat by 2030, which the project’s sub-grantee CSOs have been pursuing for full implementation in collaboration with Uganda AIDS Commission.

3.2.5(ii) Budget advocacy

As part of the activities preceding the passing and reading of the national budget (Fiscal Year 2015/16), the project and like-minded CSOs convened a series of breakfast meetings with the Parliamentary Committee on Health to discuss government funding for health (as was documented in the budget framework paper). CSOs asked the Parliamentary Committee on Health to prioritize issues such as wage bill enhancement for health workers, enhancement of primary health care at district level, and prioritization of basic non-monetary needs for health workers such as education, capacity building, and housing.

Representatives from PATH, ABH sub-grantees, and other CSOs meeting the Speaker of Parliament, Rebecca Kadaga (middle with scarf) at her office in Kampala over a number of issues including health sector budget.

The ABH project, in partnership with Engender Health, organized a breakfast meeting to raise MPs’ awareness about obstetric fistula and presented evidence about the need to increase budget for fistula management. The MPs committed to creating a separate budget for fistula by moving a motion on the floor of Parliament. To build momentum and support, an inter-ministerial meeting was recommended. The meeting would involve the Permanent Secretary of the Ministry of Health, the Minister of Finance, the Rt. Hon. Speaker of Parliament, and the Chairperson of the parliamentary forum on MCH, which will culminate into meeting his excellence the president. A small task force was formed to take the advocacy forward. The ABH project recommends Engender Health to continue pursuing this issue until tangible outcomes have been realized.

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3.2.5(iii) Establishing Parliamentary Forums and Joint Advocacy Platforms During the five years of project implementation, PATH and its sub-awardee partners established robust joint advocacy platforms and partnerships with USAID implementing partners, civil society actors, and the Parliament of Uganda (Parliamentary Forum on Nutrition, Parliamentary Caucus on TB, and Uganda Parliamentary Forum on Quality Health Service Delivery). These platforms were leveraged to push through certain policies that required timely response from different government actors. For instance, the project worked closely with the Office of the Prime Minister to fast-track review and passing of the Uganda National Action Plan (UNAP) II. The outcome of this engagement was the extension of UNAP I (2012-2016) by a few more years to enable the relevant bodies to ensure that the second UNAP was comprehensive enough to address all the issues related to food security and nutrition in the country.

Additionally, the PABH project supported and participated in the official launch of the Global Parliamentary TB Caucus (Uganda Chapter), at Hotel Africana in Kampala, where Ugandan legislators showed solidarity and commitment to support the End TB campaign. The Chief of Party for the Dr. Paddy Busulwa (with mic) of Uganda Stop TB Partnership speaking at the USAID Advocacy for launch of the Parliamentary TB Caucus in Kampala. Better Health, Moses Dombo, took part in the high-level panel discussion at the event. In response to calls from panelists for more funding to End TB, the Minister for Health who was the Chief Guest, Hon. Sarah Opendi, committed to utilize all avenues in cabinet to push for more funding for TB programs. “I will talk about this issue of TB funding in the cabinet budget meeting that I am headed for after this launch,” she pledged. Hon. Winfred Masiko (Woman MP for Rukungiri), then the Uganda Chapter Coordinator, championed the initiative with support from partners, including ABH. Her fellow caucus members pledged to create awareness on TB in their constituencies. TB remained a key priority issue on ABH’s advocacy agenda, with a critical focus on TB drug stocks, domestic financing, and HRH for TB prevention and treatment programs.

3.2.5(iv) HIV Drug Stock-out Campaign In late 2015, ABH convened indigenous CSOs to end stock-outs of antiretroviral and TB commodities through an advocacy campaign named “Drug Stock-out Kills! Stop it.” The stock-out of these essential drugs for people living with HIV had become a national crisis and donors expressed concern that government was not honoring its commitments of providing ARVs for 1.4 million people living with HIV. Through a series of advocacy engagements with the media, Ministries of Finance and Health, and the Parliament of Uganda, a short-term solution was reached

Page 40 of 59 where government negotiated with the Global Fund to frontload its budget for the following year to cover the crisis. Simultaneously, the Ministry of Finance was planning to acquire a loan from PTA bank to fill the funding gap that had caused the stock-out crisis.

This campaign was backed by efforts of 479 community groups across ABH’s 35 districts who continuously monitored health facilities using a standard assessment tool to detect any stock- outs of ARVs and report them upward through the National Forum of People Living with HIV Network in Uganda (NAFOPHANU), a national umbrella organization of people living with HIV and a sub-awardee of the project.

Also, as a result of the campaign, the National Medical Stores (NMS), which is responsible for the procurement and distribution of medicines in all public health facilities, committed to holding quarterly dialogues with CSO members to share information on the supply chain, since some of the causes of stock-outs hinged on gaps in the supply chain of medicines from national level to the last mile.

3.2.5(v) National Presidential Dialogue on the Quality of Health Services The ABH project and the Parliamentary Forum on Quality Health Services organized the First National Presidential Dialogue on Quality of Health Services in the country. The dialogue was attended by a number close to 400 participants, from CSOs, government, Ministries, Members of Parliament, donor agencies, USAID, and implementing partners. The Deputy US Ambassador to Uganda, Ms. Colette Marceline, three Ministers of State (Hon. Moriku Joyce Kaducu - Primary Health Care; Hon. David Karubanga - Public Service; and Hon. Jenipher Namuyangu - Local Government) were also in attendance. The project, on behalf of CSO partners, presented a position paper that highlighted critical areas that required action from government to improve the quality of health care in the country. These included:  Ensuring that essential health services are provided by lower level health facilities to decongest higher level health facilities. This requires leveraging community health workers to increase awareness on the importance of utilizing health services at different levels.  Increasing the annual primary health care fund allocation to Health Center IIIs and IVs to ensure that essential services are provided.  Providing guidelines for a health system-wide Continuous Quality Improvement approach implemented at each level of service delivery with supportive supervision from higher levels.  Enforcing quality of medical laboratory services, both in the public and private sector.  Reforming existing laws that govern and regulate private and public health facilities to eliminate unskilled health service providers.

Ms. Colette Marceline Charge de affaires/Deputy US Ambassador to Uganda in her remarks, said that, “Health is the greatest area of partnership between the US government and the Government of Uganda. We are proud of the work that has been ongoing to improve the health of people in Uganda.” The Rt. Hon. 1st Deputy Prime Minister, Gen. Moses Ali, represented H.E. the President of Uganda, who was intended to be the Chief Guest officially launching the presidential dialogue on quality of health services. In the speech, read by Gen. Ali, H.E. the President welcomed the effort of having the dialogue that was creating a platform to be able to discuss the challenges in the health sector. ABH and partners raised the following issues of concern:

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 Non-compliance of health sector Ministries, Departments, and Agencies (MDAs) to the National Development Plan II.  Limited financing for the health sector, including human resources for health and primary health care (PHC).  Delayed enactment of critical laws and policies, including The National Health Insurance Bill 2014.

First Deputy Premier, Gen. Moses Ali, who represented H.E. the President of Uganda, officially launching the annual presidential dialogue on quality of health services in at Colline Hotel, Mukono district.

The President’s speech emphasized that a healthy population is both an input and an outcome of social and economic development. He said that government was often aware of poor working conditions of health workers and he pledged to act to make improvements. He appealed to the advocates to continue working hand-in-hand with government and health care providers to improve service delivery to ensure quality care for all.

In his speech, His Excellency reiterated government’s commitment to address the health concerns in the country. He also urged citizens to exercise and eat well to prevent non- communicable diseases such as cancer and diabetes. The dialogue was meant to be an annual event to take stock of progress and challenges in Uganda’s health sector. Due in part to this high-level dialogue that put health high on the national agenda, the Ministry of Health enacted a policy to upgrade all HC IIs to level IIIs, ensuring that every sub county in the country at least has one HC III. This policy shift will undoubtedly see more infrastructure put in place including, maternity wards and accommodation for health workers to curb late reporting and absenteeism from duty.

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3.2.5(vi) Human Resources for Health Campaign ABH organized a successful HRH campaign that involved a series of upcountry media tours that covered six districts and national dialogue at Hotel Africana in Kampala. During the media tour, issues surrounding health worker recruitment, motivation, and retention were unearthed. Community members, health care workers, and leaders were interviewed on a range of issues. Emerging challenges included:  Staff accommodation remained a problem for most health facilities, whether rural or urban. This was found to be a serious contributing factor to health worker absenteeism, late reporting, and early departure from duty, and a big demotivator for staff.  Patient to health worker ratio was very high, especially for densely populated areas like Kisoro that have cross-border populations. This impacts on the quality of service delivery as few health workers must care for many patients without an opportunity to work in normal shifts.  New PHC grant guidelines dictated how the funds should be utilized yet the funds were not enough to cover the need. Health sub-district priorities were taking 82% and health facilities taking only 18%. For instance, majority of health facilities were having huge outstanding power and water bills (Kasana HCIV, Luwero district) that had debts of Ugx 22 million for power bills yet the percentage of PHC funds the facility was entitled could not offset the debt.  Large client populations overwhelm the available drug supply, causing stock-out of drugs and other health commodities.

With all the evidence that was collected from the media tour, a national dialogue was organized in Kampala that brought together stakeholders for a conversation on the HRH challenges hindering health service delivery. Notable among those in attendance were representatives from the Ministry of Health, Parliament, State House Health Monitoring Unit, WHO, Implementing Partners, CSOs and media. Dr. Vincent Oketcho from IntraHealth presented HRH facts in numbers. He pointed out that although there is an upward trend in staffing in the health sector (now at 71%) the progress is quickly being eroded by high rates of health worker absenteeism at 45%.

During the national dialogue, the Director General for Health Services at that time, Prof. Anthony Mbonye, revealed that the Ministry had already designed a strategy to address health sector gaps and the President had agreed to it. Dr. Diana Atwine who headed the Medicines and Health Service Delivery Monitoring Unit at State House (now the Permanent Secretary Ministry of Health) called for increased investment in prevention options to reduce the burden of disease that is draining The Permanent Secretary, Ministry of Health, Dr. Diana Atwine the country’s financial resources. (former head of State House medicines and health services She also expressed concern over delivery monitoring unit) addresses a national dialogue on HRH lack of accountability regarding in Kampala.

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HRH gaps in the health sector. She said: “civil society organizations need to come out clearly, we work together and see how we can improve parameters for measuring health worker performance.”

The Chiefs of Party of IntraHealth and ABH set the platform for dialogue by presenting evidence on the current staffing levels and key advocacy issues (including poor remuneration, absenteeism, and inadequate housing/accommodation) that require attention.

In his response, the Chief Guest (Prof. Anthony Mbonye who was representing the Hon. Minister of Health), pointed out that H.E. the President is prioritizing improving health services. He stated that this was driven by the public outcry for the need for improved health services, profiled by ABH and other stakeholders during the recently concluded elections. This would be attained by implementing the 23 guidelines that the President issued under his slogan dubbed, “Kisanja Hakuna Mchezo.” The key areas of focus for health under these guidelines were: improving infrastructure, addressing drug shortages, tackling absenteeism of health workers (especially due to dual employment), addressing lack of accommodation/houses for health workers, improving supervision especially within the Ministry of Local Government, and laying emphasis on disease prevention (given that 70% of diseases are preventable). Prof. Mbonye also informed the participants that the MoH had designed a strategy for implementing these issues on which they had consensus with the President.

A number of major recommendations were made during the dialogue. These included:

 Establishment of a wider forum that brings together the Ministries of Public Service, Local Government, Finance, Planning and Economic Development, and District Service Commissions to deliberate on the state of human resources for health and priority areas for improvement.  MoH should focus on implementing the six key issues from H.E. the President’s guidelines  MoH and MoLG should implement performance-based rewards, as a way of ensuring improved performance of health workers.  Continued advocacy to ensure HRH-related policies and strategies are implemented.

3.2.5(vii) Sing for Change Campaign ABH innovatively worked with a team of six local celebrity artists to produce songs that included messages on health advocacy, health education, systems strengthening, and citizen rights and responsibilities. The main purpose of the songs was to educate citizens on their rights and responsibilities (underscoring behavior change) through edutainment and to present advocacy asks to duty bearers through creative and innovative approaches. In total, 13 songs were composed and produced mainly in Luganda, some with parts in English, on seven thematic areas (HIV/AIDS, Family Planning, MCH, Nutrition, NCDs, TB, and general health). The songs were utilized in various national-level events such the First Presidential Dialogue on the Quality of Health Services in Uganda, the launch of the Mass Action Against Malaria, the National Family Planning Conference, and World Cancer Day. The songs have also received commendable air play—on local radio stations, in public places (e.g. buses), and at social functions—because of the messages in them and the celebrity status of the artists who were part of the campaign.

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State Minister for Housing, Dr. Chris Baryomunsi (with mic) launches the “Sing for Change” campaign at Kampala Serena Hotel.

Ever since the launch of the campaign, most of the songs have been shared on YouTube, where they have been viewed by close to half a million online viewers with corresponding positive commentary. Prior to the grand launch that took place at Kampala Serena Hotel and presided over by the former State Minister for Health. Dr. Chris Baryomunsi, who pledged to support the campaign that was spearheaded by local music icons. The methodology for disseminating the messages through music involved presenting a statement to the media at a press conference hosted by the artists, where they all voiced out their motivation to participating in such and advocacy campaign. The campaign received wide spread media attention and since then, the music has been circulated to the public on DVDs and to all sections of the media, specifically TV, radio and online platforms.

3.3 Sub R3: Institutional capacity of CSOs strengthened

This result area, led by Initiatives Inc., focused on strengthening institutional capacity of sub awardees with a focus on their management systems and advocacy capacity. The project focused its support on ensuring that sub awardees addressed the issues identified during Organizational and Advocacy Capacity Assessments (OACAs), developing clear policies and systems, understanding donor requirements, growing resources, and remaining competitive in order to attract more funding for sustained interventions. Detailed achievements registered under this result area are presented below: Key performance indicator: Number of CSOs with overall improvements in organizational capacity

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3.3(i) Organizational and Advocacy Capacity Assessments (OACA) During the implementation OACA comparative scores Y1, Y2 & Y3 period, the project 4.0 conducted 3.5 Organizational and 3.0 Advocacy Capacity 2.5 Assessments 2.0 (OACA) for 20 1.5 CSO grantees and 1.0 0.5 designed targeted 0.0 technical support in the 7 management areas of human resource, organizational Year 1 Year 2 Year 3 management, administration, finance, program, governance, and performance management. This process was aimed at strengthening the institutional capacity of CSOs to effectively manage and implement their advocacy interventions. TA supports included training in advocacy strategy development, resource mobilization, fixed amount awards, and understanding USG compliance requirements.

Key performance indicator: Number of CSOs with improvements on the advocacy component of the OACA 3.3(ii) Training of trainers in Advocacy strategy development: With technical assistance from PATH headquarters and Initiatives Inc., the project conducted a training of trainers (ToT) workshop for the ABH project staff. This training was guided by PATH’s ten-part advocacy development framework. Trained facilitators then conducted a workshop for

PATH Country Director, Dr. Emmanuel Mugisha (with mic) addresses ABH sub-grantee partners during one of the trainings in Kampala.

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21 sub-grantee CSOs on policy advocacy strategy development, as well as community mobilization and action planning. The purpose of this training was to increase the understanding and skills among participants to develop and implement policy advocacy strategies to bring about change. From this training, all the 21 CSOs developed advocacy strategies that were used to guide their advocacy initiatives and track progress.

3.3(iii) Policy Communication Training During the period, 10 project technical team members, and 7 Advocacy Officers from the sub awardees (HEPS, JIACOFE, CEHURD, ACODEV, NAFOPHANU, and RHU) participated in a five-day policy communication training that was jointly conducted by PATH and the USAID Policy Advocacy Communication Enhanced project, implemented by the Population Reference Bureau. The training was aimed at empowering the participants with the knowledge and skills in the utilization of well researched evidence for advocacy that would influence policy change or implementation. The training exposed the participants to how research can influence policy processes. They learned how to analyze research findings to get meaning out of them, package and present evidence, and effectively use media to communicate policy change.

3.3(iv) Training sub awardees in the use of QuickBooks accounting package The OACA processes had pointed out the lack of functional accounting packages in a number of partner organizations, mainly caused by inadequate skills to fully utilize the QuickBooks accounting package. The finance team facilitated orientation sessions for LADA, KADINGO, KACSOA, and MUCOBADI on essential QuickBooks functions for recording financial transactions and preparing reports. Basic forms and policies on travel, vehicle management, treasury, procurement, and workshops and meetings were discussed in addition to actual operationalization of basic internal controls and best practices for office financial operations.

The training exposed teams to hands-on skills in the use of QuickBooks by working in their system. They were able to demonstrate how entry of line items, project codes, and expense and payment approval requirements are performed and how reports and reconciliations are done among other uses. The training team referred to finance and operations manuals to ensure that the system is properly used for documenting policy. These partners were able to procure accounting packages which led to the improvement of financial management and compliance to donor requirements.

3.3(v) Governance training for board and senior management teams While reviewing partner governance structures, it was noted that some CSOs required support, particularly related to the selection of board members, board orientation, and management, including clarification of board roles and functions. The project supported nine CSO sub- grantees—Mbale Area Federation of Communities (MAFOC), HEPS, Integrated Development Options (IDO), Literacy Action Development Agency (LADA), ARUWE, KADINGO, RACOBAO, Kapchorwa Civil Society Organizations Alliance (KACSOA), JIACOFE, Community Integrated Development Initiative (CIDI), and ACODEV—to orient the board and management.

The trainings addressed the development of effective boards, clarified roles of board and senior managers, board selection, performance management, leadership succession planning, and role of policies in governance and management. From this support, CSOs constituted new boards, clarified roles of the board distinct from that of senior managers, and further developed board charters for continued guidance. One key lesson learned was that CSOs with clear governance

Page 47 of 59 boards and policies are more compliant to donor requirements and stand a better chance of increasing their resource base.

3.3(vi) Supporting CSOs to achieve Non-U.S. Organizations Pre-Award Survey (NUPAS) capacity As part of the core indicators in the project’s AMELP, ABH set out to strengthen the capacity of four CSOs to develop strong operational and compliance systems to be ready for direct funding from USAID. To achieve this target, six sub awardees were shortlisted for NUPAS and a consultant hired to assess their readiness to acquire and implement policy advocacy grants. The NUPAS assessment focused on six core areas. These included the organizations’ legal structure, financial management, human resource management, procurement, project performance management, and organizational sustainability. By the end of the project, three CSOs (JIACOFE, STF, and NAFOPHANU) had attained the required NUPAS score and the project is confident that the three can now be considered for funding from USAID to implement large scale policy advocacy projects.

3.3(vii) Training project staff and sub-grantees in financial management, USG compliance and Non-U.S. Organizations Pre-Award Survey (NUPAS) The project conducted training sessions on financial management, compliance with USG rules and regulations, and NUPAS requirements. The purpose of the training was to equip participants with the necessary guidance on the relevant USAID rules and regulations, particularly the new 2CRF200, ADS 303 guidelines, and fixed amount awards (FAA) regulations. The training also shared best practices in the areas of organizational setup and legal structure, financial management and internal control, procurement systems, human resource systems, project performance management, organizational sustainability, and provide orientation on the NUPAS process and tools. The training was facilitated by a consultant supported by the project team. The training was attended by all the sub-grantees spread in two regional workshops.

The participants appreciated the training for addressing specific concerns related to USG compliance and creating clarity on the agreement provisions. The project provided the tools and materials on the NUPAS and augmented the consultants during the sessions. Follow-up sessions were done through visits and online support, by sharing tools and reviewing draft policy documents. By the end of the project, CSOs demonstrated a better understanding of USG compliance requirements and this was evidenced by improved scores on compliance with USG requirements.

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Staff of ABH project and CSO sub-grantees after the training on financial management and compliance with USG rules and regulations in Kabale district

3.3(viii) Documenting the longitudinal case study Initiatives, Inc. led the documentation of a longitudinal case study that profiled six ABH partners and their progress in the three result areas of the project over the life of the project. The partners included HEPS, JIACOFE, MAFOC, KACSOA, ARUWE and NAFOPHANU. To support this documentation, a data base was developed to track data on the OACAs from year one to year four, document progress on the change strategies, and track percentage of planned activities completed on time and within budget. This was part of the processes that led to the final NUPAS that was done for 3 partners including JIACOFE, STF and NAFOPHANU.

3.3(ix) Strengthened CSO capacity for resource mobilization In an effort to support sub-grantee CSOs to remain sustainable, the project prioritized building their resource mobilization capacity. Some of the technical assistance included training in resource mobilization, supporting CSOs in developing resource mobilization strategies, policies, and guidance on how to write funding proposals and review draft proposals and concepts developed by these partners. These capacity development initiatives targeted both staff and governance structures and some of those partners that directly benefited from this initiative included: JIACOFE, STF, NAFOPHANU, HEPS, MAFOC, ARUWE, MUCOBADI, LADA, ACODEV, KADINGO, CEHURD and Family Life Education Program (FLEP) and KASCOA.

As a result of this demonstrated capacity, five CSO partners received additional funding from other donors:

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 MUCOBADI: Since they started working with ABH, they received funding up to US$1,900.000 from Goal Uganda, and the Bantwana project on Better Outcomes. The organization also acquired funding from URC to implement the USAID RHITES EC project.  JIACOFE received an award of US$120,747 from URC to implement the USAID RHITES EC project activities in Jinja district from December 1, 2017 to November 30, 2018, and US$15,115 for the period March 1, 2019 to September 30, 2019. The organization also received a merited proposal response for the PEPFAR community HIV/AIDS grant. From the assessments by prospective donors, JIACOFE systems were found to be strong, which contributed to the approval of these various grants.  FLEP received approval for a grant of US$80,000 from URC to implement USAID RHITES EC project from December 01, 2017 to November 30, 2018 in Kaliro district; funding for two years from Open Society Initiatives in East Africa of US$50,000 from December 01, 2016 to November 2018 to implement SHR activities in Kamuli, Iganga, and Luuka and from; Simavi to implement GUSO project in Jinja, Iganga, and Mayuge (Euros 87,950 for 2017, 139,830 for 2018, and 277,474 for 2019)  KADINGO was able to secure funding of SHS33,750,000 from Rakai Health Sciences Program for Family Community Linkages Activities for the period of July 2018 to March 2019.

3.3(x) Grants Management Collaborative (GMC) The project designed and implemented a Grants Management Collaborative (GMC) as an avenue for increasing opportunities for all the sub awardees to learn from each other and share their own experiences to improve the approaches they had planned to use in implementing their advocacy and community empowerment activities. Per the model, the collaboration had both expert sessions on key issues identified by the sub awardees and allowed for various approaches to promote sharing among sub awardees. The Plan, Do, Study, Act (PDSA) Cycle helped the sub awardees to think through the issues or challenges they were facing in their work, with improvement plans developed.

Outcomes included: KADINGO saw improvements in CSO participation in coalition meetings, while NAFOPHANU noted improvements in the timeliness of reports from community linkage facilitators, as a result of regular short phone message (SMS) reminders. MUCOBADI realized better response of duty bearers due to evidence gathering, packaging, and dissemination. IDO and Uganda Red Cross Society (URCS) realized improved community capacity to carry out advocacy initiatives without support from the CSO team, which was a true sign of sustainability of advocacy initiatives. JIACOFE was able to clearly track action plans that had been implemented by the community groups.

3.3(xi) Coaching and continuous mentorship of CSOs on change management During the course of the implementation period, many sub awardees underwent changes both at the organizational level and in implementing the ABH project. Although the sub awardees were able to manage these changes, they admitted to having inadequate knowledge and skills in change management. JIACOFE and MAFOC for example, became independent of their mother donor Child Fund after it developed a strategic plan with a new focus. As a result, sub awards were brought to an end prematurely and this abrupt change impacted these organizations. The project purposed to train CSOs on change management enabling them to manage changes without negatively affecting advocacy initiatives.

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3.3(xii) Strengthening NAFOPHANU district chapters to support achievement of the 90-90-90 HIV treatment targets

To popularize the UNAIDS 90-90-90 targets, the project supported NAFOPHANU and its district chapters in coordinating this initiative. NAFOPHANU was supported in developing a management handbook and performance standards that outlined expectations for the district chapters and strengthened its coordination role at national and district level.

The handbook outlined seven core sections, including: governance, financial management, and cross-cutting issues including gender, advocacy, monitoring, supervision, and reporting. NAFOPHANU currently has over 106 district chapters under its mandate. The key lesson was that a better coordinated HIV fraternity would promote improved mobilization of PLHIV, disseminate evidence collected on issues that affect PLHIV, promote collective voices for advocacy through joint advocacy, and get duty bearers to address key issues that affect PLHIV. Through this effort, ABH was recognized as a key contributor in the popularization of the 90-90- 90 goals across the 35 districts and national level.

4.0 Responsiveness to the CDCS 2.0 (2017-2021) development objectives

4.1 Implementation of PEPFAR COP 17&18 priorities and alignment with the CDCS Guiding Principles The project in its 4th and 5th year of implementation emphasized PEPFAR COP 17 and 18 priorities. These include socialization of the 90-90-90 HIV treatment targets, roll-out of the Differentiated Service Delivery Model, Test and Start policy, and greater engagement with key/priority populations. The project provided sub-awards to five CSOs (NAFOPHANU, ICWEA, KADINGO, STF, and CDFU) to execute these PEPFAR priority activities. The CSOs were carefully selected because of their niche in championing advocacy around HIV/AIDS-related issues. The CSOs ensured there was mobilization of key/priority populations such as men who have sex with men (MSM), commercial sex workers (CSW), long distance truckers, fisher folk, among others to discuss issues that affected delivery of quality services and ensuring the relevant duty bearers are engaged in solutions.

The project ensured its advocacy activities were in alignment with development objectives under the 2017-2021 Country development Cooperation Strategy (CDCS) specifically DO3 which talks about “key systems more accountable and responsive to Uganda’s development needs.” The project also ensured that its activities were resonating well with the guiding principles as elaborated below.

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4.1.1 Inclusive Development Right from the start, the project proposed to make all its citizen empowerment and advocacy engagements all-inclusive, targeting the most marginalized groups in the population. These included women, youth and key/priority populations. During selection of community groups to work with, women and youth were given priority. In the latter years of the project, key/priority population groups were given a special focus as part of implementation of PEPFAR COP priorities. For example, in 2017, ABH partnered with community groups and young people in central Uganda (Luwero, Nakasongola, Mityana, Mpigi, Sembabule, and Kayunga districts) to stimulate and catalyze discussions on the forms and consequences of gender- based violence (GBV) in commemoration of the 16 Days of Activism Against GBV that run under the theme, “Free Uganda’s Adolescent Girls and Women from Gender- Based Violence.”

Working with the Straight Talk Foundation and White Ribbon Alliance as sub awardees, the project involved youth in A youth displaying a key message on GBV at a commemorative event championing advocacy on in Luwero district. the need to address teenage pregnancy and early marriage. This was done through eliciting the participation and views from the youth on how to mitigate these vices.

ABH collaborated with and supported the Alliance of Women Advocating for Change to convene two consecutive meetings in 2017 and 2018 of the Annual National Sex Worker’s Update Meeting. The meeting was attended by over 100 participants from 25 districts, including representatives from grassroots sex work-led groups from urban and peri-urban communities from across the six regions in Uganda. Others in attendance were members from likeminded CSOs, representatives from Ministry of Health, researchers, academia and development partners. The two meetings focused on creating platforms for sharing experiences, strengthening joint collaborations between implementing partners and rural and peri-urban based grassroots sex workers, and harnessing their opportunities for effective involvement in the fight against HIV/AIDS toward the achievement of the 90-90-90 goals. The first meeting focused on the consolidated HIV prevention treatment and care guidelines.

The project also conducted an orientation of representatives of key and priority populations (KPPs) from twenty sub-counties in Bugiri and Busia district on the PEPFAR priorities spelled out in the COP 18. Groups included those for people living with HIV (PLHIV) and other KPPs like

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Commercial Sex Workers (CSW), boda boda riders, and truck drivers, men who have sex with men (MSM) and fisher folks. Participants were educated on tracking and documenting evidence on commodity stocks and health worker availability at health facilities and to empower them to be in position to amplify their voices as active agents of change for better health services in their respective communities.

At the national and regional level, ABH worked hand-in-hand with the national level organizations of key/priority populations to organize national and regional level meetings with a specific objective to collate issues that affect key/priority populations’ access to HIV services. This information was used to engage duty bearers and service providers on the need to provide non- stigmatizing and discriminative services, policies, and laws for key/priority populations. More than 100 representatives of key/priority populations from national to regional level networks participated in these meetings.

4.1.2 Learning and adaptation 4..1.2(i) Grant Management Collaborative The project implemented innovations that enhanced learning and adaptation such as the Grant Management Collaborative (GMC) that brought together sub-awardee civil society partners to learn and share with each other on what’s working or not. This was a quality improvement approach that the sub awardees used to develop change strategies that focused on improving the quality of results in advocacy and community empowerment. ABH project staff participated in a number of meetings, conferences, and communities of practice such as one organized by RHITES- E activity, whose core objective was to understand and appreciate the project’s SURGE strategies, status of implementation, achievements versus targets and challenges. See 3.3 above for more details.

4..1.2(ii) Regional Stakeholder Meetings The project convened three Regional Stakeholders’ meetings for district leaders and technocrats to talk about the quality of health services in the respective districts and develop action. The key participants included; District Chairpersons, Resident District Commissioners (RDCs), Chief Administrative Officer (CAOs), District Health Officers (DHOs), District Community Development Officers (DCDOs), District Planners, and representative of ABH Community Champions. Project staff also participated in a high-level regional stakeholders meeting for the South Western Region attended by key district leaders, other implementing partners, representatives from academic institutions, religious leaders and a team from the Mission. The meeting focused on key issues affecting service delivery in the region and the need to start to plan and advocate as a region and not just a district.

4..1.2(iii) Regional Consortium of Advocates on Access to Treatment (CAAT) Meetings ABH in partnership with NAFOPHANU held three regionally-based CAAT meetings as part of building on efforts to continue sharing HIV and TB service delivery concerns through engagements with duty bearers and other key stakeholders at the regional and district levels. In attendance were district PLHIV coordinators, DHOs, or their representatives, selected CAOs, district TB focal persons, and district HIV/AIDS focal persons.

4..1.2(iv) District leaders exchange learning visit Based on the government sanctioned district performance league table of 2017/18, it was found that Butaleja district was one of the poorest performing districts in critical health and social

Page 53 of 59 service indicators. After attending People’s Parliament in Butaleja that discussed high teenage pregnancy rates in the district, district leaders requested ABH support them in a visit to any of the well performing districts to learn some of the strategies used and best practices in addressing teenage pregnancy. The same problem was affecting the neighboring districts of Namutumba and Pallisa. ABH then organized a combined exchange visit for the district leaders of Butaleja, Namutumba, and Pallisa to Bushenyi, Ntungamo, and Kabale. The choice for the three districts to be visited was based on the same district league table that put Bushenyi and Kabale in the top ten districts and Ntungamo under the most improved districts. In addition, Bushenyi had greatly built community resilience, hence poverty reduction among citizens. The leaders who participated in the exchange learning visit (included RDCs, CAOs, LCV chairpersons, district planners and district councilors) have since created their own action platforms to pursue recommendations from the visit. For instance, in Butaleja district, the leaders have already initiated the process of developing a district ordinance to eliminate child marriages and teenage pregnancy.

4..1.2(v) District-based advocacy forums As part of learning and adaptation in the course of project implementation, the project also adopted the approach of conducting district-based advocacy forums, instead of at the sub-county level. This approach was found to be very effective and efficient because it reduced the frequency and cost of holding these forums at the sub-county level. Each group had an opportunity to package their issues and present them to district decision-makers who were always difficult to bring down to sub-counties. Besides, most of the issues identified by the groups at health facilities needed resources to be addressed and the district level leadership had a higher mandate in determining how and when these resources could be allocated. The majority of the district leaders appreciated the approach and have committed to continue supporting and giving a listening ear to the groups, whenever they present to them service delivery-related issues from the lower health facilities.

4.1.3 Collaboration and stakeholder engagement ABH in year four was involved in a number of partnership, collaboration, and stakeholder engagements. These included:  Working with its sub awardee ICWEA, to coordinate Ugandan CSO input into the PEPFAR COP 18 process.  Partnering with the multi-stakeholder platform member organizations under the Uganda multi-stakeholder nutrition partners’ advocacy and communication platform, to organize a series of sustained consultative and dialogue meetings especially with the OPM to generate discussions on the need to hold the second National Nutrition Forum (NNF).  Coalescing with a number of organizations that were coordinated by the Office of the Prime Minister, to organize the 2nd National Nutrition Forum. To support the event, ABH funded the Newspaper supplements for the pre and post National Nutrition Forum.  Supporting and collaborating with its sub-awardees in central region – CIDI, Luwero District Local Government and five other sub-grantees [UNASO, ARUWE, JIACOFE, MAFOC, and KADINGO] to commemorate the 2017 World AIDS Day under the global theme, “The Right to Health”, and Uganda’s specific theme being; “Reaching men, girls and young women to reduce new HIV infection.”  Partnering with district local governments and the USAID-Regional Health Integration to Enhance Services in Eastern Uganda (RHITES-E) and RHITES South West (SW) activities, to implement three sessions of People’s Parliament, a popular debate platform for citizens to air out their views on issues of concern with the quality of health and other social services. The Page 54 of 59

six sessions happened in the districts of Pallisa, Butaleja, Bududa, Nakasongola, Ntungamo, and Kisoro focused on Teenage Pregnancy, MCH, HIV/AIDS and Gender-Based Violence (GBV).  In partnership with sub-awardees CIDI, RACOBAO, ARUWE and District Local Governments, commemorating the 16 days of activism against GBV in Luwero, Nakasongola, Mityana, Mpigi, Sembabule and Kayunga districts.  Partnering with the USAID Strengthening Human Resources for Health (SHRH) project to convene a follow-on National Stakeholders Dialogue on the Absorption of PEPFAR Funded Staff.  District and sub county-based advocacy forums remained a major platform for collaboration and stakeholder engagement, bringing together citizens, community-based organizations, political and civil servants at various levels, USAID Implementing Partners, media, health workers, and members of health unit management committees to engage on issues that affect quality health delivery.  Through its sub-awardees, NAFOPHANU, ICWEA and KADINGO, the project also held a series of engagements with members of PLHIV networks regarding socialization of the DSDM, the test and start policy and 90-90-90 treatments targets. Other network members had an opportunity to learn about the management handbook that is streamlining operations and coordination efforts of all organizations that subscribe to the umbrella organization, NAFOPHANU.

4.1.4 Leadership development In year four, the project ran a successful one-year internship and fellowship program, which was part of its capacity building component. The program aimed at increasing skills among young university graduates (interns) and Master’s degree level graduates or experienced individuals (fellows) with a passion to improve their leadership skills and abilities especially in advocacy, organization development, and public health. The purpose of the fellowship and internship scheme was to develop and build local capacity for policy advocacy and through this increase the availability of skilled individuals to bring policy advocacy at scale. The project enrolled 10 fellows and 10 interns and placed them at PATH offices, regional offices, and with the CSO partners. PATH signed MOUs with receiving CSO partners and worked closely with the CSO partner to ensure that the fellows and interns based at the partner offices, received appropriate support, supervision, and “What I learned from this experience was that if you really work terms that enabled on the job want something, then you have to get out of your way to get learning over the period of the it. I had to sacrifice my comfort to get what I wanted – my internship/fellowship. The fellowship career. And I think part of the reason I was later given a job and internship followed a curriculum was because I went and worked hard.” Edith Christine designed with modules for the fellows Kemigisa, former Intern with ABH project.

Page 55 of 59 that covered classroom modules, online courses, and practical assignments. Fellows were assigned supervisors from their host institution and mentors from the ABH project.

5.0 Lessons Learnt

5.1 You can’t hit the ground running without firm footing underneath.

Build for sustainability—a strong foundation is not built overnight. The success of ABH relied on identifying and capacitating the right partners, as well as establishing a reputation in districts as a trusted partner. This required district entry meetings, community group mapping, action planning training, and skills building for CSOs—all of which took time. The first year of the project also expanded CSO focus on behavior change communication (BCC), which was much more familiar, to also strategically engaging in policy advocacy, especially at the sub-national level. Some key decision-makers—especially at district and community/facility level—pushed back completely. For instance, in Kyenjojo district, the DHO emphasized to the CSO partner working there that the district does not need any advocacy because the health department was doing well. Some health workers were hostile to community group members who would go to health facilities to obtain information from them on service delivery gaps, as evidence to present to their duty bearers. This in a way slowed down the progress the project would have made, if the perception of the project by these key people was positive and favorable from the start. The lesson here is that the pressures to achieve “quick wins” must be balanced with the need for thoughtful startup.

Use evidence wisely to differentiate advocacy from activism and political opposition. Initially, some project stakeholders were anxious that the government would perceive advocacy interventions as combative and accuse the project of stirring political opposition, especially because ABH focused on government inefficiencies, lack of transparency and accountability, and poor political will. There is a time and place for activism, but that was not the goal of this project. Throughout the project, but especially at the start, the team needed to explain clearly how advocacy approaches were important for achieving participatory outcomes in partnership with the government—rather than in opposition to it. Instead of using accusatory tones and jumping to conclusions based upon single examples, the project captured and presented meaningful evidence, and emphasized approaches rooted in dialogue, and problem solving. ABH became a trusted partner that could effectively hold cross-sectoral dialogues and meaningfully engage civil society, health workers, and policymakers at all levels.

Set clear expectations with stakeholders; ensure they see the returns beyond financial. There were high expectations from the community members and decisions makers involved in any advocacy activity. This mentality stemmed from previous service delivery projects where communities, health workers and local leaders were used to receiving payment in any project activity they would participate it, yet this project was not designed in the same way. It was important to ensure community members and decision makers saw the impact of the work they were doing in order to invest time and resources.

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5.2 Advocacy and citizen engagement as core pillar of health system strengthening

Programs should approach communities as advocates and change-makers, not just beneficiaries. Advocacy for Better Health is far from the first project to mobilize communities. But rather than mobilizing them to access a health service or change a behavior, ABH mobilized them to know their rights and responsibilities, self-identify necessary changes in health services, create action plans, gather evidence, and reach decision-makers. By mobilizing communities as advocates, they realized they had the power to change the health system. In some districts, a positive but unintended consequence was improved health seeking behavior, as people became confident that health facilities would deliver what they need.

Community groups are well-suited to integrate advocacy for health into their existing agendas. The project identified 479 existing community groups across 35 districts, each with different goals and objectives—from mother’s groups, to environmental associations, youth clubs, self-help groups for people living with HIV, and savings and credit cooperatives. After training and continuous support from ABH partners, the groups demonstrated capacity and willingness to embrace advocacy and integrate activities into their existing work. By the time the project ended, many groups indicated they would continue identifying gaps in service delivery and engaging their leaders to address them.

Focus on key themes that cut across health areas, to maintain an effective lens. Rather than focus on health issue areas alone (e.g. HIV/TB, RMNCAH, and malaria), the project strategically selected cross-cutting themes (human resources, resource mobilization, commodity security) to drive system-wide change. This enabled ABH to engage in advocacy holistically and gave the project convening power to host dialogues focused on quality and availability of health services more broadly. Through community mobilization, social accountability, and policy advocacy, Advocacy for Better Health was able to improve human resources for health, increase domestic financing, and reduce stockouts of lifesaving medicines.

Investing in advocacy can unlock domestic resources for health. Since 2014, the project has had marked success in influencing government budget allocation to the health sector. Advocates were able to avert a 30 percent cut to the health budget and compelled the MOH to be more proactive in prioritizing and ring-fencing money for PHC, MNCH, HIV/AIDS and TB. As a result of advocacy and community demand, districts have also started prioritizing health-related interventions in their annual budget allocations. This is a key lesson for donors: rather than rely solely on direct funds for health services, investing in advocacy can unlock a country’s own resources for health

5.3 Combining policy advocacy and social accountability approaches achieves both quick wins and longer-term results.

It is no surprise that changing policies and budgets, whether at district or national level, can often take a long time. The project and its sub-grantee CSOs had to sustain policy advocacy engagements for months or years, often changing tactics or approach. This was mainly because the advocacy asks required structured decision-making, involved different players and sometimes budgets had to be allocated in line with the government’s fiscal years. Social accountability approaches, on the other hand, focused on ensuring the government met

Page 57 of 59 commitments made through policies and budgets already in place. By zeroing in on decision- makers with the power to affect immediate change, results were quick.

Partnerships with media can catalyze action and responsiveness from duty-bearers. In addition to raising awareness and mobilizing communities, the media is a powerful force for holding duty-bearers accountable and compelling them to take swift action. ABH engaged journalists to profile major challenges affecting the health sector, resulting in decisions by national and district leaders to renovate or expand health facilities, deliver critical medicines to avert stockouts, or deploy more health workers to facilities with acute shortages. When the project began, many government officials were skeptical of the media and feared that they would be antagonistic. But as media champions gathered evidence, decision-makers often recognized that they could better serve their communities with this information.

5.4 Operational learnings  Being an advocacy project which, by its nature has variable timelines, milestones and evolving asks outside the control of the project, it was quite difficult to apply to it the Fixed Amount Award type of funding mechanism. Sometimes, the CSO partners would get tied up with milestones in their workplan which they could not implement because some duty bearers had not responded as expected or other factors in the environment caused variations of time and cost.

 The project experienced some funding fluctuations during implementation. These in turn affected the sub-granting tractor with several CSO sub-agreements being cut short or terminated completely. For instance, the project was able to complete with only 5 CSOs out of the 22 it initially was sub-granting to. Additionally, the project did not conduct end line evaluation for same reasons.

6.0 Recommendations for sustainability

• USAID implementing partners need to absorb the trained community groups to support their programs and have a platform to continue with citizen-led advocacy. • There were a number of project approaches and models that other USAID IPs could adopt and integrate in their programming such as institutional capacity strengthening, Grant Management Collaborative (GMCs), advocacy forums, and government participatory planning processes, and the annual presidential dialogue on health care. • Based on the successes that were realized in the 35 districts where the project operated, the same project model should be scale up to cover other districts in the country so that they equally benefit. This can be done by way of integrating citizen-led advocacy into all service delivery programs to address systemic barriers that affect the supply side of health services.

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7.0 Appreciation

PATH would like to take this opportunity to thank USAID for the financial and technical support that enabled implementation of the 5 year ABH project. Additionally, we would like to thank all our partners, both at the international and local level who took part in the implementations of the project. The government of Uganda especially Ministries of Health, local government and other line ministries that were very instrumental in the success of the project. The AAG that provided the much needed advice to the project as well all the community groups and community members at large who contributed to the success of the ABH project. We thank you all, and we look forward to a continued relationship and support as we work to improve health of those in most need.

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