USAID’s Maternal and Child Survival Program (MCSP)

Uganda - Routine Immunization (RI) Program

Quarterly Report January 1 to March 31, 2017

MCSP pre-visit to District to sensitize district leadership on the REC-QI approach.

USAID/ Quarterly Progress Report (Quarter 2 of Program Year 3)

Project Name: USAID’s Maternal and Child Survival Program (MCSP) Routine Immunization (RI) Program

Reporting Period: January 1 to March 31, 2017

Obligation Funding Amount: $829,924 (Field Support)

Project Duration: July 2014 – December 2018

Program Year (PY3): October 1, 2016 to September 30, 2017

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

Project Objectives:

1. Strengthen UNEPI’s institutional/technical capacity to plan, coordinate, manage, and implement immunization activities at national level.

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

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Acronym List ADs Auto-Disable Syringes CAO Chief Administrative Officer CBET Competence-Based Education and Training DPT Diphtheria, Pertussis and Tetanus DHMT District Health Management Team DTO District Technical Officer EC East Central EPI Expanded Program on Immunization EPCMD Ending Preventable Child and Maternal Deaths Gavi Gavi, The Vaccine Alliance Gavi PEF GAVI Partnership Engagement Framework HF Health Facility HSD Health Sub-District HPAC Health Policy Advisory Committee HQ Headquarters HRH Human Resources for Health ICHC Institutionalization of Community Health Practices Conference IIP Immunization in Practice IRB Institutional Review Board JSI John Snow Inc. MACIS Malaria and Childhood Illnesses NGO Network Secretariat MCH Maternal and Child Health MCHIP Maternal and Child Health Integrated Program MCSP Maternal and Child Survival Program MEL Monitoring, Evaluation and Learning MMEL Measurement, Monitoring, Evaluation and Learning MNCH Maternal, Newborn, Child Health MOH Ministry of Health NMS National Medical Store OPL Operational Level PDSA Plan-Do-Study-Act cycles PHC Primary Health Care PY Program Year QI Quality Improvement QRM Quarterly Review Meetings QWITs Quality Work Improvement Teams REC-QI Reaching Every Community using Quality Improvement techniques RED Reaching Every District RI Routine Immunization SAS Senior Assistant Secretary SW South West SS4RI Stronger Systems for Routine Immunization TWG Technical Working Group UNEPI Uganda National Expanded Programme on Immunization UNICEF United Nations Children’s Fund USAID United States Agency for International Development USG United States Government VHT Village Health Team WHO World Health Organization

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Introduction

The Maternal and Child Survival Program (MCSP) is a global U.S. Agency for International Development (USAID) cooperative agreement to introduce and support high-impact health interventions in 25 priority countries with the ultimate goal of ending preventable child and maternal deaths (EPCMD) within a generation. In Uganda, MCSP is working with the Ministry of Health (MOH) and the Uganda National Expanded Programme on Immunization (UNEPI) at national level to operationalize the Reaching Every Child/Community using Quality Improvement Approach (REC-QI) in ten districts. REC- QI focuses on district and health facility management processes and applies methods from the field of quality improvement (QI) to help increase coverage and reach every child with immunization services that are effective, safe, responsive to community needs and sustainable.

MCSP Uganda continues work started by USAID’s predecessor project, Maternal and Child Health Integrated Program (MCHIP) and is implemented side-by-side with the Bill & Melinda Gates Foundation’s Stronger Systems for Routine Immunization (SS4RI) Project in 10 additional districts. REC-QI is one of the seven priority “innovations” that MCSP is introducing and studying as part of its global innovations and learning agenda.

The REC-QI implementation process (shown in Figure 1 below) entails: 1) introducing the approach to the district and health facilities (Orient); 2) implementing REC-QI and determining its contributions to the routine immunization system (Establish and Strengthen); and, 3) adding it into the routine operations and plans of districts and health facilities (Sustain). REC-QI implementation from start to finish takes approximately 24 months in each district. Depending on which stage of REC-QI implementation a district is in, it receives differing amounts and kinds of support from MCSP (Figure 1). In general, MCSP supports the training of district managers, health workers and village health teams (VHTs) in immunization, microplanning, EPI management, and the use of key REC-QI tools. The program also trains supervisors in supportive supervision, and supports quarterly review meetings (QRMs) that are led by district health management teams (DHMTs). QRMs are the platform for health facility staff, DHMTs and district and sub-county political, religious and civic leaders to jointly reflect on the performance of routine immunization and other maternal and child health (MCH) services and to develop action plans to address challenges.

Figure 1: REC-QI steps, inputs and timeline.

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I. Summary of PY3 Quarter 2 Achievements

During this reporting period, MCSP continued its efforts to strengthen the capacity of UNEPI and focus on promoting REC-QI practices in the districts, health sub-districts (HSD) and health facilities. MCSP phased out its support to the two PY1 (e.g., support initiated during PY1, October 2014 to September 2015) districts of Kanungu and Butaleja after 22 months of support. MCSP continued to provide support to the four PY2 districts of , Mitooma, and . Additionally, MCSP initiated support to four PY3 districts of Mbarara, Bushenyi (South West region), Mayuge (East Central region) and (Eastern region). Step one, “Orient”, was completed in the four PY3 districts, with the exception of a five-day REC-QI training to prepare the districts for Step two, “Establish and Strengthen”, which is planned for April 2017. The REC-QI approach encourages frontline health workers to “think outside the box” while addressing their RI challenges. For example, thinking of how to tap community, local government and private partners’ resources in the district instead of only relying on primary health care (PHC) grants from central government.

Technical input to key national and global meetings MCSP attended and provided technical input to several important global and national level meetings, including the UNEPI EPI Technical Working Group (TWG), Inception Meeting for Immunization Financing Sustainability organized by MOH and partners, Gavi teleconference meetings, New RED Guide and Equity guide adaptation workshop, USAID’s Chief of Party & Communications meetings, Eastern and Southern Africa (ESA) EPI Manager’s Meeting held in Uganda from March 20-22, 2017, Institutionalizing Community Health Conference (ICHC) held in South Africa from March 27-30, 2017, and a WHO regional workshop to facilitate modification of the Home-Based Child Health Records for Immunisation. These meetings provided opportunities for MCSP to coordinate with other in-country and international partners and key players in immunization, share implementation experiences and results of MCSP’s work, and contribute to national and global knowledge in RED/REC and immunization in general.

MCSP continued to support the EPI Newspaper Pull Out publication on district EPI performance that provides feedback to stakeholders and stimulates debate/attention to RI, and contributed to the mapping of the geographical distribution of EPI partners’ support to facilitate donor coordination, universal coverage and enhancement of synergies.

Immediately after the ESA EPI Manager’s Meeting in Uganda, JSI held a one day meeting on March 23, 2017 that was dedicated to REC-QI work in Uganda with the aim of sharing lessons learnt for scale up within immunization and other health interventions. The meeting was attended by 38 participants, including 5 representatives from USAID (e.g., USAID/Washington, Africa Bureau, Uganda, and Mozambique), 2 senior staff from the Bill & Melinda Gates Foundation, the UNEPI Program Manager (PM) and Deputy PM, plus JSI immunization staff from eight countries.

REC-QI “Sustain” step completed in two PY1 districts (Kanungu and Butaleja) MCSP conducted sustainability forum meetings, which is the last activity in the REC-QI timeline of activities, in both PY1 districts. During these meetings, results of REC-QI implementation were compared to baseline and a sustainability plan was developed. Notable results included an increase in the proportion of health facilities with completed REC microplans from 6% (baseline June 2015) to 67% (assessment conducted in October 2016), and a reduction in the Pentavalent (DPT1-3) dropout rates from 6.4% to 2.6% and from 21% to 14% for Kanungu and Butaleja districts, respectively. To close the remaining gaps and ensure sustainability of these improvements in RI service delivery, an action plan was jointly developed by MCSP and district health leadership with action points focusing on strengthening

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cold chain maintenance, community mobilisation for RI services, and strengthening recording of children vaccinated in the MOH Child Register.

Four PY2 districts in the “Establish and Strengthen” step (Ntungamo, Mitooma, Kibuku and Bulambuli) In the four PY2 districts, MCSP conducted Operational Level (OPL) trainings on immunisation practices for 156 health workers (111 female, 45 male) from the district, HSD and health facilities. The trainings equipped district, HSD and health facility managers with knowledge and skills to plan, deliver, monitor and evaluate quality immunisation services.

Four PY3 districts selected and “Orient” step completed (Mbarara, Bushenyi, Pallisa and Mayuge) MCSP selected and then conducted pre-visits to sensitize district leadership on the REC-QI approach in the four PY3 districts of Mbarara and Bushenyi in South West (SW) region, Mayuge in East Central (EC) region, and Pallisa in Eastern Region. In February 2017, baseline data was collected from 222 health facilities; results from the analysis will be shared with the districts during subsequent QRMs or other REC-QI activities.

Table 1: Steps of REC-QI implementation in MCSP-supported districts by program year/quarter/month (April 2015 to March 2017).

District 2015 2016 2017

# Apr-June Jul-Sep Oct-Dec Jan-Mar Apr-June July-Sept Oct-Dec Jan-Mar

A M J J A S O N D J F M A M J J A S O N D J F M

PY1 Districts 1 Kanungu 2 Butaleja PY2 Districts 3 Ntungamo 4 Mitooma 5 Kibuku 6 Bulambuli PY3 Districts 7 Mbarara 8 Bushenyi 9 Serere 10 Mayuge

KEY: Orient Establish Sustain

II. Description of Activities for the Quarter

Objective 1: Strengthen UNEPI’s institutional/technical capacity to plan, coordinate, manage, and implement immunization activities at national level.

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MCSP attended and provided technical input in three national EPI meetings (one EPI Annual Workplanning Workshop on February 7, one EPI TWG on February 17, and one RED Guide Adaptation Workshop on March 27) where the REC-QI practices and updates on uptake were shared with partners to make them aware of the successes and challenges associated with implementing REC-QI and encourage scale up of REC-QI to districts where MCSP is not operating. Additionally, MCSP actively participated in the Inception Meeting for Immunization Financing Sustainability organized by MOH and partners. A technical brief to communicate obstacles to REC that are beyond the direct control of MCSP and leadership was shared with the UNEPI PM for action. No response has been received yet, but MCSP will follow up in the next quarter.

MCSP supported the EPI Newspaper Pull Out publication on immunization in the national leading daily newspaper, the New Vision, that covered EPI performance for the 2016 calendar year, assessing the RI performance of each district using the RED categorization. The Pull Out provides feedback to all EPI stakeholders including district leaders (technical, political and administrative) on how their districts/regions are rated. Based on the district performance reported in the Pull Out, some district leaders have put in place measures designed to improve their RI performance in subsequent quarters. The UNEPI PM reported receiving telephone calls from several districts over their reported performance. MCSP also contributed to the mapping of the geographical distribution of EPI partners’ support to facilitate improved coordination among partners, universal coverage and enhancement of synergies.

MCSP attended and actively contributed to the ESA EPI Manager’s Meeting that was organized by WHO in , Uganda from March 20-22, 2017. JSI (MCSP lead implementing organization in Uganda) used the opportunity to hold a one-day side meeting, immediately following the EPI Managers Meeting, which was used as a platform to share experiences and lessons learnt from implementing REC-QI. This REC-QI side meeting was attended by 38 participants including JSI technical staff from headquarters and eight countries (Uganda, Tanzania, Malawi, Zimbabwe, Madagascar, Kenya, Ethiopia and South Sudan), as well as USAID staff from Washington, Africa Bureau, Uganda, and Mozambique, and 2 senior staff from the Bill & Melinda Gates Foundation. In addition to MCSP/Uganda and SS4RI staff, the UNEPI PM and Deputy PM also participated and presented. One highlight of the meeting was a panel of MOH district health workers sharing their personal experiences implementing REC-QI, demonstrating how it has facilitated and empowered them in managing RI services. The meeting also provided an opportunity for all participants to share their experiences with implementing the different components of RED/REC.

Additionally, MCSP played a leading role in preparing the Uganda country delegation for the ICHC that took place in Johannesburg, South Africa from March 27-30, 2017. The outcome of that meeting was a Ugandan country road map to finalize and implement the Community Health System Policy and Strategy with a focus on Community Health Extension Workers (CHEW) that will strengthen the work of VHTs. MCSP is a member of the National Coordination Committee to finalize Uganda’s Community Health System Policy and Strategy.

Lastly, MCSP participated in a regional workshop organised by WHO/AFRO and held in Kampala to support four countries, including Uganda, in modifying their Home-Based Records (HBR) for immunisation. For Uganda, a prototype of the Child Health Card was drafted jointly with the MOH and is currently undergoing further review and modification. The revised Child Health card is intended to link with the mother-child passport, be user-friendly for caretakers, and provide enough room for the addition of new vaccines without requiring further revision.

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

a) PY1 Districts (Kanungu and Butaleja) MCSP conducted sustainability forum meetings, which are the last activities in the REC-QI approach in a given district. Progress on district capacity strengthening to manage RI from baseline to date was shared, discussed and action plans jointly developed to ensure sustainability of the lessons learned. Action plans also targeted bridging RI gaps, especially: strengthening cold chain maintenance, community mobilisation and data management practices, and maintaining the engagement/involvement of non-health stakeholders such as the Chief Administrative Officer (CAO), Chairperson LCV, and Resident District Commissioner to address management gaps.

b) PY2 Districts (Bulambuli, Mitooma, Kibuku and Ntungamo) From the baseline analysis conducted previously, health workers in most districts have never had OPL training, and the last such training is reported to have been over five years ago. MOH requested MCSP to support development of OPL training materials from the revised Immunization in Practice (IIP) manual based on a Competence-Based Education and Training (CBET) approach. MCSP conducted OPL trainings in the four PY2 districts reaching 156 health workers (111 female, 45 male). The trainings employed the CBET, as opposed to theory-based training, and were used to pre-test and refine OPL training materials developed from the MOH revised IIP. The training therefore, focused on providing essential theory and stressed skills/competencies needed by the trainees to manage and deliver quality RI services. Below is a table showing health workers trained by district.

Table 2: Number of health workers trained in PY2 districts. District No. of health workers Female Male trained Bulambuli 40 29 11 Kibuku 33 26 7 Mitooma 35 25 10 Ntungamo 48 31 17 Total 156 111 45

QRMs were conducted in Bulambuli district starting with HSD meetings (79 participants - 55 male, 24 female) that fed into the DHMT review meeting with 17 participants (12 male, 5 female). Individual health facility, HSD and district performance in a quarter was reviewed by the DHMT together with health facility in-charges, EPI focal persons, and political, civic and religious leaders. A number of resolutions with the goal of improving RI coverage in the district were reached, including: minimising staff transfer within the financial year to reduce disruptions in services and ensure continuity, ensuring that Quality Work Improvement Teams (QWITs) are conducted every month at health facility level, and enacting by-laws to counter the efforts of cults that discourage people in communities from accessing services, promote more engagement of qualified health workers in RI in order to improve the quality of service delivery, and minimise recording gaps especially in the Child Register.

c) PY3 Districts (Mbarara, Bushenyi, Mayuge and Pallisa) MCSP initiated its support to four new districts through the following activities: - Pre-visits: MCSP was introduced to the districts as an EPI partner supporting the strengthening of RI services, and the districts reflected on the current status of RI service delivery in their respective districts. MCSP and the district health leadership

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jointly developed an action plan of key activities to be implemented that was guided by the key REC-QI activities detailed in Figure 1 above. - Baseline data collection: Baseline data was collected by Malaria and Childhood Illness NGO Network Secretariat (MACIS), a secretariat of civil society organizations that has expertise in conducting surveys, and was subcontracted by MCSP to collect data on a routine basis from the MCSP-supported districts to establish a bench mark for future monitoring of program progress. The tables and figures below summarize the total number of units from where baseline data was collected, and the key findings.

Table 3: Number of units visited during baseline data collection, Feb 2017 District No. of HFs assessed No. of HSD Offices No. of District Offices Mbarara 85 3 1 Bushenyi 47 3 1 Pallisa 34 2 1 Mayuge 56 2 1 Total 222 10 4

Figure 2: Percentage of health facilities implementing key REC-QI practices prior to MCSP intervention at baseline – February 2017 (Functional QWITs were defined as those that met at least once in the past 3 months)

100%

90%

80%

70%

60% 48% 50% 38% 37% 40% 32% 29% 30% 23% 20% 18% 20% 14% 11% 6% 6% 10% 3% 5% 4% 3% 0% 1% 0% 0% 0% Micro-plans Micro-mapps Functional QWITs PDSAs

Mbarara Bushenyi Pallisa Mayuge Overall

Mbarara district reported the highest presence of REC-QI practices, except for the functional QWITs, while Pallisa reported the lowest among the four PY3 districts. The most prominent practice in place across the districts was micro-maps which were found in 37% of all health facilities, followed by micro-plans which were found in 20% of all health facilities. Functional QWITs and PDSAs were found in 5% and 3% of all health facilities, respectively.

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- REC-QI orientation and planning workshops: Orientation workshops to plan for REC-QI implementation were conducted in Bushenyi and Pallisa districts in January 2017. District staff were mentored in identifying and assigning catchment populations to health facilities, analysing district performance using the WHO RED categorisation tool, conducting root cause analysis of identified challenges using the fishbone, and developing change ideas and action plans to guide improvement. On-the-job training through routine supportive supervision visits was scheduled to further support lower level health facilities in development of REC micro-plans.

Table 4: Number of participants who attended the workshops on planning for REC- QI implementation, Jan to Mar 2017.

District No. of participants trained Female Male Bushenyi 103 52 51 Pallisa 129 82 47 Total 232 134 98

Of the 103 participants in , 58 were health workers, while 45 were non-health workers. In , of the 129 participants, 57 were health workers, while 72 were non-health workers. The non-health stakeholders included Sub-county Chairpersons, Sub-county Senior Assistant Secretary (SAS) / Town Clerks, District Councillors, CAOs, Chairpersons Local Council V, and Resident District Commissioners. The non-health stakeholders are important because of their role in managing funds needed for cold chain, vaccine distribution, payment of outreach allowances, and mobilization of communities to create demand.

III. Challenges, Solutions and Actions Taken

Actions taken to address the Results of actions Challenges faced during the quarter challenges taken

National Level Competing priorities for Conducted joint planning sessions Improved MOH/UNEPI, which delay the and harmonized work plans to suit harmonization of completion of MCSP activities that the availability of the MOH/UNEPI activity timelines. 1 require their participation (e.g. the management team or work with Meningitis A campaign) MOH regional support supervisors.

Presence of challenges related to Planned technical briefings of the TBD leadership, infrastructure, human MOH/UNEPI PM and presentations resources for health (HRH), delayed in the EPI TWG, so that these kinds release of PHC funds, etc. in of challenges can be flagged for 2 supported districts which is further discussion in the Health negatively affecting RI, yet these are Policy Advisory Committee (HPAC). beyond the mandate of MCSP and the capacity of the districts to address. District Level 1 Through the analysis of baseline data MCSP to engage district leadership TBD

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Actions taken to address the Results of actions Challenges faced during the quarter challenges taken and modified exchange (e.g., other partners, health, political, visits/experience sharing meetings, civic and opinion) to preside over three top management bottlenecks and seek solutions for these district were found cross-cutting in the management challenges. majority of health facilities, which negatively affect program performance: 1) payment of outreach allowances for health workers and VHTs 2) allocated budget for vaccine distribution and cold chain repair/maintenance 3) VHT/leaders’ participation in community mobilisation. It is hypothesized that addressing these management bottlenecks, coupled with REC-QI implementation, would improve RI coverage rates.

IV. Lessons, Best Practices and Recommendations

1. The non-health stakeholders are instrumental to mobilizing and maintaining support for RI and should be fully engaged to enable them to play a complementary role in strengthening RI services. The non-health stakeholders control budgets and have a comparative advantage in the area of social mobilization for EPI. Therefore, MCSP needs to build their capacity to understand RI and recognize its importance. MCSP regularly updates them on the status of RI in their districts, presenting the challenges beyond health that they are in a unique position to address. In the districts where MCSP has established a relationship with these non-health stakeholders, they are willing to address some of the key management challenges mentioned above; however, they need adequate information and EPI performance reports. 2. The REC-QI timeline of activities was under-estimated at 13-20 months because it did not take into account other national and district competing priorities. The revised REC-QI timeline, which is really a reallocation of time lost to these unforeseen competing priorities, is 20-24 months at no additional cost to the program. 3. MCSP should prepare occasional briefs for the MOH/UNEPI PM and TWG highlighting challenges in the districts that need to be escalated to HPAC level for discussion and action. These briefs should focus on management challenges that districts cannot address themselves, such as recruitment of district senior managers, streamlining of vaccine distribution from the national medical stores, and establishment of health facilities in sub- counties that are lacking them.

V. Success Story

None developed this quarter.

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VI. Management Issues

As more districts get enrolled on REC-QI support, and with the new realization that REC-QI implementation requires 20-24 months, MCSP District Technical Officers (DTOs) are increasingly fatigued from being on the road for the majority of every month. MCSP in collaboration with SS4RI, have co-funded the hiring of a new DTO to support both program teams with REC-QI implementation and to alleviate some of the travel burden on the current DTOs to prevent “burn out”. Additionally, MCSP and SS4RI have co-funded hiring of a new Knowledge Management (KM) Advisor to support documentation of lessons learnt from REC-QI implementation across both programs.

With the inception of the MCSP Uganda Child Health program, MCSP/SS4RI has restructured the Finance & Administration (F&A) team to be led by a Finance & Administration Director (FAD), with support from 2 Finance & Administration Managers (FAMs) and one Finance & Administration Officer (FAO). The team was restructured to increase efficiency and better leverage skills and capacity across both MCSP programs (Child Health and RI) and SS4RI.

To minimize instances when MCSP staff carry large sums of funds to the field to support district level implementation, MCSP has introduced a mobile money system of payment to district vendors and training participants. This revision to MCSP/JSI’s operational procedures was intended to mitigate risk to both MCSP/JSI and its staff.

Additionally, Disha Ali, MCSP MMEL Advisor, travelled to Uganda March 4-18, 2017 to: facilitate MCSP RI staff through discussions and a participatory process to develop a program learning strategy that takes into consideration the program data being routinely collected and the two learning studies; support in-country plans and processes to enable launch of the two RI learning studies; finalize specifications for a web-based database to manage and analyze program data; and conduct a one-day field visit to project sites.

Lastly, Kate Onyejekwe, MCSP Country Support Manager, travelled to Uganda March 8-18, 2017 to: meet with USAID, UNEPI and other local partners to discuss current program activities, successes, challenges and future plans focusing on progress of MCSP RI PY3 workplan activities; participate in programmatic discussions with key stakeholders and MCSP staff on the RI program learning strategy and two learning studies; conduct a one-day field visit to project sites; provide headquarters oversight for the work of the MCSP Uganda program; and provide senior management support to HR and administration systems as needed.

VII. Monitoring and Evaluation

The MCSP Monitoring, Evaluation and Learning (MEL) team in-country and the Measurement, Monitoring, Evaluation and Learning (MMEL) Advisor from HQ reviewed the data collection systems for all indicators, discussed the data collection tools and mapped the tools (question by question) with different indicators that are being used regularly to show program performance. This exercise resulted in development of a matrix clearly laying out the utility of different data collection forms, data sources and frequency of data collection. The matrix has provided a much needed vision of and justification for different variables in the data collection tools and the importance of the variables for learning activities.

With support from an HMIS Advisor at JSI’s home office, MCSP initiated development of an internal, online, DHIS2-based, program data management system. The current data management system of entering data into a Microsoft Access database is not user-friendly and offers limited access to program data beyond the in-country MEL team. The new web-based system will function as a data repository and

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will be accessible to technical and management staff outside the MEL team both in-country and at HQ. Development of the system is now underway and expected to be completed with all the data collection forms reconciled in the system by the end of next quarter.

The preliminary report of the Uganda Demographic and Health Survey (UDHS) 2016 has just come out. According to the UDHS, 79% of children aged 12-23 months received the recommended three doses of DPT.

Program Learning Question 1: What are the tangible results of the REC-QI approach and the principle enablers/drivers of change along the REC-QI continuum from “Orient” to “Sustain”? The protocol was approved by USAID and preparations are underway for international and local IRB review, and contracting of the Principal Investigator/Consultant to support the assessment locally.

Program Learning Question 2: What are the enablers and inhibitors of uptake and sustainability of REC-QI practices in ? The protocol for this assessment was reviewed by the local IRB at Mulago Hospital that shared feedback with MCSP to be addressed prior to resubmission. The process of international IRB in the United States by Johns Hopkins University / JSI was initiated and awaits the final version of the protocol to be resubmitted to the local IRB.

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VIII. Summary of Quarterly Results

The following table shows the compiled MCSP Uganda RI performance indicators for data available from the six districts where MCSP implemented in Quarter 2. As noted above, MCSP completed REC-QI orientation workshops and baseline data collection in the four PY3 districts, but was not yet actively implementing REC-QI in these districts during the reporting period.

No. Indicators Location Quarterly Quarterly Achievement Target Numerator Denominator Percentage Comments (Percentage) (%) 1 Number of deaths in Countrywide 64 deaths Per 1,000 live Source: UDHS 2016

the under five births

children per 1000

live births (context) 2 DTP3 coverage in Countrywide Indicator reported annually. children less than 12 months of age Source: DHIS2 and UBOS Census 2014 (nationwide) Projections for the target population 3 DPT3 coverage in Districts Indicator reported annually. children less than 12 months of age by Source: DHIS2 and UBOS Census 2014 district Projections for the target population Number of children PY1 districts Reporting rates for Kanungu and 4 who at 12 months Kanungu 90% 2,769 2,962 93%% Butaleja are 100%. have received three Butaleja 90% 2,747 2,868 96% doses of DPT/Penta Total 90% 5,516 5,830 95% vaccination from a PY2 districts Reporting rates for Ntungamo, USG- supported Ntungamo 90% 4,460 5,684 99% Mitooma, Kibuku and Bulambuli are immunization Mitooma 90% 1,632 2,155 76% 99%, 100%, 100% and 100%, program. (Standard respectively. 3.1.6 – 61) Kibuku 90% 2,219 2,373 94%% Bulambuli 90% 1,247 2,050 61% Bulambuli’s performance remains low Total 90% 9,558 12,262 78% largely due to the few health facilities in the district as reported last quarter.

Mitooma district continues to face challenges of leadership commitment that affect service delivery. 5 % of planned RI PY1 districts No new data collected for this sessions that were Kanungu 91% N/A N/A N/A indicator during the quarter. Data for No. Indicators Location Quarterly Quarterly Achievement Target Numerator Denominator Percentage Comments (Percentage) (%) conducted in the Butaleja 91% N/A N/A N/A this indicator is collected every 6 year (IP custom) Total 91% N/A N/A N/A months. PY2 districts Ntungamo 91% N/A N/A N/A Mitooma 91% N/A N/A N/A

Kibuku 91% N/A N/A N/A

Bulambuli 91% N/A N/A N/A

Total 91% N/A N/A N/A 6 # of national level National No target set for this indicator for this guidelines, manuals, quarter. and tools in which REC-QI concepts are Finalization of the IIP Manual was incorporated (IP delayed to enable inclusion of equity custom) and integration of services. Both areas have been included, and the IIP Manual is awaiting MOH endorsement before printing.

MCSP was asked by UNEPI to lead the Secretariat in updating OPL training materials from the revised IIP Manual, based on CBET. Draft tools are being pre-tested through OPL training in MCSP- supported districts. 7 Number of people PY1 districts MCSP support to PY1 districts was trained in child Kanungu 100% N/A completed and transitioned to the health and nutrition Butaleja 100% N/A districts. through USG- Total 100% N/A supported programs PY2 districts (IP custom) Ntungamo No target 48 These were activities that were Mitooma No target 35 delayed from the previous quarter Kibuku No target 33 but had not been included in the Bulambuli No target 40 quarterly workplan, and therefore, no Total No target 156 target was set for this quarter. PY3 districts Bushenyi 100% 103 237 43% The trainings were conducted in Pallisa 100% 129 147 88% Bushenyi and Pallisa to plan for REC- Mbarara 100% 0 334 0% QI implementation. Trainings such as

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No. Indicators Location Quarterly Quarterly Achievement Target Numerator Denominator Percentage Comments (Percentage) (%) Mayuge 100% 0 287 0% OPL, REC-QI tools and planning for Total 100% 232 1,005 23% REC-QI implementation for some districts were not conducted due to competing priorities and plans set out by the districts. 8 % MoH / UNEPI National 100% 1 3 33% UNEPI only held one TWG to discuss TWG coordination RI this quarter. Three TWG meetings meetings held are expected per quarter (e.g., one where Routine each month). Immunization was discussed in a year (IP custom) 9 % of planned PY1 districts Some districts did not conduct QRMs quarterly Kanungu 100% 0 3 0% as planned due to funding review/coordination Butaleja 100% 1 1 100% constraints. meetings held Total 100% 1 4 25% where routine PY2 districts immunization was Ntungamo 100% 1 4 25% discussed in a Mitooma 100% 0 1 0% district per year (IP custom) Kibuku 100% 1 1 100% Bulambuli 100% 0 1 0% 100% 7 29% Total 2 10 % of planned PY1 districts Some districts did not conduct integrated Kanungu 100% 1 3 33% supportive supervision visits as supportive planned due to funding constraints. Butaleja 100% 1 1 100% supervision visits Total 100% 2 4 50% conducted in a district in a year (IP PY2 districts custom) Ntungamo 100% 1 4 25% Mitooma 100% 0 1 0% Kibuku 100% 1 1 100% Bulambuli 100% 1 1 100% Total 100% 3 7 43% 11 % of health facilities PY1 districts No new data collected for this with complete REC Kanungu 40% N/A N/A N/A indicator during the quarter. Data for micro-plans (IP Butaleja 40% N/A N/A N/A this indicator is collected every 6

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No. Indicators Location Quarterly Quarterly Achievement Target Numerator Denominator Percentage Comments (Percentage) (%) custom) Total 40% N/A N/A N/A months. PY2 districts Ntungamo 40% N/A N/A N/A Mitooma 40% N/A N/A N/A Kibuku 40% N/A N/A N/A Bulambuli 40% N/A N/A N/A

Total 40% N/A N/A N/A

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IX. PY3 Quarter 3 Planned Activities

The following are the activities planned for next quarter, April to June 2017:

National Level Activities • Finalization of technical brief on challenges outside MCSP’s mandate that are affecting RI in MCSP-supported districts, and share with MOH for action • Attend EPI-related TWG Meetings • Plan an information-sharing meeting with key immunization partners to describe the tools and methods from REC-QI and how they help operationalize the MOH’s REC strategy, discussing options for coordination and collaboration. • Train tutors in prototype curriculum using the revised IIP Manual and CBET

PY 1 Districts (Kanungu and Butaleja) • Potentially provide technical assistance, if requested by the district, to strengthen sustainability

PY2 Districts (Mitooma, Bulambuli, Kibuku and Ntungamo) • Conduct supportive supervision visits and QRMs in PY2 districts as part of the “Establish and Strengthen” step

PY3 Districts (Mbarara, Bushenyi, Serere and Mayuge) • Support OPL trainings • Plan for implementation of REC-QI in Mbarara and • Training of district and health facility staff on selected EPI tools (e.g. health facility REC microplanning tools, Child Register, RI monitoring charts) • Orient VHTs

Monitoring, Evaluation and Learning • Collect, enter and analyse REC-QI monitoring data from MOH/UNEPI, district health offices and HSD headquarters across all the 10 supported districts (e.g., PY1, PY2 and PY3 districts) • Compile quarterly progress report • Share findings from the data collected from PY2 districts with the DHMT and other district and national level stakeholders, during other REC-QI activities e.g. QRMs, workshops for planning for REC-QI implementation, etc. • Develop and begin operationalising a web-enabled database to track REC-QI performance • Initiate IRB review and contract consultant for the program learning assessment on Tangible results of the REC-QI approach and the principle enablers/drivers of change along the REC-QI continuum from “orient” to “sustain” • Revise and resubmit the protocol to the local Ugandan IRB for the program learning study on Enablers and inhibitors of uptake and sustainability of REC-QI practices in Kapchorwa District based on local IRB feedback, and complete international IRB.

Program Management • Hold regular meetings between the USAID/Kampala Activity Manager and MCSP staff to update him on progress and solicit guidance as needed

Annex A: EMMR Quarterly Update

List each Mitigation List of any Measure from outstanding issues Status of Mitigation Measure Remarks Column 3 in the relating to required EMMP Mitigation conditions Plan Utilization of auto- Vaccinators were trained in vaccine MCSP only gives disable syringes and and immunization logistics technical needles for all management, including ordering from assistance to immunization the health sub-district vaccine management of activities. store/district vaccine store that auto- disable includes bundling of auto-disable syringes (ADs), syringes (ADs) with vaccines to ensure does not procure available stock of vaccines doses at the nor distribute health facility at any time have equal them to districts number of ADs, stock management and health and the use of only ADs for facilities (this is immunization. responsibility of the National Medical Store (NMS)).

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

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

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List each Mitigation List of any Measure from outstanding issues Status of Mitigation Measure Remarks Column 3 in the relating to required EMMP Mitigation conditions Plan Put in place a system MCSP Uganda builds local capacity to Overall, MCSP to identify expired ensure systems are in place to identify Uganda aims to vaccines and expired vaccines and remove them discuss consumables, remove from the cold storage (EPI fridges) at environmental them from shelves, health facilities and drugs for district impact place them in well retrieval and disposal, locked storage as part of labeled boxes, and place for filled safety boxes exist are technical forward them to communicated and monitored in assistance, incineration / disposal project trainings, quality improvement training and points. activities, and supportive supervision other materials. visits conducted. Identification of expired drugs and their removal from drug stores for disposal. Training, quality improvement activities, and supportive supervision Before final disposal are geared towards building local of filled safety boxes, capacity to properly use incinerators, they should be stored where they exist and the ‘burn and in a secure place that bury’ method recommended by is inaccessible to MOH/UNEPI is known and practiced people and animals. at health facilities where incinerators do not exist. Construction of incinerators to be used for burning of safety boxes and other wastes.

Fencing of the MCSP Uganda works to ensure that disposal sites. mercury thermometers are destroyed and fridge tags are disposed of Ministry of health Where incinerators according to WHO protocols. /UNEPI now uses are unavailable, use alcohol burn and bury thermometers methods in areas with for its EPI fridges limited access that is and other cold adequately protected storage from ground equipment as contamination. clarified by UNEPI. Mercury thermometers will be

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List each Mitigation List of any Measure from outstanding issues Status of Mitigation Measure Remarks Column 3 in the relating to required EMMP Mitigation conditions Plan disposed of in a safe place where the mercury will not contaminate the ground water. They should not be burned in open spaces where the fumes will destroy the environment.

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

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

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Annex B: Photo Gallery

MOH/UNEPI officer moderating a session during REC-QI planning in Bushenyi District.

Health facility teams presenting their PDSAs in Bushenyi District.

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District Biostatistician presenting the RED categorisation tool in Bushenyi District.

Trainees in small group demonstration during the OPL training in .

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Facilitators engaged in a facilitators’ meeting during the OPL training in Ntungamo District.

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