USAID’s Maternal and Child Survival Program (MCSP)

Annual Report

October 1, 2015 to September 30, 2016

Top: District Supervisor working together with MCSP District technical officer during an Integrated Supportive Supervision Session with staff at Nyakinoni HC II in – February 9, 2016

Bottom Left: MCSP staff facilitating a REC-QI planning session in –May 31, 2016

USAID/Uganda Annual Progress Report (Program Year 2)

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

Reporting Period: October 1, 2015 1 to September 30, 2016

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

Project Duration: July 2014 - September 2019

Program year (PY2): October 1, 2015 to September 30, 2016

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

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.

Acronym List

ACAO Assistant Chief Administrative Officer ADHO Assistant District Health Officer CAO Chief Administrative Officer COP Chief of Party CSO Civil Society Organizations DHMT District Health Management Team DHT District Health Team DTO District Technical Officer EPI Expanded Program on Immunization Gavi Gavi, the Vaccine Alliance HC Health Centre HF Health Facility HP &E Health Promotion and Education HSD Health Sub-District IIP Immunization in Practice IP Implementing Partners JSI John Snow Inc. MACIS Malaria and Childhood Illnesses NGO Network Secretariat MCHIP Maternal and Child Health Integrated Program ME&L Monitoring, Evaluation and Learning Advisor MOH Ministry of Health NTD National Technical Director OPL Operational Level OPV Oral Polio Vaccine IPV Inactivated Polio Vaccine PDSA Plan-Do-Study-Act cycles PHC Primary Health Care QI Quality Improvement QITs Quality Improvement Teams QRM Quarterly Review Meetings QWITs Quality Work Improvement Teams REC-QI Reaching Every Community using Quality Improvement techniques RI Routine Immunization SS Supportive Supervision SS4RI Stronger Systems for Routine Immunization UNEPI Uganda National Expanded Programme on Immunization UNICEF United Nations Children’s Fund USAID United States Agency for International Development VHT Village Health Team WHO World Health Organization

Definition of Key terms used in report

Micro-map – List of villages assigned to RI service delivery points (static & outreaches) in the HF catchment area

Micro-plan – Appropriately filled set of 12 REC tools used for planning and management of RI services as recommended by Ministry of Health / UNEPI

RI Program – Health facility program for RI services at static and outreaches within its catchment area that describes the place, day of the month, time, responsible HF staff and VHT with their contact information.

RI Schedule – A standard MOH description of RI antigens/vaccines, age of the child when given, frequency/number of doses, site and route of administration

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 24 priority countries with the ultimate goal of ending preventable child and maternal deaths (EPCMD) within a generation. MCSP carries forward the momentum and lessons learned from USAID’s Maternal and Child Health Integrated Program (MCHIP), which made significant progress in improving the health of women and children in over 50 developing countries throughout Africa, Asia, Latin America and the Caribbean from 2008-2014. MCSP engages governments, policymakers, private sector leaders, health care providers, civil society, faith-based organizations and communities in adopting and accelerating proven approaches to address the major causes of maternal, newborn and child mortality and improve the quality of health services from household to hospital. MCSP also tackles these issues through cross- cutting approaches that focus on health systems strengthening, household and community mobilization, equity, gender, eHealth, and others.

In PY2, MCSP continued its efforts in Uganda to strengthen the capacity of the Uganda National Expanded Programme on Immunisation (UNEPI); phased out support in (the last of the reamining MCHIP districts) and expanded REC-QI implementation in the two districts of Kanungu and Butaleja. MCSP also began to provide support to four additional districts: Ntungamo, Mitooma, and Kibuku. MCSP promoted REC-QI practices in the districts, health districts and health facilities, including: data analysis and use, quarterly review meetings, integrated supportive supervision visits, mapping of health facility catchment areas, micro-planning, community engagement, quality work improvement teams and testing changes in plan-do-study-act (PDSA) cycles.

Summary of PY2 Achievements

MCSP/Uganda supports immunization system strengthening at both the national and district levels. Immunization achievements during Program Year 2 (PY2) of MCSP implementation in Uganda are summarized as follows:

National level achievements In April 2016, MCSP provided technical assistance to the Ministry of Health to introduce and roll out Inactivated Polio Vaccine (IPV) and promote the switch from tOPV (trivalent OPV) to bOPV (bivalent OPV) in the districts. This also provided opportunity for teams to strengthen the technical capacity of health workers across all the 6 MCSP supported districts in management of the switch from tOPV to bOPV and administering IPV. Aspects covered included; vaccine storage and management, records management, micro-planning as recommended by MoH UNEPI, benefits of IPV, community mobilisation, data analysis and use, all of which are critical for delivery of quality RI services.

MCSP supported MoH-UNEPI to finalise the pull-out section on Uganda’s immunization performance in the New Vision, Uganda’s leading newspaper in April and July 2016, included information on RI performance for all districts in Uganda and upcoming EPI activities e.g. new vaccine introduction for sensitisation of the districts and the public. This newspaper pull-out is one of the MOH’s means of providing feedback on EPI performance to the districts and non-traditional stakeholders e.g. the president, government ministers, members of Parliament, district leaders (political and civic) and cultural leaders for action. A case to mention, in Ntungamo, the district chairperson arranged a meeting for the District Health Team (DHT), Health Sub District (HSDs), Health Facility in-charges, Chief Administrative Officer (CAO), Assistant Chief Administrative Officer (ACAO) and Sub-county leaders to discuss the poor performance of the district shown in the newspaper pull-out and drew a plan of action to improve RI performance (revealed by the Assistant District Health Officer for MCH/ Ntungamo during the MCSP pre-visit meeting May 5, 2016).

MCSP provided technical assistance to UNEPI during the process of preparing its application to Gavi for health system strengthening support. One of the REC-QI key processes i.e Microplanning supported by mapping of health facility (HF) catchment areas tool for more accurate target populations was incorporated for scale up into the whole country to facilitate HF micro planning for the Reaching Every Community (REC) approach.

MCSP completed its “REC-QI How-to-Guide” and is printing and distributing among national and district level stakeholders. The “How-to-Guide” details a step-by-step process for implementing REC- QI in most settings. MCSP is providing technical assistance to MOH (UNEPI and the Health Promotion & Education division of MOH) in the review of the EPI communication strategy 2016-2020. This platform may provide an opportunity to include REC-QI approach processes. MCSP staff attended two Diarrhoea, Pneumonia Coordination Committee (DPCC) meetings of MOH, two TWG meetings (one for EPI and another for Quality Assurance) to ensure harmonization of REC-QI implementation with Government policy guidelines. MCSP participated in a workshop to review draft regulations and provided technical guidance on establishment of a government Immunization Fund in Uganda. The Polio End game activities, including SIAs, IPV introduction, and the tOPV to bOPV switch, occupied UNEPI and districts causing near stoppage of MCSP planned activities for one month of the third quarter, hence delays in implementation.

District level achievements

PY 1 Districts (Kanungu and Butaleja) Out of the three steps of the REC-QI implementation i.e. “Orient”, “Establish and Strengthen”, and “Sustain”, MCSP completed all scheduled activities in the first and second steps in the two PY1 districts (Kanungu and Butaleja) except the Operational Level Trainings (OPL) trainings for immunisation planned for PY3, due to delays in national level activities in PY2. OPL is a training conducted for EPI managers and service providers at District, Health sub district and health facility levels to equip them with knowledge and skills in planning, delivering, monitoring and evaluating quality immunisation services.

MCSP provided two rounds of support to quarterly review meetings in the two districts at the HSD and district levels. This provided a platform for the District Health Management Teams together with district and Sub-county political, religious and civil leaders to jointly reflect on performance in RI and other MCH service areas and develop strategies for improvement. During these meetings, participants discussed strategies for sustaining the quarterly review meetings after MCSP support ends. Ideas proposed included: prioritizing the meetings for funding by the Primary Health Care (PHC) funds and including the cost of participation of political leaders in the existing budget for sub-county meetings.

MCSP also trained up to 2,057 health facility staff and Village Health Team (VHT) members (1,182 and 875 in Kanungu and Butaleja districts respectively). These are expected to support Health Facilities to jointly plan with their communities to reach every child with RI services. This involved; identification and allocation of villages to service delivery points (micro-mapping), registration of children in their catchment areas and defaulter tracing. MCSP also supported health workers and VHTs to review micro-plans to accommodate any emerging needs for reaching all communities with RI services. This is shown by the percentage of health facilities with completed REC micro-plans for the financial year July 2015 to June 2016 increased from 6% in June 2015 to 44% in October 2015 and eventually to 70% in April 2016.

A total of 95 and 30 supervisors from Kanungu and Butaleja districts respectively were trained in a selected set of REC-QI tools and approaches namely; Health Facility REC microplanning, micro- mappoing, the WHO RED categorization tool, RI monitoring charts, Quality Work Improvement Teams (QWITs), and Plan Do Study Act (PDSA) cycles. The supervisors left with increased awareness and stringer knowledge in using these tools. These supervisors later provided on-site mentorship to staff across all the health facilities in their districts of operation. This is shown by the proportion of health facilities implementing REC-QI practices (i.e. had complete micro-plan and were practicing QI – working on a PDSA or had a QWIT that had met at least once in the past 3 months) increased from 1.5% in June 2015 to 18% in October 2015 and eventually to 57% in April 2016 respectively

MCSP provided technical assistance to a team of 30 district supervisors; 18 and 12 from Kanungu and Butaleja districts respectively. The aim was to strengthen their knowledge and skills in conducting supportive supervision. During this support activity, up to 74 health facilities (50 and 24 in Kanungu and Butaleja districts respectively) providing RI services were visited by the district supervision teams backstopped by the MCSP technical teams. Emphasis was directed towards addressing RI and REC-QI issues. However, support was integrated to include issues related to other service delivery areas e.g. Maternal and Child Health in general and malaria among others. In PY3, MCSP will be implementing an MNCH project in the Eastern Region and will use successful strategies from immunization, like REC.

PY 2 Districts (Ntungamo, Mitooma, Kibuku and Bulambuli)

In April/May 2016, MCSP enrolled the four districts of Ntungamo and Mitooma (in South West region), and Kibuku and Bulambuli (in Eastern region) on REC-QI support. The districts accepted to partner with MCSP to implement REC-QI, signed Note for Record documents, and developed the initial plans for REC-QI implementation. MCSP also trained district EPI stakeholders (including leaders and health workers) in the REC micro-planning process recommended by the MoH UNEPI. A total of 287 (181 females, 106 males) health workers, political, religious and civil leaders were trained in REC micro- planning, distributed as follows- 80, 50, 48 and 109 for Bulambuli, Kibuku, Mitooma and Ntungamo respectively.

A total of 212 district supervisors (101 female and 111 male) were further re-oriented to boost their knowledge and skills in the key tools used in the REC-QI approach. The numbers of participants trained, by district, are as follows: Bulambuli–50, Kibuku–38, Mitooma–47 and Ntungamo–77. Tools focused on during these trainings included, among others: monitoring charts, HF REC micro-planning tools, PDSA cycles, child registers, and tally sheets for data collection and reporting. The district supervisors are expected to mentor lower level health facility staff in use of these tools to improve RI management.

MCSP also conducted VHT orientation workshops reaching out to 6,050 VHT members (1,744 male, 4,306 female). VHTs trained by district were as follows: Bulambuli - 2,546, Kibuku – 480, Mitooma - 1,063 and Ntungamo - 1,961. This activity supported the micro-mapping process and the VHTs are expected to facilitate linkages to RI services within communities in the districts. See attached success story for more details on community linkages.

All districts In September 2016, MCSP organised a learning workshop with 37 health workers from the 6 supported districts (Kanungu, Butaleja, Kibuku, Bulambuli, Mitooma and Ntungamo)). Health facilities shared their package of practices that had contributed to consistent recording of children vaccinated in the child register, vaccine availability and increasing utilisation of RI services. This guided the development of best practices and platforms for rolling out more widely in the districts.

Building Capacity of MACIS and data collection MCSP conducted a Training of Trainers-TOT) of 7 trainers (2 females and 5 males) to the MACIS umbrella body of CSOs to support data collection. Those seven trainers in turn trained 31 data collectors drawn from various CSO organisations operating in the regions covered by MCSP. The data collectors collected information from the 6 MCSP supported districts at the different levels of service delivery namely; District, HSD and health facilities. One hundred and seventy-four (174) health facilities were visited for data collection; 41, 24, 18, 16, 24 and 51in Ntungamo, Mitooma, Bulambuli, Kibuku, Butaleja and Kanungu districts respectively. Information from data collected from the PY1 districts was shared with the districts during the quarterly review meetings while data for the 4 new districts was shared during workshops for planning for REC-QI implementation and trainings in selected REC-QI tools. When working at full capacity, MACIS’ assistance will lighten the burden of district data collection from MCSP staff to allow the latter more time for participation in other program activities and documentation.

Overall Progress of the Project for PY2

The table below explains activities accomplished during PY2

Activities Planned Activities Accomplished

Objective 1: Strengthen UNEPI’s institutional/technical capacity to plan, coordinate, manage, and implement immunization activities at national level. IPV introduction MCSP supported the roll out of IPV at national level and across all the 6 PY2 supported districts i.e. Kanungu, Butaleja, Bulambuli, Kibuku, Mitooma and Ntungamo. MCSP technical staff participated in the national TOT (national trainers/supervisors) and teamed up with Ministry of Health teams to facilitate district trainings (ToTs). These in turn provide training to all operational level staff in the IPV and tOPV to bOPV switch processes. They trained sub-county vaccination teams; conducted training and planning workshops at sub-county levels; and reviewed strategies to ensure high quality supervision and monitoring of the entire IPV and switch process. Participants were equipped with knowledge and skills to administer IPV. The trainings marked the beginning of the process for health facilities to administer IPV and withdraw tOPV from the district cold chain systems. The switch was generally successful, due to the long planning process, it did, however, delay other planned activities.

National EPI MCSP supported MoH-UNEPI to finalise and release a pull-out section on Newspaper Pull out immunization in the New Vision (the leading newspaper in Uganda) in April and July 2016. This pull-out included information on RI performance for all districts in Uganda and upcoming EPI activities namely: Polio campaign and activities related to new vaccine introduction for sensitisation of the districts and public.

MOH Coordination MCSP staff attended two Diarrhoea, Pneumonia Coordination Committee (DPCC) Meetings meetings of MOH, two TWG meetings (one for EPI and another for Quality Assurance) to ensure harmonization of REC-QI implementation with Government policy guidelines.

GAVI/HSS application MCSP provided technical assistance to UNEPI during the process of preparing its writing application to Gavi for health system strengthening support. REC-QI key process. As a result of MCSP’s involvement, its process for HF catchment area mapping which helps generate more accurate target populations was incorporated for scale up into the whole country to facilitate HF REC micro planning.

EPI Communication MCSP is providing technical assistance to MOH (UNEPI and the Health Promotion & Strategy Education division of MOH) in the review of the EPI communication strategy 2016- 2020. This platform may provide an opportunity to include REC-QI approach processes.

Immunization Fund MCSP participated in a workshop to review guidelines and provided technical guidance on Establishment of an Immunization Fund in Uganda. Activities Planned Activities Accomplished

Objective 2: Improve district capacity to manage and coordinate the immunization program as guided by UNEPI leadership. MCHIP Close out In February 2016, MCSP held a close out meeting in Busia District, one of the districts in Busia District previously supported by MCHIP. This meeting provided a forum for sharing achievements, challenges and lessons learnt during the years of REC-QI implementation in the district. It also provided a forum for key stakeholders to discuss how REC-QI gains could be sustained even after project close out.

The meeting was attended by 80 participants that included: District and Sub-county leaders, DHT, HSD in-charges, Health Facility in-charges and District Implementing Partners (IPs).

Some of the plans to ensure sustainability of REC-QI gains included; - Working together with existing IPs to integrate RI support activities in their plans - Continue holding discussions with MoH regarding obtaining more funding to deal with critical financial challenges affecting RI service delivery in some sites. - Hold discussions with partners and other stakeholders to support EPI infrastructure e.g. Installation of Solar for Fridges, - Maintain the approach of integration of several health technical areas during district support activities e.g. Quarterly Review Meetings and Support Supervision to ensure optimal use of available resources to address a broader range of issues affecting health service delivery. - Realign some RI innovations to be supported through the GAVI health systems strengthening support - Conduct more regular support supervision and mentorship to health facility staff in order to further spread and enable adoption of REC-QI concepts across all sites in the district. Continued promotion of REC-QI practices in Kanungu and Butaleja districts (PY1 districts)

VHT orientation to Having facilitated planning for REC-QI implementation during PY1 as part of the first facilitate linkages with phase of REC-QI implementation (“Orient”), MCSP continued to support activities RI services under the second phase (“Establish and Strengthen)” These included the following:

MCSP oriented a total of 2,044 health workers and VHTs (Kanungu total 1,159 – Males 410 & Females 749; Butaleja total 875 – Males 467 & females 408) to facilitate linkages to RI services with communities in the districts,. These were drawn from all the 73 health facilities conducting RI in the two districts.

Given their good knowledge of the villages in health facility catchment areas and other community dynamics, VHTs played a pivotal role in supporting health workers in identification of villages and assigning them to the most suitable RI service delivery points. This process is dubbed “micro-mapping” under the REC-QI implementation approach. VHTs also guided health facility staff on the most suitable locations and times when outreaches can be conducted in communities.

Activities Planned Activities Accomplished

VHT and Health The VHTs also participated in mobilisation of caretakers, registration of children in facility review of their catchment areas, and defaulter tracing to facilitate reaching every child with RI micro-maps and plans services. for strengthening linkages with This activity provided opportunity for the VHTs and health workers to jointly review communities and plan for delivery of Routine immunisation services in the community. Health workers were re-equipped with knowledge and skills to plan, implement, monitor and mobilise caretakers and resources for routine immunisation. Health facilities conducting routine immunisation were supported to review their micro-maps (list of villages assigned to service delivery points). This process involved review and re-allocation of villages (where necessary) to RI service delivery points and creation of new service delivery points where necessary.

Technical Assistance These meetings were attended by 1,122 (401 Male, 721 Female) and 827 (296 Male, to District Quarterly 531 Female) participants in Kanungu and Butaleja districts respectively. Review Meetings During the year, MCSP conducted two rounds of technical assistance visits to each of

the two districts to support Quarterly Review Meetings. A total of of 10 QRMs

supported (6 in Kanungu and 2 in Butaleja). In Kanungu 2 QRMs were conducted at

the district level while 4 were conducted at HSD level (2 in each HSD). In Butaleja all

2 meetings were conducted at district level.

HSD level meetings were attended by health facility in-charges, EPI focal persons, sub-

county and religious leaders whereas the DHMT meetings were attended by the

DHT, HSD in-charges together with the district political and civil leaders.

These meetings provided opportunity for health workers and nontraditional

stakeholders to jointly analyze their RI performance, share best practices and

solutions to challenges for adaptation across health facilities. HSD level meetings were

facilitated by the DHMT who prepared and shared feedback during the district level

meetings.

MCSP conducted a 3-day training in each of the two districts targeting district based Training on key REC- supervisors, mainly health facility in-charges and the members of the DHT. A total of QI tools 95 (35 Female and 60 male) supervisors were trained from the two districts; 65 (23 Female and 42 Male) and 30 (12 Female and 18 Male) from Kanungu and Butaleja districts respectively. The aim was to further strengthen the knowledge and skills of supervisors in the key REC-QI tools so as to enable them to provide better quality supportive supervision, monitor performance and use of data for action in bid to improve spread and adoption of REC-QI practices across all health facilities in the districts. The trainings also aimed at promoting improvements in the quality of PDSAs implemented by sites.

During this training, participants in Kanungu and MCSP staff jointly brainstormed on setting up a central “RI Information Corner” in each health facility. Each health facility

Activities Planned Activities Accomplished

agreed to designate separate space on a notice board within the EPI section where all key REC-QI information elements would be openly displayed for easy reading and comprehension by all staff. The information would include; summary of current PDSAs, Micro-Mapp (List of villages assigned to service delivery points), Macro-Mapp (Parishes served and target populations), RI schedule, RI Programme, RI Performance Monitoring Charts, and a Summary Standard Operating Procedure to guide staff on timelines to update key documents. The aim was to increase visibility of all the key REC-QI concepts within the health facility so as to ease reference by all staff and other stakeholders to quickly inform processes of planning and monitoring for RI. This is also expected to motivate health facility staff to further appreciate the importance and benefits of these practices in RI service delivery.

Support to Integrated MCSP re-oriented and mentored a team of 30 supervisors (18 in Kanungu and 12 in Supportive Butaleja) in supportive supervision as part of efforts to strengthen district level Supervision; integrated supportive supervision. During tehse visits, MCSP consolidated gains in knowledge and skills in conducting integrated supportive supervision for the district supervisors attained during the first district supportive supervision activities supported by MCSP in August and September 2015. During this exercise, 74 health facilities providing RI services in the two districts were visited by the supervision teams supported by the MCSP technical teams; 50 and 24 in Kanungu and Butaleja respectively. Emphasis was directed towards addressing RI and REC-QI issues. However, support was integrated to include issues related to other service delivery areas e.g. Maternal and Child Health in general and malaria among others.

Follow up During the year, two assessment visits for periodic project data collection were performance conducted in the two districts. A total of 74 health facilities were visited by data assessment of REC-QI collection teams from CSOs under MACIS (the agency sub-contracted to support implementation data collection by MCSP). Some of the results from these assessments included the following; - The percentage of health facilities with REC micro-plans increased from 6% in June 2015 to 44% in October 2015 and eventually to 70% in April 2016. - The proportion of health facilities implementing REC-QI practices (i.e. had complete micro-plan and were practicing QI – working on a PDSA or had a QWIT that had met at least once in the past 3 months) increased from 1.5% in June 2015 to 18% in October 2015 and eventually to 57% in April 2016 respectively.. - Recording of children in child registers remains low with only 63% of doses tallied were recorded in the child register - Availability of the required vaccines also remains low with only 43% of health facilities reporting no stock out of any of the key vaccines required during the period October 2015 to March 2016. District learning To address the gaps identified from the assessments, MCSP organised an inter-district workshop learning workshop in September 2016 with 37 health workers from the 6 supported districts, including staff from selected health facilities that demonstrated good utilisation of the child register, management of vaccines and steady increase in number of vaccinations performed. This workshop took an assets-based approach to identify Activities Planned Activities Accomplished

proven and promising practices whose uptake could be expanded. Recording of children in child registers remains low with only 63% of doses tallied recorded in the child register.

Health facilities shared the following as practices that have contributed to good child register utilisation; - Deploying more than one health worker per RI session to minimise events when both recording and vaccination is left to one health worker - Streamlining the client flow system clarifying stages when data should be collected and who should be responsible - Conducting daily crosschecks between child register records and compare with entries in the tally sheets - Conduct Continuous Professional Development sessions on use and filling of the child register - Start RI sessions on time to minimise panic and cases where registration of children in the child register is omitted - Having one child register per service delivery point and registering children per village

The following were mentioned as key enablers to ensure availability of vaccines and injection materials; - Knowledge of the target population to enable accurate vaccine quantification - Consistent use of the Vaccine and Injections Materials Control Book - Proper Cold Chain Maintenance; daily monitoring of temperature, proper arrangement of vaccines in the fridge, defrosting among other practices. - Maintaining a regular schedule of vaccine distribution from the district to health facilities - Placing orders on time to the district (without waiting for stock outs to occur). This could be done using SMS, MTRAC, WhatsApp, email among other means of communication

Below are the key practices stated as enablers for scaling up number of vaccinations in health facilities - Conducting regular community mobilisation and sensitisation with the help of non-traditional stakeholders namely; VHTs, Religious leaders, Schools and other community social gatherings / activities. - Conducting continuous Health Education at all RI sessions and within all departments to create more demand - Completion and use of micro-plans to guide RI activity implementation - Develop and adhere to RI programs - Proper use of data management tools e.g. Child register and monitoring charts

Holding monthly QWIT meetings to review performance; identify gaps and develop change ideas to facilitate improvements. These practices are going to be promoted in other health facilities within MCSP supported districts.

Implementation of activities in PY2 districts (Ntungamo, Mitooma, Bulambuli and Kibuku)

Pre-visits In April 2016 MCSP officially began implementing activities in 4 districts: Ntungamo, Mitooma, Bulambuli and Kibuku.

Activity implementation commenced with pre-visits by MCSP teams accompanied by the MoH/UNEPI Official and Regional EPI Supervisors. Through these visits, MCSP was introduced as a partner in the districts. The district leadership (both political and technical) was able to reflect on the current status of RI services in the district. MCSP was able to share its road map of key activities to be implemented in the districts during the anticipated two years of collaboration.

Baseline assessment / The pre-visits were followed by collection of data from all the four districts to Situation analysis understand the situation of RI service delivery. Analysis of results revealed that 21% (21/99) of sites visited were found with completed REC micro-plans; 11% (2/18), 0% (0/16), 0% (0/24) and 46% (19/41) in Bulambuli, Kibuku, Mitooma and Ntungamo respectively. Up to 13% were found to be implementing quality improvement practices (either working on a PDSA or having a functional Quality Work Improvement Team focusing on solving RI problems); 12% (5/41), 4% (1/24), 0% (0/16) and 39% (7/18) in Ntungamo, Mitooma, Kibuku and Bulambuli respectively. Information generated out of this situation analysis also includes baseline data upon which future progress of program performance in these districts will be monitored.

Planning for REC-QI MCSP conducted 4 day trainings in each of the districts to guide planning for REC-QI implementation implementation. Health workers were oriented in the process of developing the district macro-map (list of health facilities and their catchment areas and populations - parishes covered and populations), data utilisation using the WHO RED categorisation tool, problem analysis using the fishbone technique, development and testing of changes using the PDSA cycle approach and compilation of Health facility REC-micro plans. Trainings were attended by 287 participants (181 female, 106 male); 80, 50, 48 and 109 in Bulambuli, Kibuku, Mitooma and Ntungamo districts respectively. Other resolutions reached included: enacting by-laws to counter activities of some religious cults that preach against health programs including RI, formally write to the Ministry of Health about the absence of health facilities in up to 7 out of 20 sub-counties in Bulambuli district and improving information flow between the district and health sub-districts and health facilities to ensure availability of vaccines and other health logistics.

REC-QI sensitisation MCSP also introduced REC-QI to the district and sub-county leaders during separate of district and sub- meetings conducted in the districts. District Routine Immunisation Performance for county leaders the financial year FY 2015/2016 was shared and discussions were held in relation to the role the district and sub-county leaders could play in improving RI performance. Participants during the sensitisations included; DHT, Councillors, LC III Chairpersons, representatives of Implementing Partners, Civil Society Organisations, and District heads of departments, among others. These meetings also provided a platform for identification of possible synergies and opportunities for collaboration. A case in point is the participation of the RHITES SW Director in the sensitisation meeting in Ntungamo district that enabled singling out activities where possible partnerships between the two programs could be explored. Other partners present included ARISE (a local NGO focusing on nutrition) from which leveraging opportunities were discussed to enable children who access RI services also access nutrition services.

Training on select A 3 day training focusing on improving district trainers’ and supervisors’ knowledge REC-QI tools and skills in working with selected REC-QI tools was conducted by the MCSP team. Some of these tools included the REC micro-plan, RI Charts, use of child registers, PDSA documentation formats, Data Quality Self-Assessment and improvement and data collection and reporting tools for RI. These trainings were attended by 212 supervisors (101 female, 111 male) drawn from the DHT, HSD, and all health facilities; 50, 38, 47 and 77 in Bulambuli, Kibuku, Mitooma and Ntungamo Districts respectively. These trainees were expected to mentor health facility staff during subsequent meetings and support supervision visits.

As done in the PY1 districts, MCSP conducted VHT orientation workshops in PY2 districts as well during the year. These reached out to 6,050 VHTs (1,744 male, 4,306 female). VHTs trained by district were as follows; - Bulambuli - 2,546 (637 Male, 1,909 Female) - Kibuku - 480 (120 Male, 360 Female) - Mitooma - 1,063 (262 Male, 801 Female) - Ntungamo - 1,961 (725 Male, 1,236 Female)

VHT orientation to The VHTs supported the micro-mapping process under REC-QI. The VHTs are facilitate linkages with expected to facilitate linkages to RI services within communities in the districts; RI services participate in mobilisation of caretakers, registration of children in their catchment areas and defaulter tracing to facilitate reaching every child with RI services.

Project Management and Administration

Program management During the year, MCSP Uganda received technical assistance from the and administration Headquarters to discuss and streamline management issues. Resolutions and action plans were drawn to guide management and technical operations within the project moving forward.

During the year, one Civil Society Organisation (CSO), MACIS was selected following a review of bids submitted. MACIS was selected to support MCSP in processes of data collection and participation in Quarterly Review Meetings. Discussions are still under way to jointly review the budget and work plan for the CSO before the stage of contract signing.

During the quarter, a total of 7 staff from the CSO were briefly oriented on MCSP and REC-QI. This was followed by a detailed orientation on the tools expected to be used for data collection. Trainers from MACIS, both from the central and regional offices, then joined a training practicum session as MCSP conducted trainings for district based data collectors and HMIS/records staff. This was done before the data collection exercise in Kanungu and Butaleja Districts. A detailed report about this exercise will be shared at the end of the current quarter.

II. Challenges, Solutions and Actions taken

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

National level The Polio End game An accelerated Work plan was developed to Activities carried over activities, including SIAs, IPV catch up with lost time after the Polio End to the next quarter introduction, and the tOPV game. and were absorbed in to bOPV switch, occupied the accelerated work UNEPI and districts causing plan. 1 near stoppage of MCSP planned activities for one month of the third quarter, hence delays in implementation. Understaffing at UNEPI Engaging National Trainers to fill the gap National Trainers fill makes it difficult for UNEPI the gap but not fully. staff to carry out all planned 2 activities such as monthly TWG and participating in MCSP district training activities for REC-QI. Failure to identify another This item has been incorporated in the GAVI Application is not yet funder for the newspaper HSS application approved pull-out section on 3 immunization yet its value is highly appreciated by both the Ministry of Health and partners. District level Comprehension of change MCSP technical staff together with the DHMT During mentorship ideas and action points for continued to guide health facility staff on how sessions held, some of PDSA cycles to guide to formulate proper change ideas and action the health facilities implementation remains a points for PDSA cycles with clear timelines visited were able to challenge among some and responsible persons. A case in point is restate their action health facility staff Bwindi Hospital (Kanungu district) which had points with clear formulated “Increase the number of staff at timelines and every RI session” as its change idea. Guidance responsible persons was provided to the team to further articulate 4 this change idea into specific action points to ease its implementation; e.g. 1. Identify staff from other departments who could support EPI 2. Conduct CME for the staff identified 3. Include staff identified in RI schedule Follow up will be done to sites during the next round of supportive supervision visits to provide more support to improve the quality of PDSAs. Challenges faced during Results of actions Actions taken to address the challenges the year taken In Bulambuli district, The District leadership pledged to formally There are no results MCSP’s mapping process write to the Ministry of Health about the yet of the action taken revealed that a total of 7 absence of these health facilities. sub-counties (25%) were found not to have a single health facility. This made it difficult for these populations to be assigned to any suitable health 5 facility during the macro- mapping process. These sub-counties were identified after MCSP’s comprehensive mapping process of health facilities and their targeted catchment areas and populations. Recording of details on Data on levels of recording of In Kanungu, the DHO children immunized in the immunization data in the child register per pledged to write a child register remains very health facility was shared during the circular to all health low across all districts. This Quarterly review meetings. facility in-charges is largely attributed to few MCSP technical staff together with the DHMT about the issue of the staff allocated to support RI sensitised health workers on the importance of child register. and limited awareness on recording details of children immunized in the the importance of child register. recording in child registers. 6 A workshop was also held with staff from There are no results health facilities performing well with recording yet for the action children in the child register. These shared taken their experiences and enabling factors to District Focal persons and other staff from other districts. A package of interventions was developed and will be promoted by DHMT from all districts during supervision visits to health facilities. Some of the activities were REC-QI sensitisation sessions for the district Information intended conducted amidst leadership were shifted to other dates within for the district interruptions like the year. leadership was shared preparations for swearing as planned though not in for political leaders in on the dates Ntungamo and Kibuku. This scheduled. 7 led to low turn up of invited participants and some sessions could not be conducted as scheduled on the REC-QI road map e.g. REC-QI sensitisation for the district leadership. Challenges faced during Results of actions Actions taken to address the challenges the year taken

There was a delay in The MoH/UNEPI Central supervisor team lead Funds and logistics release of funds and continuously followed up with the centre to arrived later to logistics by the Ministry of ascertain progress with the release of funds and support the activity Health to the districts to other logistics. The supervisors also discussed facilitate IPV introduction with the district leadership about mobilisation 8 activities to kick start the activities. MCSP contributed to provision of transport to conduct supportive supervision visits and distributed supplies once they arrived.

The challenge of vaccine During the knowledge exchange workshop No results yet for this stock outs continues in conducted with selected health facilities, a set intervention some health facilities of improvement interventions were developed affecting quality and for districts to promote in their districts to coverage of RI services. reduce vaccine stock outs. These include; This has been largely development and updating of target populations attributed to challenges of to guide vaccine quantification, consistent use communication, of the Vaccine and Injection Materials Control 9 coordination and Book (VIMCB), maintaining a regular schedule distribution between the for vaccine distribution from the district store District stores and health to health facilities, proper cold chain facilities. maintenance and placing orders on time. These are to be rolled out by DHMT during integrated supportive supervision.

In some health facilities, it Districts agreed to ensure early communication No results reported was difficult to engage to each of the sites to allow health workers to yet for this health workers during put aside more time separately to attend to intervention supportive supervision supervision sessions. activities as many had to attend to patients especially 10 in the morning hours. This made it difficult to ensure that knowledge is passed on to all health workers in health facilities.

Transportation to access There is no clear solution identified to address No results reported some health facilities during this challenge. Districts only devised a strategy yet for this field activities remained a to always focus on the far away sites during the intervention 11 challenge especially those in first days of any supervision activity and end areas with poor road with sites closer to the District Health Office. network and terrain.

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

Districts still face Districts were advised to put aside funds No results yet for this challenges of limited for QRMs while MCSP supports some of intervention prioritisation of them to enable districts appreciate their finances to conduct importance and prioritise them. District and Health sub 12 district level Quarterly Review Meetings and integrated supportive supervision visits as planned.

III. Lessons, Best Practices and Recommendations

National level When planning (scheduling REC-QI activities), MCSP needs to consider other competing activities (national and district) that can hinder program implementation. In addition, MCSP should work more closely with MOH/UNEPI to be in the know of upcoming activities.

The role of REC-QI national trainers is paramount to supplement both MCSP and UNEPI-led activities, hence MCSP should further build their capacity to carry out this responsibility.

District level Consistency in trainees selected to participate in REC-QI activities is key in ensuring that knowledge gained is well translated into practice at health facilities. It is important for districts that select participants to ensure a similar pool of trainees is selected for each training to enable easy follow up of issues rather than starting with fresh trainees during trainings conducted mid-way the road map.

Practical sessions provide a better environment for participants to relate directly with the concepts and develop practical solutions relevant to their health facilities. It is important to allocate more time to practical sessions than theory sessions during trainings in order to maximise learning. Through interaction with district health staff, MCSP has learnt that identification of catchment areas and target populations is a key motivator for health workers to complete their REC micro-plans as recommended by UNEPI.

IV. Success story

See Attached.

V. Management Issues

None.

VI. Monitoring and Evaluation

Building capacity of CSOs and Data collection

During the year, a CSO, MACIS, was contracted to support MCSP in data collection and participate in Quarterly Review Meetings.

MCSP trained (training of trainers) a total of 7 trainers (2 female and 5 male) under the MACIS umbrella body of CSOs. Through a cascade approach, the trainers trained 31 data collectors drawn from various CSO organisations located in the regions of MCSP operation. Trainings were conducted together with 87 HMIS staff drawn from health facilities. The data collectors together with the HMIS staff collected data to inform REC-QI implementation from the six MCSP supported districts. Other trainings will be conducted right before subsequent data collection exercises with data collectors trained previously and are still available together with any new ones to fill gaps of those who may have left the district.

Table showing number of CSO supervisors, data collectors and HMIS staff trained

No. of CSO data District No. of HMIS staff trained collectors trained PY1 districts Kanungu 8 (2 Female, 6 Male) 15 (4 Female, 11 Male) Butaleja 4 (1 Female, 3 Male) 14 (5 Female, 9 Male) PY1 Sub Total 12 (3 Female, 9 Male) 29 (9 Female, 20 Male) PY2 districts Bulambuli 3 (1 Female, 2 Male) 19 (8 Female, 11 Male) Kibuku 3 (1 Female, 2 Male) 12 (7 Female, 5 Male) Mitooma 5 (4 Female, 1 Male) 12 (8 Female, 4 Male) Ntungamo 8 (1 Female, 7 Male) 15 (7 Female, 8 Male) PY2 Sub Total 19 (7 Female, 12 Male) 58 (30 Female, 28 Male) Grand total 31 (10 Female, 21 Male) 87 (39 Female, 48 Male)

Data collection, including interviews and documentation reviews were conducted at all District Health Offices, all 8 Health Sub-districts, and 174 out of the 179 health facilities in the 6 MCSP supported districts, as shown in the table below. Table showing HSDs and health facilities visited for assessment.

No. of HSDs No. of Health facilities District headquarters visited visited PY1 districts Kanungu 2 / 2 51 / 52 Butaleja 1 /1 24 / 24 PY1 Sub Total 3 /3 75 / 75 PY2 districts Bulambuli 1 / 1 19 / 19 Kibuku 1 / 1 15 / 15 Mitooma 1 / 1 24 / 25 Ntungamo 3 / 3 41 / 45 PY2 Sub Total 5 / 5 99 / 104 Grand Total 8 / 8 174 / 179

Findings from these assessments conducted in the PY1 districts were shared with the district health teams during quarterly review meetings, workshops for planning for REC-QI implementation and REC- QI select tools trainings. This enabled development of plans to scale up uptake of REC-QI practices. These included: using the district SMS reminder system to remind health facility in-charges about submitting copies of the health facility REC micro-plans to the district; and including elements of REC-QI on the checklist of items to follow up during support supervision.

Data collection feedback session During the year, MACIS held a feedback session with all its supervisors and MCSP to discuss what went well, challenges faced and recommendations to improve the quality of the data collection process. Issues discussed included; training approaches used in the different districts, stepping up supervision of data collectors, providing clarification to some questions in the data collection forms that were not clear, and dealing with the challenge of absence of some health workers to be interviewed at health facilities. Some of the resolutions included: conducting teaming outside the training room together with the DHT rather than conducting it during the training with all participants, ensuring that each supervisor is able to provide one sit-in session to every data collector on the very first day of the data collection exercise, developing more guiding statements in the questionnaires for better understanding of some questions by data collectors, to mention but a few.

Program Learning Questions Following feedback from USAID, MCSP team is in the process of finalising two protocols for the program learning question. Both protocols will be submitted for both local and international approval next quarter.

1. “Tangible results of the REC-QI approach and the principle enablers/drivers of change along the REC-QI continuum from ‘orient’ to ‘sustain’”.

2. “Enablers and inhibitors of uptake and sustainability of REC-QI practices in ”

Doer / Non Doer Assessment in Kapchorwa; Mr. Xavier Nsabagasani, a qualitative research consultant was hired to provide technical assistance to the operationalisation of the “doer/non-doer” assessment to be conducted in Kapchorwa aimed at examining the factors associated with uptake and sustainability of REC-QI practices in the district. The protocol for this assessment was finalised for submission for approval by the local Institutional Review Board (IRB) at Makerere University School of Public Health and the JSI IRB.

VII. Summary Quarterly Results

The following table shows the compiled MCSP Uganda Performance Indicators for data available in Q2 for the two districts of Kanungu and Butaleja.

MCSP indicators PY2 Q3 target PY2 Q3 achievement Comments Number of children who PY1 Districts PY1 Districts at 12 months have - Kanungu – 11,502 - Kanungu – 10,075 (88 %) PY1 Penta3 coverage for received three doses of - Butaleja – 11,138 - Butaleja – 10,280 (92 %) Kanungu was 98% while DPT/Penta vaccination Penta3 coverage for Butaleja from a USG- supported PY2 Districts PY2 Districts (Baseline) was 83%. There is a notable immunization program. - Ntungamo – 22,072 - Ntungamo – 17,623 (80%) increase in Penta3 coverage (Standard 3.1.6 – 61) - Mitooma – 8,368 - Mitooma – 6,924 (83%) for Butaleja from 83% in PY1 - Kibuku – 9,216 - Kibuku – 7,588 (82%) to 92% in PY2 - Bulambuli – 7,961 - Bulambuli – 5,462 (69%)

Target populations based on Date of download: 15th October 2016 Census 2016 projections (4.3% of total populations) % of planned RI sessions Actual: Oct 2015 to Mar 2016: that were conducted in the year (IP custom) PY1 Districts – 84% PY1 Districts (2,233/2,663) The three commonest - Kanungu – 76%(1,228/1,626) reasons cited by health - Butaleja – 97% (1,005 / 1,037) facility staff in Kanungu, where the target was not achieved, were: vaccine stock 91% outs, absence of records (Annual target) (tally sheets) for several PY2 Districts (baseline) sessions conducted and long 78% (3,269 / 4,170) public holiday periods. - Ntungamo – 94% (1,521/1,613) - Mitooma – 78% (559/717) PY2 Districts - Kibuku – 52% (402/764) These were baseline results - Bulambuli – 73% (787/1,076) that will be used as benchmarks to assess progress during subsequent quarters Number of people trained PY1 Districts – 2,940 PY1 Districts - 2,162 A total of 8,711 participants in child health and REC-QI tools training - 100 REC-QI tools training - 95 were reached with trainings nutrition through USG- - Kanungu- 50 - Kanungu- 65 (16 M, 49 F) out of 8,628 targeted (101% supported programs - Butaleja – 50 - Butaleja – 30 (18 M, 12 F) achievement of the target (IP custom) VHT training – 2,760 VHT training – 2,067 - Kanungu – 1,871 - Kanungu – 1,182 (429 M, 753 F) OPL trainings were not - Butaleja – 889 - Butaleja – 875 (467 M, 408 F) conducted because the IIP manual has not yet been OPL training – 80 OPL training – 0 approved by MoH - Kanungu – 40 - Kanungu – 0 - Butaleja – 40 - Butaleja – 0

PY2 Districts – 5,448 PY2 Districts – 6,549 Planning for REC-QI Planning for REC-QI Implementation - 312 Implementation - 287 Bulambuli - 78 Bulambuli - 80 (57 M, 23 F) Kibuku - 78 Kibuku - 50 (27M, 23F) Mitooma - 78 Mitooma - 48 (25M, 23F) Ntungamo - 78 Ntungamo - 109 (72M, 37F)

REC-QI tools training - 200 REC-QI tools training - 212 Bulambuli - 50 Bulambuli - 50 (25 M, 25 F) Kibuku - 50 Kibuku - 38 (21M, 17F) Mitooma - 50 Mitooma - 47 (22M, 25F) Ntungamo - 50 Ntungamo - 77 (43M, 34F)

VHT training – 4,776 VHT training – 6,050 Bulambuli – 1,194 Bulambuli – 2,546 (637 M, 1,909 F) Kibuku – 1,194 Kibuku – 480 (120 M, 360 F) Mitooma – 1,194 Mitooma – 1,063 (262 M, 801 F) Ntungamo – 1,194 Ntungamo – 1,961 (725 M, 1,236 F)

OPL training – 160 OPL training – 0 Bulambuli – 40 Bulambuli – 0 Kibuku – 40 Kibuku – 0 Mitooma – 40 Mitooma – 0 Ntungamo – 40 Ntungamo – 0

Central level trainings -240 Central level trainings -0 Tutors training in Tutors training in new EPI curricula - 40 new EPI curricula - 0 Final year students training in Final year students training in new new EPI curricula - 200 EPI curricula - 0

% MoH / UNEPI TWG coordination meetings held where Routine 92% or 11/12 Immunization was (Annual target) discussed in a year (IP custom) % of planned quarterly PY1 Districts (40% - 8/20) The challenge of shortage of review/coordination - Kanungu – 6/12 funds continues to hinder the meetings held where - Butaleja – 2/8 ability of districts to conduct routine immunization was quarterly review meetings discussed in a district per PY2 Districts (3% - 1/40) both at the district and HSD year (IP custom) [baseline] levels. MCSP will continue to - Ntungamo – 1 / 16 facilitate some meetings 40% - Mitooma – 0 / 8 while guiding the districts to - Kibuku – 0/8 leverage resources from - Bulambuli –0/8 PHC and other partners to conduct QRMs.

% of planned integrated PY1 Districts (20% - 4/20) The challenge of shortage of supportive supervision - Kanungu – 3 / 12 funds continues to hinder the visits conducted in a - Butaleja – 1 / 8 ability of districts to conduct district in a year (IP quarterly integrated custom) PY2 Districts baseline supportive supervision. (18% 7/40) MCSP will continue to 70% - Ntungamo – 3 / 16 facilitate some meetings

- Mitooma – 1 / 8 while guiding the districts to - Kibuku – 2 / 8 leverage resources from - Bulambuli – 1 / 8 PHC and other partners to conduct QRMs.

% of health facilities with PY1 districts – For the PY1 districts, this complete REC micro-plans Results for April 2016 figure as reported last (IP custom) 70% (52/74) quarter was higher than 44% - Kanungu – 62% (31/50) discovered in October 2015 - Butaleja – 88% (21/24) and 6% at baseline. The commonest reasons cited PY2 Districts from the assessment for the Results for May 2016 - Baseline low score for Kanungu 21% (21/99) include; some health facilities - Ntungamo – 46% (19/41) compiled the micro-plans but 30% - Mitooma – 0% (0/24) submitted to the district - Kibuku – 0% (0/16) remaining with no copy, - Bulambuli – 11% (2/18) some health facilities did not have adequate knowledge of how to fill some sections of the micro-plan.

Micro-plans had been introduced by UNICEF in Ntungamo and Bulambuli

Report completion rates were 91%, 94%, 82%, 92%, 94% and 93% by 8th October 2016 for Kanungu, Butaleja, Ntungamo, Mitooma, Kibuku and Bulambuli districts respectively

VIII. PY3 Planned Activities

The following are the activities planned for the financial year October 2014 to September 2016:

National level activities

• Participate in UNEPI quarterly RI review meetings with partners to share REC-QI lessons learned by presenting/discussing different topics at each meeting and in subcommittee work • Train tutors in new EPI curricula • Provide TA and support for EPI newspaper pull-out • Actively participate in planning and implementation of the GAVI Joint Appraisal, UNICEF Equity Assessment and WHO/UNEPI coverage survey • Provide national level technical input in planning Rota introduction and support TOT training in Program-supported districts • Participate in UNEPI Technical Working Group meetings, Quality Assurance Department Meetings, WHO/EPI managers’ meetings • Support printing and dissemination of the IIP manual • Coach and mentor national level staff in tools and approaches for performance monitoring • Support central level supervision activities in MCSP focus districts • Draft and disseminate fact sheets and technical briefs for distribution to in-country partners and stakeholders. Topics may include: Integration of immunization into a health platform, Logistics /cold chain improvements, Use and importance of a child register

District level activities

PY 1 districts (Kanungu and Butaleja) • Conduct Operational level (OPL) trainings, once the new IIP manual is published and distributed • Provide technical assistance to the DHMT during integrated supportive supervision • Provide technical assistance to the DHMT during Quarterly Review Meetings • Conduct end of support sharing meetings in the two districts of Kanungu and Butaleja

PY2 districts (Mitooma, Bulambuli, Kibuku and Ntungamo) • Conduct Operational Level (OPL) training, once the new IIP manual is published and distributed • Provide technical assistance to the DHMT during integrated supportive supervision (2 activities to be facilitated in each district) • Support the review of health facility micro-plans by health workers together with the VHT • Provide technical assistance to the DHMT during Quarterly Review Meetings (2 meetings to be facilitated in each district)

PY3 districts (Mbarara, Bushenyi, Serere and Mayuge) • Conduct initial visit to sensitise district leadership about MCSP activities (pre-visit) • Facilitate planning for REC-QI implementation • Train health workers in selected key REC-QI tools • Conduct Operational Level (OPL) training, once the new IIP manual is published and distributed • Provide technical assistance to the DHMT during integrated supportive supervision • Provide technical assistance to the DHMT during Quarterly Review Meetings • Orient VHTs to support health facilities with community sensitisation, registration of children targeted for immunisation, defaulter tracing among and support with identification of allocation of villages to RI service delivery points (micro-mapping)

Monitoring and evaluation activities: • Collect, enter and analyse REC-QI monitoring data from MoH/UNEPI, district health offices and HSD headquarters across all the 10 supported districts i.e. PY1, PY2 and PY3 districts • Compile and submit quarterly progress reports • Share findings from the data collected from PY2 districts with the DHMT and other district and national level stakeholders. This will be done during other REC-QI activities e.g. Quarterly Review Meetings, Workshops for planning for REC-QI implementation etc • Develop and operationalise a web-enabled database to track REC-QI performance • Follow up on USAID review/ approval/ and implementation of protocols for the operational learning by the program i.e. the protocol on “Enablers and inhibitors of uptake and sustainability of REC-QI practices in Kapchorwa District” and “Tangible results of the REC-QI approach and the principle enablers/drivers of change along the REC-QI continuum from ‘orient’ to ‘sustain’” and submit to US and Ugandan Institutional Review Boards (IRB)

Program Management activities:

• Work with USAID and MCSP partners to design and approach to the MNCH program description, draft and submit workplan, recruit staff and start up project • Obtain mission and AOR approval for the PY3 workplan • Provide technical assistance to country program activities i.e. performance reviews, work planning, operations and other activities

Annex A: EMMR quarterly update

List each Mitigation Measure List of any outstanding from Column 3 in the EMMP Status of Mitigation Measure issues relating to Remarks Mitigation Plan required conditions Utilization of auto-disable syringes and Vaccinators will be trained in vaccine and immunization logistics Training in OPL will be Overall, MCSP Uganda needles for all immunization activities. management, including ordering from the health sub-district conducted next year after the aims to discuss vaccine store/district vaccine store that includes bundling of IIP manual is finalised (delayed environmental impact auto-disable syringes (ADs) with vaccines to ensure available due to delay in the IIP as part of technical stock of vaccines doses at the health facility at any time have finalization) assistance, training and equal number of ADs, stock management and the use of only other materials. ADs for immunization. MCSP only gives technical assistance to management of auto- Training of vaccinators to avoid MCSP Uganda will contribute to efforts aimed at avoidance of disable syringes (ADs), recapping of needles after vaccination recapping syringes by promoting proper use of the AD syringes does not procure nor and use of safety boxes following (provided through MOH/UNEPI)through project trainings, distribute them to guidelines, with the motto “no safety quality improvement activities, and supportive supervision visits. districts and health box, no vaccination.” facilities (this is responsibility of the National Medical Store Reduction in waste generation and Through the trainings, quality improvement activities, and (NMS)). segregation of wastes during vaccination. supportive supervision visits that it supports, MCSP Uganda Sharps to be separated from other promotes segregation of waste by proper use of safety boxes wastes. Sharps containers which for sharps disposal during vaccination sessions. puncture-proof, impermeable and tamperproof with fitted covers should be used. Put in place a system to identify expired MCSP Uganda builds local capacity to ensure systems are in MCSP has not conducted the Overall, MCSP Uganda vaccines and consumables, remove them place to identify expired vaccines and remove them from the Operational level training that aims to discuss from shelves, place them in well labeled cold storage (EPI fridges) at health facilities and drugs for district could partly contribute to environmental impact boxes, and forward them to incineration retrieval and disposal, locked storage place for filled safety boxes addressing this. This is as part of technical / disposal points. exist are communicated and monitored in project trainings, scheduled for Q3, (delayed due assistance, training and quality improvement activities, and supportive supervision visits to delay in the IIP finalization). other materials. Identification of expired drugs and their conducted. removal from drug stores for disposal.

Before final disposal of filled safety boxes, they should be stored in a secure List each Mitigation Measure List of any outstanding from Column 3 in the EMMP Status of Mitigation Measure issues relating to Remarks Mitigation Plan required conditions place that is inaccessible to people and animals.

Construction of incinerators to be used Training, quality improvement activities, and supportive for burning of safety boxes and other supervision are geared towards building local capacity to wastes. properly use incinerators, where they exist and the ‘burn and bury’ method recommended by MOH/UNEPI is known and Fencing of the disposal sites. practiced at health facilities where incinerators do not exist.

Where incinerators are unavailable, use burn and bury methods in areas with limited access that is adequately protected from ground contamination.

Mercury thermometers will be disposed Ministry of health of in a safe place where the mercury will MCSP Uganda works to ensure that mercury thermometers are /UNEPI now uses not contaminate the ground water. They destroyed and fridge tags are disposed of according to WHO alcohol thermometers should not be burned in open spaces protocols. for its EPI fridges and where the fumes will destroy the other cold storage environment. equipment as clarified by UNEPI. 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.

29

Annex B: Photo Gallery

Top Left: MCSP Chief of Party facilitating a session VHT orientation in Kanungu District introducting MCSP to the Ntungamo District leadership – Photo: MCSP/JSI

Mentorship session in REC-QI tools in progress in Kanungu RI information centre in Kirima HC III (Kanunngu District district

Annex C: Success story

See Attached.