USAID/UGANDA PRIVATE HEALTH SUPPORT PROGRAM YEAR 1 REPORT: JULY 2013 – SEPTEMBER 2014
Dr. Francis Runumi, Health Planning Commissioner, Ministry of Health at the USAID/Uganda Private Health Support Program annual work planning meeting in August 2014 October 30, 2014 This report is made possible by the support of the American People through the United States Agency for International Development (USAID). The contents of this report are the sole responsibility of Cardno Emerging Markets USA, Ltd. and do not necessarily reflect the views of USAID or the United States Government. USAID/UGANDA PRIVATE HEALTH SUPPORT PROGRAM YEAR 1 REPORT: JULY 2013 – SEPTEMBER 2014
Submitted by: Cardno Emerging Markets USA, Ltd.
Submitted to: USAID/Uganda
Contract No.: AID-617-C-13-00005
DISCLAIMER The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.
USAID/Uganda Private Health Support Program
Table of Contents ACRONYMS ...... III EXECUTIVE SUMMARY ...... V PRINCIPAL ACHIEVEMENTS ...... VI TASK 1: EXPANDED AVAILABILITY OF HEALTH SERVICES BY PRIVATE SECTOR PROVIDERS ...... 9 TASK 1.1: GROW NUMBER OF PRIVATE FACILITIES OFFERING COMPREHENSIVE HEALTH SERVICES ...... 9 1.1.1 Conduct project baseline ...... 9 1.1.2 Engage employers in target districts ...... 10 1.1.3 Increase private sector participation in HIV prevention and other programs ...... 11 TASK 1.2: EXPAND PRIVATE SECTOR CAPACITY ...... 13 1.2.1 Design and implement a clinical capacity building program ...... 13 1.2.2 Expand the Private Public Partnership Laboratory Network ...... 16 1.2.3 Support child nutrition and development ...... 17 1.2.4 Assume management of the NBL PPP ...... 18 1.2.5 Support innovative approaches for orphans and vulnerable children ...... 19 TASK 1.3: INCREASE DEMAND FOR AND ACCESS TO CREDIT BY PRIVATE PROVIDERS ...... 19 1.3.1 Identify the constraints and opportunities of financial institutions in Uganda to serve private health sector providers ...... 19 1.3.2 Work with DCA banks and other financial institutions to expand lending to the private health sector in Uganda ...... 20 1.3.3 Provide assistance to current and potential borrowers of DCA Bank (Centenary Bank and Ecobank) and other banks currently involved in lending to the health sector ...... 26 1.3.4 Provide business strengthening assistance to USAID/Uganda Private Health Support Program target private facilities...... 26 TASK 1.4: IMPROVE PRIVATE SECTOR PARTICIPATION IN DISTRICT SERVICE DELIVERY COORDINATION ...... 27 1.4.1 Strengthen district PPPH coordination ...... 27 1.4.2 Strengthen the Health Management Information System and integrate in DHIS-II ...... 28 1.4.3 Support private health facilities to offer comprehensive healthcare service package ...... 29 Challenges ...... 31 Recommendations ...... 32 Key planned activities for the next quarter ...... 33 TASK 2: INCREASED AFFORDABILITY OF PRIVATE HEALTH SERVICES AND PRODUCTS ..... 33 TASK 2.1 EXAMINE AND MONITOR CURRENT PRICING OF PRIVATE SECTOR SERVICES AND PRODUCTS ...... 33 2.1.1 Assess cost drivers for drugs and health commodities ...... 33 2.1.2 Explore task shifting to lower cadres as a means to reduce costs ...... 34
TASK 2.2: EXAMINE HEALTH FINANCING MECHANISMS TO REDUCE THE PRICE OF HEALTH SERVICES AND DRUGS ...... 34 2.2.1 Expand the scope of the voucher program ...... 35 2.2.2 Link health savings plans to USAID/ Uganda Private Health Support Program ...... 35 2.2.3 Explore introduction of micro-insurance to larger organization networks ...... 35 Challenges ...... 36 Recommendations ...... 36 Key activities for the next quarter ...... 36 TASK 3: IMPROVED QUALITY OF PRIVATE HEALTH SECTOR FACILITIES AND SERVICES .... 36 TASK 3.1: ASSIST THE MOH TO IMPLEMENT THE PPPH POLICY TO ENABLE PFP PROVIDERS TO DELIVER QUALITY SERVICES ...... 37 3.1.1 Analyse key stakeholder groups to inform USAID/Uganda Private Health Support Program activities ...... 37 3.1.2 Create a regulatory and enabling environment to implement the PPPH policy ...... 37 3.1.3 Design a strategic investment plan for PPPs ...... 38 3.1.4 Assess PPP Unit capacity to implement PPPH policy ...... 38
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3.1.5 Work with the PPP Unit to raise awareness on the PPPH Policy ...... 38
TASK 3.2: BUILD DISTRICT HEALTH MANAGEMENT TEAM CAPACITY TO ENGAGE AND PARTNER WITH PFPS ...... 39
TASK 3.3: BUILD A MORE COHESIVE AND CAPABLE PRIVATE SECTOR TO PROMOTE STANDARDS OF CARE FOR PFP PROVIDERS ...... 39 3.3.1 Grow the core group of champions to promote private sector issues ...... 39 3.3.2 Build UHF’s capacity ...... 39 3.3.3 Build UHF and other organizations’ capacity to advocate and engage in dialogue on behalf of the private sector ...... 40
TASK 3.4: STRENGTHEN COUNCILS’ CAPACITY TO REGULATE AND OVERSEE QUALITY OF PRIVATE HEALTH PROVIDERS ...... 40 3.4.1 Update the Council Acts ...... 40 TASK 3.5 DEVELOP A VOLUNTARY ACCREDITATION PROGRAM ...... 41 3.5.1 Finalize standards and design the peer accreditation program ...... 41 3.5.2 Pilot test the tool with USAID/Uganda Private Health Support Program partners ...... 42 Challenges ...... 42 Recommendations ...... 42 Key activities for the next quarter ...... 42 YEAR 1 OVERVIEW OF GRANTS PROGRAM ...... 43 YEAR 1 OVERVIEW OF MONITORING AND EVALUATION ACTIVITIES ...... 44 ANNEX 1: DCA BASELINE SURVEY REPORT – EXECUTIVE SUMMARY ...... 47 ANNEX 2: PUBLIC-PRIVATE PARTNERSHIPS FOR HEALTH SURVEY REPORT - EXTRACTION ...... 48 ANNEX 3: SUCCESS STORIES ...... 56
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ACRONYMS A2F Access to Finance ACP AIDS Control Program ANC Antenatal Care ART Antiretroviral Therapy ASSIST Applying Science to Strengthen and Improve Systems BDS Business Development Services CBO Community Based Organization CLA Collaborating, Learning and Adapting CPD Continuing Professional Development CQI Continuous Quality Improvement DCA Development Credit Authority DHIS-II/DHIS2 District Health Information System DHMT District Health Management Team DQA Data Quality Assessment EID Emerging Infectious Diseases eMTCT Elimination of Mother to Child Transmission FP Family Planning FUE Federation of Uganda Employers HCT HIV Counselling and Testing HIPS Health Initiatives for the Private Sector HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome HMIS Health Management Information System IFC International Finance Corporation IHA Insight Health Advisors IDI Infectious Disease Institute IPs Implementing Partners IPT Intermittent Preventive Therapy IR Intermediate Result JMS Joint Medical Stores KCCA Kampala Capital City Authority MARP Most-At-Risk-Populations MEEPP Monitoring and Evaluation of the Emergency Plan Progress MCH Maternal and Child Health
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MGLSD Ministry of Gender, Labor and Social Development MOH Ministry of Health MOUs Memorandum of Understanding MSU Marie Stopes Uganda MUAC Mid-Upper Arm Circumference NACS Nutrition Assessment Counselling and Support NBL Nile Breweries Limited NGO Non-Governmental Organization OVC Orphans and Vulnerable Children PBG Performance-based grant PHA People Living with HIV/AIDS PFP Private For Profit PHP Private Healthcare Provider PMP Performance Monitoring Plan PMTCT Prevention of Mother to Child Transmission PPP Public Private Partnerships PPPH Public Private Partnerships for Health RUTF Ready to Use Therapeutic Food SIDA Swedish International Development Agency SMC Safe Male Circumcision TB Tuberculosis UHF Uganda Healthcare Federation UHMG Uganda Health Marketing Group UMA Uganda Manufacturers Association USAID United States Agency for International Development UVRI Uganda Virus Research Institute VLE Virtual Learning Environment VSLA Village Savings and Loan Associations WAOS Web Based Ordering and Reporting System
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Executive Summary The USAID/Uganda Private Health Support Program aims to strengthen, organize and mobilize the private sector to provide Ugandans with the option of obtaining high-quality health services from private health providers (PHPs). This supports USAID/Uganda’s 2011 – 2015 Country Development Cooperation Strategy (CDCS), in particular Development Objective 3, where three of the four sub-results under Intermediate Results (IR) 3.1 (IR3.12, IR3.1.3 and IR3.1.4) align well with leveraging and expanding the existing capacity of the private sector. The goal of the Program is to improve the credibility and cohesiveness of the private sector and expand the capacity of private sector providers. The focus of its support is to provide technical expertise, enhance quality standards, improve access to capital, support accreditation and provide leadership in the private sector. In order to achieve this, the Program has three main objectives: > Expanded availability of health services by private providers; > Increased affordability of private health services and products; and > Improved quality of private health sector facilities and services. This report serves as the Year 1, Quarter 4 Report and the FY 2013 Annual Report. In Year 1, the USAID/Uganda Private Health Support Program focus was on setting up a full program office and reactivating all the network of Private Health Providers and Associations. The Program quickly mobilized all the 100 accredited clinics inherited from the predecessor program, Health Initiatives for the Private Sector and an additional 45 private facilities assigned to the USG under the ART rationalization process in the area of brokering access to affordable quality HIV/AIDS, TB, malaria, MCH, nutrition, orphans and vulnerable children (OVC) services and products. The purpose was to ensure continuity of services, especially the lifesaving ARVs provided through the Joint Medical Stores (JMS) with PEPFAR support. During the year, 37 of these sites began to offer high impact interventions to prevent transmission of HIV from infected mothers to their newborn babies (PMTCT) while 45 sites offered TB services. A majority of these clinics are now reporting their data through the DHIS- 2. District based meetings conducted by the Program in all the focus districts acted as the platform to introduce the Program to stakeholders and provided an opportunity for partners to give valuable input into the Year 1 work plan. During the year, the Program hired key personnel, conducted baseline and training needs assessments that provided bench marks to monitor progress, and submitted the Program work plan and Performance Monitoring Plan (PMP). During the 4th quarter, and following the approval of USAID, two large Business Development Services performance-based grants were issued to both the Private Sector Foundation of Uganda and Makerere College of Health Sciences. These performance grants are among several performance based grants that the USAID/Uganda Private Health Support Program is strategically deploying to support a range of activities for which institutionalization and local capacity building are critical to the sustainability of the Program. The goal of the one- year Business Training and Counselling program for the private healthcare sector is to improve the quality of and expand services to healthcare in project targeted locations. The program will provide access to financing, business/financial services training, and hands-on business and financial management counselling to 150 selected healthcare facilities or colleges/schools while building the capacity of the private sector to deliver these services. The Program continued to engage private sector companies and facilities to participate in delivery of quality integrated services using a variety of approaches including training, mentorship, HMIS support, logistical onsite support and support to integrated outreaches to
Year One Report: July 2013-September 2014 Page v USAID/Uganda Private Health Support Program underserved communities. Following the nutrition assessment in Quarter 3, the Program finalised the nutrition capacity building plan and roll out plan for the private sector. 27 health workers were trained during the quarter on nutrition interventions at the community and facility level. Drawing on successes and lessons from Year 1, the Year 2 work plan was developed with focus on consolidating the current gains to support PHPs to offer quality services on a sustainable basis. The emphasis in this area will be on high volume sites, building their capacity to offer integrated services and employing innovative approaches to improve patient retention and follow up. The USAID/Uganda Private Health Support Program is pleased to submit the Quarter 4 and Year 1 annual report.
Principal Achievements Program start-up and management: The USAID/Uganda Private Health Support Program mobilized quickly ensuring coordination among the three main tasks of the Program. The Chief of Party (COP) started work within 15 days of contract signature and all key personnel reported within the first six weeks of the Program. The technical team was fully on board within the first six months. During the first year, the Program added a new 12-month activity involving grants to Private Not-For Profit (PNFP) sites that was transitioned from the Inter-Religious Council of Uganda (IRCU). This new activity has expanded the overall Program team and scope. Overall the USAID/Uganda Private Health Support Program comprises 21 technical staff and 14 support staff. Baseline assessment: To provide benchmarks to monitor progress, forecast outcomes and form the basis for continued learning and operational research throughout the life of the project, the USAID/Uganda Private Health Support Program completed the baseline assessment in Quarter 1. A dissemination meeting was held on 8th November 2013 and the report submitted to USAID on 12th November 2013. Based on the baseline findings and feedback from USAID, the Program PMP with revised targets was re-submitted together with a revised work plan and indicator reference sheets. Cost and pricing study: The purpose of this study was to determine factors that influence the costing and pricing of selected health services in the private sector, and use these findings to inform short and long term strategies to improve affordability of health services in Program targeted districts in Uganda. Dissemination of findings to key stakeholders took place on 31st July 2014. Nutrition assessment: The Program was supported by the Ministry of Health (MOH) to carry out a rapid assessment of nutrition activities at 28 partner health facilities. Findings from this assessment informed the Program on the appropriate nutrition interventions to be carried out at different health facilities. Grants management: The Program developed a grants manual that will guide the granting processes. The grants manual provides a single source of reference for policies and guidelines for solicitation, negotiation, award, and management of grants. In Quarter 1, the grants manual was submitted to USAID for review and approval. During the year, 15 grants were issued to support HIV/AIDS prevention, OVC care and support, build capacity of the Uganda Healthcare Federation and provide Business Development Services for the private sector. Ambassador’s visit to partner private for profit (PFP): The US Ambassador Scott DeLisi and the Swedish Ambassador Urban Andersen visited Rhona Medical Centre in Kansanga, Kampala on 10th April, 2014. The Ambassadors visited the facility to understand the impact of
Year One Report: July 2013-September 2014 Page vi USAID/Uganda Private Health Support Program the Development Credit Authority (DCA) program guaranteed by both governments. The Ambassadors also sought to understand the challenges faced by a typical private healthcare business and strategies employed by the owners/ management. Access to finance: The USAID Health DCA at Centenary Bank has been able to book 56 loans worth $1.385 million or 46.2% of their overall $3 million portfolio limit. Of the 56 loans, 28 (50%) worth $ 690,274 were to businesses located outside the central region. The DCA at Ecobank in its first year (launched in Nov 2013) has booked 2 loans worth $505,882 million or 7.2% of their overall $7 million portfolio limit. One of the 2 loans worth $505,882 went to the construction of a nurse’s training school in Northern Uganda. The portfolio quality of both DCAs is good. There have been no claims nor notices of default made so far under the Ecobank DCA while only one borrower has defaulted under the Centenary DCA. Clinical capacity building: The Program conducted various clinical capacity building courses for private sector health workers as summarized below. > PMTCT Option B+ training for 20 healthcare workers: This was a five-day course targeting healthcare workers that were previously implementing PMTCT Option A. > HMIS/Data Management training for 21 healthcare workers: The course introduced healthcare workers from 21 private health facilities to the MOH data collection and reporting tools. > Safe Male Circumcision training for 30 healthcare workers: This course equipped ten teams of healthcare workers from private health facilities with the skills to perform Safe Male Circumcision. > Malaria case management training for 26 health workers: Emphasis was placed on the evaluation and management of patients presenting with fever in these two service areas. > Two courses in Comprehensive HIV Care for 15 healthcare workers: The course in HIV Management aimed to update clinical officers and nurses on the changes that have taken place in the field of HIV Care over the last two years. Innovative approaches for OVC support: During Quarter 4, the Program signed grant agreements with 10 OVC supporting community based organizations, working in partnership with private sector companies, to address the needs of OVC within their catchment areas. All 10 groups proposed private sector approaches in matching our grants with contributions from private sector partners. Through these innovative partnerships, the Program will leverage over US $215,000 from the private sector against USAID’s $300,000 contribution. District coordination and M&E support: The Program worked with respective stakeholders to ensure that the private sector contribution to health care delivery was appropriately reflected in the national data/reports. Several M&E private sector partners’ meetings were held with participants from MOH, Districts and private sector partners. The meetings discussed the challenges PHPs face in using the HMIS and reporting to districts. The meetings also discussed expectations from MOH/Districts/Partners and the Program and agreed on a way forward. The objective of the meetings was to discuss strategies for improving private health sector engagement and challenges faced by PHPs in reporting through the DHIS-2 using HMIS tools. Web based reporting and logistical support: The Program completed a Logistics Assessment and on-site mentorship. The goal of this activity was to improve private sector ART ordering and reporting through the web based ordering and reporting system (WAOS) in DHIS-2. 97 facilities were visited. During the assessment, facilities were mentored on the ordering, reporting processes, tools (both WAOS and paper based) and the ordering schedule, provided with stock cards, and trained on how to take stock. Two facilities managed to make their orders for the first time since ART accreditation. By the end of the activity there was
Year One Report: July 2013-September 2014 Page vii USAID/Uganda Private Health Support Program marked improvement in submitted orders and reports to JMS from 42% in June 2014 to 68% in August 2014. Implementation of the PPPH Policy: The MOH secured funding for seven staff in addition to the Director of the PPPH Unit. The USAID/Uganda Private Health Support Program worked with the PPPH Unit to build its capacity and systems in a bid to translate the PPPH Policy into action. The MOH has typically struggled to operationalize the PPPH Unit, primarily due to a lack of investment (e.g. number of staff, operating budget, capacity building). In collaboration with the PPPH Unit, the Program assessed the staff’s skills base and systems at the national and district levels. Based on the assessment, the Program designed a sustainability plan that identifies areas for technical assistance and activities requiring financial support to grow PPPH capacity within the MOH.
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Task 1: Expanded availability of health services by private sector providers The USAID/Uganda Private Health Support Program works with health service providers and other key players in both the private and public sector to expand availability of health services through the private sector. Focus in this area is towards building capacity of PHPs for improved geographical coverage, expanded service offerings, and access to capital. Below is a description of strategies and activities that the Program undertook in Year 1 towards expansion of availability of health services by private sector providers.
Task 1.1: Grow number of private facilities offering comprehensive health services The Program worked with private providers to widen the breadth of services to specifically include safe male circumcision (SMC), MCH, FP, TB, PMTCT-Option B+, nutrition, services targeting adolescents and young adults, and ART. In the first year, the Program undertook the following activities:
1.1.1 Conduct project baseline The purpose of the baseline survey was to establish baseline values of the Program monitoring plan and to establish baseline information for other key Program aspects. The specific objectives of the baseline were: > To map out the registered private health service providers in targeted districts including geographic location > To assess the level of private health service providers’ participation in district health service delivery/coordination, HMIS/DHIS-2 reporting, data use and learning > To understand the awareness and implementation of the PPPH policy by private health services providers > Examine current health financing mechanisms (e.g. voucher system, health savings plans, micro insurance & health insurance) including access to finance by private health service providers that support reduction in price of health services and products > Map the key stakeholders (USG and non-USG including their geographic location) that are active in private health service provision in the targeted districts to ascertain areas for partnership and collaboration > Profile the existing public-private partnerships and linkages to reference laboratories, pharmaceutical outlets and CBOs within the targeted districts examining opportunities for enhancing the partnerships. > Assess the level of Knowledge, Attitude and Practices among beneficiaries (boys, girls, youth ––female & male--women and men) towards the use of private health services and factors that influence their uptake/utilization of private health services. > Using known epidemiology data from the districts and MOH, examine the disease burden in the target districts and identify the ‘hotspots’ where Most-At-Risk-Populations (MARPs) operate. Findings from the baseline survey were used to inform programming in Year 1 and develop the Program PMP.
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1.1.2 Engage employers in target districts Throughout the year, the USAID/Uganda Private Health Support Program identified and approached former HIPS private sector partners –– specifically, large employers - and new private sector partner sites in target districts to assess their capacity and interest to expand health services to include SMC, MCH, FP/RH, TB, PMTCT, ART, nutrition as well as services targeting adolescents and women. During the first year, the Program approached a total of 27 key former USAID/Health Initiatives for the Private Sector (HIPS) project partners to introduce the Program, establish formal relationships, solicit input on collaboration mechanisms, and address gaps that appeared after the conclusion of USAID/HIPS. All these employers have onsite workplace clinics that provide HIV/AIDS treatment to employees, their dependents, and surrounding community members. Among these 10 have signed MOUs with the Program. They are New Forests Company, Mpanga Growers Tea Factory Ltd, Rwenzori Commodities, Mabale Growers Tea Factory Ltd., TUMU Group of Companies, Nile Breweries Ltd., Kakira Sugar Ltd, Caring Hands, Kakira Out growers Development Fund (KORD), and Mpongo limited/Lambu. Tullow Oil, Kinyara Sugar Ltd, Hima Cement Ltd, McLeod Russell Uganda, Southern Range Nyanza Ltd, Fiduga Flowers, RoyalVanZanten Flowers (Mukono), Royal Van Zanten Flowers (Wakiso), Bead for Life, Jomo Fruit Company, Kakira Out growers Development Fund (KORD), Music, Life Skills, and Destitution Alleviation, Cornerstone Foundation, Farmers Center, and Uganda Clays Ltd have not yet signed formal MOUs with the Program. The Program also pursued opportunities to leverage resources of other USAID and non-USAID supported implementing partners to provide a comprehensive health package to its clinics. In March, the Program partnered with Program for Accessible Health, Communication, and Education (PACE) and Marie Stopes Uganda (MSU) to create demand for RH/FP services due to their extensive expertise in the area. With PACE, the Program sought to tap into its marketing expertise to create demand for these services at partner sites. The Program also introduced the USAID/SIDA supported DCA program to PACE’s 200 Profam clinics. With MSU, the Program is already working with two of what will eventually be five companies to introduce comprehensive MCH services at Program partner facilities. The Program has also tapped into MSU’s Blue Star franchise network to introduce the USAID/SIDA supported DCA program to its 150 plus Blue Star clinics. The Program linked large tea and sugar estates interested in large-scale malaria control on their estates with the USAID funded Indoor Residual Spraying (IRS) Program. As a result, health focal persons at Toro and Mityana Tea Company Limited and McLeod Russel Uganda Limited have been scheduled to attend the IRS trainings early next year. During the fourth quarter, the Program introduced four private sector partners to the two grantees awarded prevention-related performance based grants, Uganda Manufacturers Association (UMA) and Federation of Uganda Employers (FUE), to start implementing HIV/AIDS prevention activities. These were Kakira Sugar Limited (Jinja), Sugar Corporation of Uganda Ltd (Buikwe), Royal Van Zanten Flowers Ltd (Mukono) and Royal Van Zanten Flowers Ltd (Wakiso). The Program formalised four of these partnerships with Memoranda of Understanding and shared these with both grantees. Four other MOUs were signed during the quarter. These were with the New Forests Company Ltd, Kakira Sugar Limited, Mabale Growers Tea Factory Limited, and Rwenzori Commodities Ltd. This brought the total number of MOUs signed in the year to 10.
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1.1.3 Increase private sector participation in HIV prevention and other programs During the first year, the Program issued two performance based HIV prevention grants to UMA and FUE, as above. The goal of these grants is to increase private sector participation in HIV prevention and other programs. UMA and FUE have so far engaged 30 companies to deliver a range of health services that include HIV counseling and testing, condoms distribution, peer education and safe male circumcision. To date, 218 people have been circumcised, 2,245 have received HCT services, 106 people have been trained as peer educators at three companies, 16,072 male condoms have been distributed through 11 condom outlets, and 50 MARP peer educators have been trained at two companies. The Program also engaged all aforementioned 10 companies with signed MOUs to encourage their private sector facilities to participate in HIV prevention activities. The Program, through the prevention grantees, ensured that all 10 private sector facilities with which it had MOUs and the seven that had signed MOUs with the grantees were availed with the necessary MOH tools and registers to adequately report to the district. The Program also ensured they were linked to JMS and other implementing partners (IPs) to receive family planning commodities. During the fourth quarter, the Program approached two new partners, Royal Van Zanten – Wakiso and SOS clinic – Kakiri. At Royal Van Zanten, the Program is working to increase the scope of health services the company clinic provides to include HIV/AIDS treatment since the company agreed to open its doors to surrounding community members. The Program will support the company clinic to receive MOH accreditation to offer ART. The Program has already linked the company to FUE to start supporting onsite and off-site prevention activities. These include peer education trainings and integrated community health outreaches. The Program also scheduled the facility’s two medical personnel for clinical capacity building trainings. At SOS clinic – Kakiri, the Program will work with the facility to open up its doors to more community members and to get accredited by MOH to start providing AIDS treatment. The Program will also link these services to the site’s HIV-- positive OVC beneficiaries. Still during the quarter, the Program supported implementation of 16 integrated outreaches at high volume partner private sector facilities at Kakira Hospital in Jinja; SIMS Medical Centre, Uganda Baati and Span Medicare in Kampala; Kyotera Medical Centre in Rakai; Mabale Tea Estate Clinic in Kyenjojo; Community Health Plan in Wakiso District; Mehta Hospital of Sugar Corporation Lugazi (SCOUL) of Buikwe District; Family Health Resource Centre in Kiruhura District; Rwenzori commodities tea estate clinic and TAMTECO-Tooro Kahuna in Kabarole. Services offered to the community included HIV counselling and testing, SMC, malaria testing diagnosis and treatment, TB diagnosis, FP, MCH, nutrition, condom distribution as well as provision of health education messages on disease prevention and behaviour change.
Table 1: Safe Male Circumcision1
Indicator 2-< 5 5-14 15-49yrs 49+ Years Quarterly Cumulative Annual Target Years Years Total Total Number of clients 101 1,309 2,301 238 3,949 9,650 9,000 counselled, tested and received HIV results as part of SMC package
1 Please note for all results tables: cumulative totals may not necessarily add up to Quarter 3 cumulative and Quarter 4 numbers because the Program recently carried out data cleaning for all Program data from October 2013 onwards, and added data that had been missing. The Program used the MEEP HIBRID data which is the reference data for USAID. There were no trainings carried out during Quarter 4.
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Number of males 123 1,574 2,838 240 4,775 10,426 10,000 circumcised as part of the minimum package of MC for HIV prevention services disaggregated by age Indicator Severe AE(s) Moderate AE(s) Quarterly Cumulative Annual Target Total Total Number of circumcised 0 0 0 14 51 clients experiencing at least one moderate or severe adverse event (AE) during or following surgery, within the reporting period
Table 2: Condom Distribution
Indicator Quarterly Total Cumulative Total Annual Target
Number of condoms distributed 29,870 342,880* 500,000 Number of targeted condom outlets 69 100
* Program expected partners to request for these condoms directly. When we realized this was not happening, the Program started requesting for them on their behalf. The Program has taken the two HIV/AIDS prevention activity grantees, FUE and UMA, through the right process of ordering for condoms.
Table 3: Counselling and Testing
Indicator < 5 Years 5-17 18+ Years Quarterly Cumulative Annual Target Years Total Total Number of individuals who received testing 475 1108 20985 22,568 113,449 100,000 and counselling services and received their test results Total number of individuals who received 9 74 1,008 1,091 4,062 6,000 Testing and Counselling (T&C) services for HIV and were found HIV Positive Number of service outlets providing T&C 67 109 services
Table 4: Prevention of Mother to Child Transmission (PMTCT)
Indicator Single-dose Maternal Maternal Lifelong ART or Quarterly Cumulative Annual Target nevirapine AZT + triple ARV already on ART Total Total (SD NVP) others Prophylaxis (HAART/Option B+) or Option B+ Number of HIV+ 2 83 224 316 625 1,974 1,123 women receiving ARVs to reduce MTCT Number of service outlets providing PMTCT services 48* 65 Number of women attending 1st ANC visit at service outlets 2,125 16,028 20,000 Number of pregnant women with known HIV status (includes women who tested for HIV and 18,720 3,838 24,513 received their results) Number of HIV+ pregnant women identified during the reporting period 349 2,881 1,123
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* Not all sites could meet the accreditation requirements to offer PMTCT services. However in year 2 new health facilities have been identified for accreditation.
Table 5: Early Infant Diagnosis
Indicator PCR1 PCR2 Quarterly Cumulative Annual Target Total Total Number of exposed infants tested for HIV below 18 139 146 285 916 600 months Percentage of exposed infants testing HIV positive below 18 months 11% 11%* 8% * Lack of mother-baby pair follow up at the sites to increase retention in care is one of the main reasons for not meeting the 8% target. During the second year, the Program will increase mother-baby pair retention at facilities through improved follow up. This will be achieved through the clinical grant.
Table 6: Malaria
Indicator Quarterly Cumulative Annual Target Total Total Number of women receiving 2 or more doses of IPT for malaria 1,080 7,755* 14,000 Number of health workers trained in IPTp 0 50 50 * IPT in the private sector is provided at a cost and no free Fansidar was supplied to the sites to be given to pregnant women
Task 1.2: Expand private sector capacity Lack of provider competence and capacity has led to low availability of quality health services in the private sector. In Year 1, theProgram developed technical capacity of private sector healthcare providers at both the individual and facility levels to provide comprehensive services.
1.2.1 Design and implement a clinical capacity building program The Program built the technical capacity of private healthcare providers through training in health service packages such as expanded TB, malaria, MCH, nutrition, FP, and HIV/AIDS services (including HCT and ART). During Year 1, the USAID/Uganda Private Health Support Program carried out a training needs assessment to identify the knowledge, skills, and competencies needed to deliver improved comprehensive primary healthcare services. The assessment was limited to aspects that directly influence provision of comprehensive primary healthcare packages at a health facility, such as the human resource, infrastructure and the logistical supplies essential in the provision of HCT, SMC, nutrition and PMTCT Option B+; pre-ART and ART, pediatric HIV care, TB treatment, malaria treatment and laboratory tests as well as data management. A detailed report was shared with USAID.
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The Program conducted various clinical capacity building courses for private sector health workers as summarized below. > PMTCT Option B+ training for 20 healthcare workers: This was a five- day course targeting healthcare workers that were previously implementing PMTCT Option A. The goal was to equip them with knowledge and skills to start implementing PMTCT Option B+ according to the new National Ending One of the MoH facilitators delivering a session Mother to Child Transmission during the PMTCT training that took place at IDI in (EMTCT) guidelines. April 2014 To further improve PMTCT Option B+ service delivery in the private sector, the USAID/ Uganda Private Health Support Program launched the first distance learning course in PMTCT Option B+ with 11 trainees from large private sector PMTCT sites within Kampala. The course started off with a two day face-to-face workshop held at the Infectious Diseases Institute (IDI) Learning Hub during which they became familiar with the Virtual Learning Environment (VLE) and the basics of ART and PMTCT. Following the face-to-face workshop, trainees began independently studying six modules, one per week, covering: primary prevention, family planning, ANC, ART, safe delivery practices, exposed infant care, and reporting. Trainees are assessed through online assignments, and participation in forums. Trainees were given modems and data to enable them to access the VLE and CDs with offline versions of the modules. This online course was successfully completed by nine out of Midwives from Private Health facilities in Kampala the eleven trainees that started the and Wakiso attending the introductory face to face sessions of the PMTCT online Course at the IDI in course. March 1 2014 > HMIS/Data Management training for 21 healthcare workers: The course introduced healthcare workers from 21 private health facilities to the MOH data collection and reporting tools. The training also addressed the MOH reporting requirements and how to improve private sector compliance to these reporting requirements. The course was sponsored by the Program and provided by IDI at IDI’s training facility.
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> SMC training for 30 healthcare workers: This course equipped ten teams of healthcare workers from private health facilities with the skills to perform SMC. Each team consisted of a surgeon, theater assistant and counsellor. This course was sponsored by the Program and provided by IDI at IDI’s training facility. > Malaria case management training for 26 health workers: the second Fever Case Management Course was adapted for midwives and nurses working in the antenatal and Young Child Clinics (YCC). Emphasis was placed on the evaluation and management of patients presenting with fever in these two service areas. Clinical Officers and Nurses attending the The healthcare workers were also Comprehensive HIV Course for Mid-Level taught about Intermittent Practitioners at IDI Presumptive Treatment of Malaria in Pregnancy (IPTp). The course was sponsored by the Program and provided by IDI at IDI’s training facility. > Two courses in Comprehensive HIV Care for 15 healthcare workers: The course in HIV Management aimed to update clinical officers and nurses on the changes that have taken place in the field of HIV Care over the last two years. Healthcare workers from health facilities which are part of the Quality Improvement Program implemented jointly with the USAID ASSIST Program were specifically targeted for this training. To further strengthen technical capacity of private healthcare providers the Program conducted integrated post training and on site mentorship for the healthcare workers who were trained. Working in groups, the teams mentored a total of forty healthcare workers from 34 healthcare facilities in nine Districts (Hoima, Fort Portal, Masindi, Kyenjojo, Kibaale, Masaka, Kiruhura, Mubende and Kasese). The activity was carried out in partnership with MOH AIDS Control Program, the Resource Center and the Central Public Health Laboratory. Multidisciplinary teams comprising of three trainers (clinical, lab and data personnel) each visited the health facilities to assess knowledge retention and the implementation of the principles that were taught during the training. Most of the health facilities were making an effort to implement new practices that they had been taught. The major challenges as noted by the follow-up teams were lack of HMIS tools that affected recording and reporting. In order to bridge this gap in reporting, the Program planned to print and distribute these. However, this has taken longer as we await the MOHMOH Resource Center’s finalization of the new tools. As a result of the mentorship, two health facilities (Rwenzori Commodities Buzirasagama and McLeod Russel Muzizi Estate Clinic) started PMTCT Option B+ programs after the training and mentorship
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Table 7: Private Sector Health Worker Training
A participant from Nile Breweries Clinic receiving a certificate of completion from the Deputy Head of Training at the IDI following the end of the Comprehensive HIV Course for Clinical Officers and Nurses. Indicator Quarterly Cumulative Annual Target Total Total Number of health care workers who successfully completed an in-service training - 241 220 program during the reporting period PMTCT Option B+ - 59 45 SMC - 30 30 Pediatric HIV - 0 15 TB/HIV Co-Management - 15 10 Laboratory - 20 20 Data management / HMIS - 40 40 Advanced HIV Management - 10 10 Comprehensive HIV Management - 15 0 Integrated Management of Malaria - 50 50
1.2.2 Expand the Private Public Partnership Laboratory Network During Year 1, the Program trained a total of 20 health workers in laboratory techniques and good laboratory management at IDI. Participants came from accredited private sector sites providing ART and PMTCT services. The PPP-HIV reference laboratory became operational in January 2014. SIMS Medical Laboratory installed the CD4 FACS Count machine during the first week of January and the laboratory staff were trained on how to use the equipment. The HIV PCR-Viral load machine was installed on January 20th and staff were trained on use of the machine. The Program has linked the SIMS lab to the private sector partners (starting with the ones in the Kampala area) so that private sector clinics can start sending samples. The Lab also received 100 CD4 lab reagents from JMS. The Program held discussions with Central Public Laboratory (CPHL)—now National Public Laboratory (NPHL)—to ensure Program support to the national strategic plan and contribute to the strengthening of laboratory services. The Program shares related quarterly reports with NPHL.
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The Program held discussions with the Uganda Virus Research Institute (UVRI) and other private sector laboratories’ leadership to ensure high quality lab services. From these discussions, it was agreed that: i. UVRI would offer capacity building support to some private sector labs including testing training. ii. UVRI and the Program could collaborate in mutually benefiting research areas.
1.2.3 Support child nutrition and development During Year 1, the USAID/Uganda Private Health Support Program held meetings with (a) the USAID Food and Nutrition Technical Assistance (FANTA) Project (b) the Ministry of Health AIDS Control Program and (c) the MOH nutrition unit. The goal of these meetings was to design an implementation plan for assessment of nutrition gaps, training, counselling and support as well as ensuring provision of the Ready to Use Therapeutic Food (RUTF) for patients in the partner private sector health facilities. It was agreed that the plan for nutrition activities in the private sector would include: > Training of private health care staff in nutrition assessment, counselling and support (NACS): The FANTA / MOH NACS training curriculum for trainers will be used by the Program to carry out the training with support from MOH National and Regional trainers. > Development of HMIS tools for NACS: FANTA and MOH have incorporated nutrition indicators into the new HMIS tools (HMIS 105) to be launched and made available for use at health facilities where reports on performance indicators would be done through DHIS- 2. > Provision of equipment for NACS: the equipment needed to include Mid-Upper Arm Circumference (MUAC) tapes, height/length boards, weighing scales, wall charts and FANTA will recommend the possible suppliers for their procurement. The programs will as much as possible avail these items to the private sector facilities (where required). > Provision of RUTF: the Program has held discussions with USAID on inclusion of at least two private sector sites for RUTF. The Program has carried out a quick assessment of these two sites for quantification of RUTF needs for severely malnourished patients. Following the above meetings, the Program worked with the MOH nutrition unit to conduct a rapid assessment of nutrition services at private sector facilities. The goal of the assessment was to ascertain the status of nutrition services, the health workforce available to implement nutrition activities and any capacity gaps that may exist among the healthcare workers. The assessment report was disseminated on the 31st of July 2014 during a meeting attended by 69 stakeholders from the private sector, MOH and USAID implementing partners. Summarized findings from the assessment were: > PFP staff did not have sufficient knowledge on Nutrition Assessment, Counselling and Support (NACS). None of the staff at the health facilities visited had undertaken any course in Integrated Management of Acute Malnutrition (IMAM), Infant and Young Child Feeding Counselling (IYCF), NACS, or Baby Friendly Health Facility Initiative (BFHI). > MUAC taking and follow up of nutrition care are not routine services provided in the majority of the health facilities and over 70% of the health facilities did not have a nutrition focal person; this negatively impacts the quality of services provided. However, the PFPs were very positive about integrating nutrition services in the health service delivery system courses. > Micronutrient supplements--iron/folate, folic acid, vitamin A--were available at some health facilities although some HC IVs, HC IIIs and HC IIs had run out of stock.
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During Quarter 4, a nutrition training for 27 health workers from the private sector was carried out to equip them with skills on NACS, IMAM, IYCF, NACS, or BFHI Site support supervisions for the trained health workers will be done as well as continued training health workers from all partner private health facilities.
1.2.4 Assume management of the NBL PPP During the first year, the Program effectively resumed NBL PPP activities. The Program developed an MOU with NBL clearly indicating each partner’s responsibilities, expected contributions, and time frame for completion. The MOU outlined specific activities that would be implemented under the PPP such as home based counselling and testing and sensitization of MARPs. The partnership kicked off in April 2014 with prevention activities that included HIV counselling and testing, condom use promotion and distribution, and peer education. The PPP targets NBL’s truck drivers, smallholder farmers and bar tenders/hospitality workers. The Program also supported two health facilities operating in Dokolo and Katakwi to provide treatment and other HIV/AIDS related services to aforementioned MARPs. Specific activities included: > Two peer education trainings conducted for a total of 50 participants > 1,134 individuals (186 truck drivers and 948 hospitality workers) reached with health messages by the peer educators through one-on-one sensitizations and small group approaches. They were sensitized on HIV prevention, positive living, malaria prevention and treatment, and family planning > Three HCT outreaches/health fairs conducted for truck drivers and hospitality workers in Mbarara and Wakiso districts. A total of 1,555 individuals were tested for HIV/AIDS. > Home based testing and counselling services provided in Adok sub-county, Dokolo district: a total of 1,589 small scale farmers tested for HIV/AIDS.
Table 8: NBL PPP achievements FY 2014
Result Area Achievement Training community based peer educators to provide prevention messages and peer-education to 50 truckers, bar workers and smallholder farmers as well as to their partners. People reached with health messages through peer education 1,134 Providing VCT/HCT services to truckers and bar workers 1,555 Scale up of HBHCT for small holder farmers (Dokolo) 1,589 Training of bar owners and bar workers on responsible alcohol consumption 346 Procuring and distributing of condoms 83,520 During Quarter 4, the Program received USAID approval of two consultants to carry on NBL PPP activities. Due to the timing of the approval, the two proposed consultants will resume PPP activities in October for a duration of three months. The Program has also scheduled a data quality assessment exercise at two PPP sites in Dokolo and Katakwi. These will take place in the next quarter. Key planned activities for the next quarter > Resume NBL/OGAC partnership for the next three months by signing new contracts with the consultants. > Conduct Data Quality Assessment for the Home Based Couple Counselling and Testing program in Adok sub-county, Dokolo district.
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1.2.5 Support innovative approaches for orphans and vulnerable children During the first year, the National OVC policy and other Ministry of Gender, Labor and Social Development (MGLSD) guidelines and tools were disseminated among the 10 OVC partners/grantees to guide them in their implementation. The Program oriented the partners on the completion of the OVC service register and district summary reporting formats. The Program also conducted a capacity assessment to establish existing technical and organisational capacity gaps. During the exercises, the Program team and each of the Program Staff meet with Kakira Outgrowers Rural OVC partners developed capacity building Development Fund (KORD) and an OVC care giver in plans. The Program also guided the partners Mafubira Sub-county Jinja District. on the use of the OVC vulnerability assessment tool. The Program pre-tested the tool with them and came up with a way forward on how best to conduct the assessment. The Program also participated in the MGLSD IP’s coordination meeting and formally introduced the USAID/Uganda Private Health Support Program to the Ministry and other IPs. The Program received a $3,000 donation that was raised by Cardno Washington DC staff through their annual Cake-Off Bake sale. The Program allocated the donation to a former USAID/HIPS partner, Music Life Skills and Destitute Alleviation (MLISADA) in June 2014. Through the donation, 30 OVC have been provided with scholastic materials while maize and vegetable seeds have been procured and planted for 100 OVC. Also 15 HIV positive OVC were identified, facilitated and referred to the Mildmay Center for care and treatment. In addition, MLISADA also supported eight caretakers boost their incomes by supporting them with start-up funding to engage in income generating activities such as tailoring and fresh food retailing. During the fourth quarter, the Program signed performance based grant agreements with 10 OVC supporting community based organizations, working in partnership with private sector companies, to address the needs of OVC within their catchment areas. All 10 groups proposed private sector approaches in matching our grants with contributions from private sector partners. Through these innovative partnerships, the Program plans to leverage over $215,000 from the private sector against USAID’s $300,000 contribution. The Program distributed and disseminated the National OVC policy and other ministry guidelines and tools among the OVC grantees to guide them in implementation.
Task 1.3: Increase demand for and access to credit by private providers The current engagement of financial institutions in the private health sector is not well understood, nor are the financial needs of private health providers in Uganda.
1.3.1 Identify the constraints and opportunities of financial institutions in Uganda to serve private health sector providers During the year, the Program embarked on understanding the health lending market to the private health sub sector by: (a) Engaging Compuscan, the Bank of Uganda licenced the sole Credit Reference Bureau (b) as part of the Program baseline survey, collecting information on
Year One Report: July 2013-September 2014 Page 19 USAID/Uganda Private Health Support Program establishing the current use of financial services by private health providers and their projected financial needs in the near future and (c) working together with Centenary Bank and the Credit Reference Bureau on the identification and extraction of the required records from the credit bureau before any analysis can take place and thereafter perform analysis on the data. Outcomes of these activities were: (i) Private Health Lending Report (Compuscan Report): that gives an up-to-date status of current lending to the private health sector based on market data. The report sheds light on the use of financial services (financial inclusion) by private health providers and projected financial needs in the near future based on the baseline survey will be part of the health sector lending report. (ii) Health impact baseline assessment: In response to SIDA’s request, we gathered baseline data on each Centenary borrower as at the end of December 2013. The Program has established a baseline of health services impact of the DCA. Continued technical assistance to DCA Banks is needed in the following areas: (1) additionality to the DCA especially in strategies that will lead to reduction of interest rates and collateral requirements. Some of the strategies include leveraging the portion of the DCA guarantee (i.e. 50% of loan amount) as a direct contribution in the reduction of the collateral requirements. This has commenced with two borrowers under the Centenary Bank DCA portfolio. Other strategies include providing financial management and business skills training to improve financial record keeping (especially cash flows) that are determinant used by banks to determine the risk rating for the facilities enabling them to attract a lower interest rate ; (2) ensure that borrowers fully understand the interest rates and charges they are paying; (3) provide a shorter approval period that would enable borrowers to better plan the use of the loan; (4) provide longer repayment periods for equipment financing; and (5) ensure borrowers make appropriate loan requests for loan use and follow-up to monitor proper loan use (6) assist Ecobank to meet its female loan participation target. The Program will link DCA borrowers to appropriate training to enable them start reporting via the HMIS. See Annex for executive summary of report. (iii) Housing financing assessment: New financial products such as housing finance have been explored. The Program undertook a survey of available health specific housing financing from the existing providers (eight commercial banks) and completed the housing finance needs survey of private healthcare businesses and health workers with the aim of developing a suitable product. We assessed the demand, feasibility and proposed terms and conditions for housing finance for private health providers and health workers. A validation workshop with 36 participants to discuss and vet the study’s findings was carried out. The Program will explore if a relationship can be built with a commercial bank to extend more flexible conditions to health clinics for renovations and housing. Proposals were made recommending micro-mortgages as the most suitable housing financing product that could be rolled out to eligible and qualified private health borrowers under two commercial banks (Equity and Stanbic Bank).
1.3.2 Work with DCA banks and other financial institutions to expand lending to the private health sector in Uganda The DCA at Ecobank in its first year (launched in Nov 2013) has booked two loans worth $505,882 million or 7.2% of their overall $7 million portfolio limit. One of the two loans worth
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$ 505,882 went to the construction of a nurses’ training school in Northern Uganda. The Program’s Year 1 work with EcoBank has produced strong results: > Ecobank booked their first loan under the DCA. The borrower is located in Lira Town and has taken out a loan worth UGX 2,000,000,000. The borrower profile is that of First Time, New Borrower/Business. Since the maximum cumulative principal amount of qualifying loans made to any one qualifying borrower is the local currency equivalent of $500,000 (UGX. 1,275,000, 000), the balance of $200,000 (UGX 725,000,000) will be booked outside the DCA. The purpose of the loan is to equip and finish construction of a Nurse Training School and has a maturity period of 5 years. The loan was taken out at interest rate of 23%, which has a 0.5% margin above the bank prime rate of 22.5%. The repayment plan is instalment of UGX 200,000,000 per school term (3 terms in a year). A second loan worth $15,686 has also been booked. The loan purpose is purchase of medical equipment. > Ecobank DCA Utilisation has reached a cumulative total utilisation of UGX 1,290,000,000. See the tables and figures below. The portfolio quality of the Ecobank DCA is good. There have been no claims nor notice of default made so far under the Ecobank DCA portfolio. > The Program has continued to provide technical assistance to Ecobank to help them build a credit pipeline under the Ecobank DCA for Medical Equipment and Construction and expansion financing. > To date The Program has built a medical equipment financing loan portfolio worth $24,186. The target is to build a credit pipeline worth $700,000 equivalent to 10% of the total DCA guarantee amount by end of December 2014. Strategically, it has been agreed that Ecobank leverage its DCA for equipment loans given that: (1) it has a limited branch network. It has 11 branches in the Central Region with only two outside (Jinja branch which was opened in March 2014 and Mbarara which was opened up in July 2014; (2) the size of its DCA compared to Centenary ($7 million versus $3 million); and (3) the significant demand for equipment loans from the healthcare sector. > Ecobank has been slow to draw in female owned healthcare businesses into the health DCA portfolio. This is attributed to their lack of expertise and lending strategies in attracting this particular borrower type. In the coming quarter the Program will give dedicated TA to Ecobank to assist it with its outreach to female borrowers to meet the 15% DCA utilisation rate set for this target market by Year 7.
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Figure 1: Utilisation of Ecobank DCA to date (Disaggregated by borrower type)
100% 100% 100% 90% 80% 70% 60% 50% 50% 50% 50% 50% 40% percentages 30% 20% 10% 0% 0% 0%
100% 100% 100% 90% 80% 70% 60% 50% 50% 50% 50% 50% 40% percentages 30% 20% 10% 0% 0% 0%
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Table 9: Utilisation of Ecobank DCA to date (Disaggregated by borrower type)
Indicator Quarterly Total Cumulative Annual Target Total Overall utilization of the DCAs for Ecobank % 7.2% 10% Numerator 7.2% 1,290,000,000 1,785,000,000 UGX UGX Denominator 1,290,000,000 17,850,000,000 17,850,000,000 UGX UGX UGX Number of relationships established with banks (DCA & non 7 10 DCA) Urban 4 5 Rural 3 5 Percentage of Development Credit Authority ( DCA) bank loan 7.66% 10.1% 30% portfolio held by private health provider borrowers that are not current clients of the DCA bank Overall utilization of the DCAs for Ecobank 7.23% 7.23% 10% Rural 7.00% 7.00% 5% Urban 0.22% 0.2% 95% New borrowers 7.00% 7.00% 53% Existing borrowers 0.22% 0.2% 47% Female Owned Business 0.00% 0.00% 17% Business Borrowers 7.23% 7.0% 44% Individual/owner Borrowers 0.00% 0.00% 32% Number of relationships established with banks (DCA & non DCA) 4 10 Percentage of participants attending Access to Finance workshops 0.00% 20% that are successful in their loan applications Percentage of successful loan applications from rural private health 7.66% 50% providers outside the central region (both under the DCA and non DCA financial institutions)
Overall USAID/SIDA Health Centenary Bank DCA progress to date:
> The USAID Health DCA at Centenary Bank had by the end of Year 1 been able to book 56 loans worth $1.385 million or 46.2% of their overall $3 million portfolio limit. Of the 56 loans booked so far, 28(50%) worth $690,274 were to businesses located outside the central region. Centenary Bank DCA Utilisation has reached a cumulative total of UGX 3,532,200,000. See the figures and table below. The portfolio quality of the DCA is good. There has been only one notice of default made so far in the program, and nine loans have since been fully paid off. > In November 2013, USAID made preliminary assessments of the DCA and made suggestions to re-orient the DCA loan disbursements and advised Centenary Bank to place a temporary halt to loan disbursements. The goal was to ensure that there is objectively verifiable additionality to the DCA so that new clients (outside the bank’s existing ones) are signed up; demonstrate that there has been an increase in the loan sizes; and demonstrate that the collateral requirements and or interest rates have been made less onerous as a result of the DCA. In response the Program assisted Centenary Bank to identify and lend to first time borrowers. The Program built a Rural, First Time, and New Borrower Pipeline,
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comprising of 4 loans worth $58,309. The loans included one female owned private healthcare business who took out a loan worth $ 7,800. > The four new, first time rural loans were put to the following purposes: purchase of land to construct shelter for out-patients at a clinical facility; purchase of property in which clinic was previously renting; purchase medical equipment; and complete construction of a new clinic.
Figure 2: Utilisation of Centenary DCA to date (disaggregated by borrower type)
90% 88% 90% 83% 80% 70% 60% 50% 50% 50% 40%
PERCENTAGES 30% 17% 20% 10% 12% 10% 0%
90% 88% 90% 83% 80% 70% 60% 50% 50% 50% 40%
PERCENTAGES 30% 17% 20% 10% 12% 10% 0%
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Table 10: Utilisation of Centenary Bank DCA (Disaggregated by borrower type)
Indicator Quarterly Total Cumulative Total Annual Target Overall utilization of the DCAs for Centenary Bank 0.65% 46.2% 70% Numerator 50,000,000 UGX 3,532,200,000 5,355,000,000 UGX UGX Denominator 7,650,000,000 7,650,000,000 3,000,000 UGX UGX UGX Percentage of Development Credit Authority ( DCA) bank loan 7.66% 30% portfolio held by private health provider borrowers that are not current clients of the DCA bank Overall utilization of the DCAs for Centenary Bank 0.65% 41.35% 70% Rural 0.65% 23.0% 18% Urban 0.84% 23.2% 82% New borrowers 0.65% 4.9% 54% Existing borrowers 0.84% 1.2% 46% Business Owners 1.49% 21.4% 45% Individual/Owner borrowers 0.00% 18.5% 38%
> The Program has engaged with Equity Bank; Crane Bank and Gold Trust Bank (non DCA banks) currently engaged in health lending. The Program has agreed to work with them to set up a referral system to channel non DCA bank borrowers to these banks. During the year we made client referrals to Ecobank of potential clients. First referral is of a client who is seeking financing to construct a pharmaceutical plant worth $780,000.The Program also brokered the linkage between a cohort of dental firms under the umbrella of the Uganda Dental Officers and Technologies Association (UDOTA) and Ecobank to facilitate the possibility of future loans. The dental firms are seeking financing to purchase dental equipment. The Program also referred to Ecobank two (2) potential clients: one a Medical Health Centre in Kampala seeking up to $500,000 and another in Mityana Medical Centre $65,000 referred. Credit applications are still under appraisal.
Table 11: Bank Referrals/ Relationships established with DCA Banks
Number of relationships established with banks (DCA & non DCA) 7 10 Percentage of participants attending Access to Finance workshops that are successful 11% 20% in their loan applications Percentage of successful loan applications from rural private health providers outside 28% 50% the central region (both under the DCA and non DCA financial institutions) Number of relationships established with banks (DCA & non DCA) 3 4 Urban 2 2 Rural 1 2 > During the year the Program developed a DCA loan monitoring tool that has been adapted by both DCA banks.
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> The Program has provided technical assistance to both Centenary and Ecobank to map out the entire credit process for pipelines under the DCA. The purpose of the mapping was to establish bottlenecks and constraints in the lending procedure. Solutions to reducing or eliminating these bottlenecks have been identified and shared with the bank for implementation. Solutions identified will mitigate cost and delays in the loan process. > USAID and the Office for Development Credit determined the Program’s report recommendation for a third DCA commercial bank unnecessary. Instead USAID decided to launch a new DCA for girl’s education.
1.3.3 Provide assistance to current and potential borrowers of DCA Bank (Centenary Bank and Ecobank) and other banks currently involved in lending to the health sector The Program refined and revised an existing Access to Finance (A2F) curriculum developed by Banyan Global. A shorter and more targeted 3-hour session was developed for the Uganda A2F workshops, which will be delivered with two objectives in mind: (1) offer an initial introduction on financing, (i.e., is borrowing risky, why should health clinics borrow?); and (2) provide a platform for the banks to introduce their offerings and provide the entry point for potential borrowers into a health credit pipeline of either a DCA or non DCA bank. During the year the Program held nine A2F workshops for 82 private healthcare service providers drawn from the Profam (PACE) and Blue Star (Marie Stopes) franchises. Trainings were conducted in conjunction with the Centenary Bank staff at the bank premises. Participants were equipped with financial management skills required to successfully borrow under the DCA. The A2F workshops equipped the potential borrowers with the skills to articulate their financing needs through viable project proposals backed with financing plans. Out of the 82 participants, 54 have expressed a firm interest to borrow and are being assisted by the USAID/Uganda Private Health Support Program accordingly. Up to 15 of the A2F workshop participants wishing to go ahead and borrow under the DCA have received one-on-one follow on assistance with their loan applications following the A2F workshops held so far. During the year, the Program worked with the Applying Science to Strengthen and Improve Systems (ASSIST) Project, to establish a framework for channelling DCA borrowers into the ASSIST Project processes of continuous quality improvement. The P also engaged with private health networks and other partners in scaling up business strengthening and access to finance activities (PACE, UHMG, MSH/SURE, and Marie Stopes). All these will be formalised in an MOU between the private health networks and USAID/Uganda Private Health Support Program partnerships in Quarter 2. The Program assisted one distressed borrower under the Centenary DCA to reschedule his loan due to the cash flow constraints that the healthcare business faced after taking out a DCA loan. Rescheduling of loan repayments was made following a written request of the agent and a modification made on both the loan tenor (36 months to 48 months) and monthly instalment repayment amounts (from UGX 3,900,000 down to UGX 2,600,000) on a UGX 100 million loan.
1.3.4 Provide business strengthening assistance to USAID/Uganda Private Health Support Program target private facilities An MOU was signed between the USAID/Uganda Private Health Support Program and PACE. Under the partnership the USAID/Uganda Private Health Support Program will increase access to health financing for PACE franchisee clinics to both the credit guarantee schemes in the USAID health DCA and to non DCA banks. In addition to facilitating access to finance, the USAID/Uganda Private Health Support Program will provide business development services
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(BDS) to PACE partner clinics and drug stores. These will be based on a full due diligence carried out on the individual clinics and drug stores to determine their capacity gaps. The Program will thereafter tailor targeted business strengthening activities for the clinics to increase their profitability and suitability. Business development services include financial management training, business skills training, financial literacy workshops, and business counselling and advisory services. A due diligence tool for determining capacity gaps as well as business counselling needs of private healthcare businesses has been developed, tested and now used extensively to carry out a due diligence on all the DCA borrowers. The tool has also been adapted to capture baseline data to measure the health impact of DCA borrowers. The tool has also been used to collect data in the TA we are giving banks in creating credit pipelines that are aligned to USAID development objectives. The Program awarded two performance based grants to two grantees (not for profits-PSFU and Makerere College of Health Sciences) to deliver Business Skills, Financial Management Training and Business Counselling. Grantees are to commence implementation in October 2014. A Financial Literacy training and mini A2F workshop for the MSH SURE Drug Resellers Training in Kyenjojo was carried out during the year.
Task 1.4: Improve private sector participation in district service delivery coordination The Uganda MOH outlined the PPPH as one of the mechanisms to enable implementation of the 2010/11 – 2014/15 Health Sector Strategic Investiment Plan (HSSIP). Objective 5 of the plan focuses on effectively building and utilizing the full potential of the public and private partnership in the health sector. In Year 1, theProgram contributed as follows:
1.4.1 Strengthen district PPPH coordination During the first year, the Program engaged 17 districts to align private health sector partners’ activities with district health plans. The focus was to develop joint strategies on how best to coordinate private health sector activities. These were Kabarole, Mukono, Kyenjojo, Jinja, Dokolo, Buikwe, Mpigi, Mityana, Mubende, Nakasongola, Lira, Masindi, Hoima, Rakai, Masaka, Wakiso and Kasese. In addition to sharing its technical work plans and existing MOUs, the Program ensured that it was also a signatory on the existing implementing partner agreements that were shared with each district via the district management committee meetings. The Program also reviewed policy materials on PPPH district coordination mechanisms in other East African countries. The Program will work with the MOH PPPH unit to adapt the materials to local Ugandan context and share them with PPPH district focal persons to guide their PPPH activities at district level. During the fourth quarter, the Program completed the assessment of PPPH coordination in 15 districts. The assessment report was shared with the Ministry of Health- PPP unit. It will also be shared with all Program district health offices. The assessment revealed that only eight districts (Jinja, Buikwe, Mukono, Mubende, Kyenjojo, Kabarole, Dokolo, and Masindi) had PPPH desk officers. Even in these eight, the presence of desk officers did not imply desk functionality. For instance Jinja district was the only one with an active PPPH desk officer and a vibrant PPPH coordination team. The Program noted that in Jinja, the desk officer (1) had a job description and appointment letter, (2) the DHO was very supportive, (3) the DHMT was aware of and understood the PPPH policy, and (4) the private sector was heavily involved. It
Year One Report: July 2013-September 2014 Page 27 USAID/Uganda Private Health Support Program was evident that all the districts will require a lot of capacity building if their PPPH units are to perform as expected. The Program has documented best practices from this district to be shared with the other districts. The Program held PPPH coordination meetings in Kamwenge and Kyenjojo districts. The coordination meetings revealed that some districts, such as Kamwenge, in addition to not having a PPPH desk officer, did not even work with the private health sector at all. The two only interfaced during registration and licensure of private health facilities. Kyenjojo district on the other hand had formed an association of private sector actors called the Kyenjojo Private Health Practitioners Association. See Annex 2 of the report.
1.4.2 Strengthen the Health Management Information System and integrate in DHIS-II To strengthen efficiency of service provision within the private sector and to ensure that the private sector’s contribution to healthcare delivery is adequately reflected by national data, the USAID/Uganda Private Health Support Program strengthened data collection and reporting within the private sector and worked to integrate private sector outputs in the National District Health Information System (DHIS-2). During Year 1, the Program worked with respective stakeholders to ensure that the private sector contribution to health care delivery was appropriately reflected in the national data / reports. On 22nd January 2014, an M&E Private Sector Partners’ meeting was held with participants from MOH, Districts and private sector partners. The meeting discussed the challenges PHPs face in using the HMIS and reporting to districts. The meeting discussed expectations from MOH/Districts/Partners and the Program and agreed on a way forward. Following the above meeting, district meetings were held in Kampala, Jinja, Buikwe, Rakai, Kiruhura, Masaka, Kabarole, Kyenjojo Mubende, Mityana, Lira, Masindi, Mpigi, Hoima and Kibaale Districts. In each district, the team met with District Health Officers, Biostatisticians, HMIS Focal Persons, HIV Focal Persons and PPPH coordinators or contact persons where available. The objective of the meetings was to discuss strategies for improving private health sector engagement and challenges faced by PHPs in reporting through the DHIS-2 using HMIS tools. Furthermore, quarterly visits were made to 101 partner facilities to provide on-site HMIS technical support. The team checked for availability of HMIS registers, their use (completeness, accuracy and timeliness of reports) and data use. The team provided on-site mentoring to the partner staff involved in compiling the HMIS reports. As a result, 62% of the Program supported partner sites are now reporting through the DHIS-2 using HMIS tools moving from 27% at baseline. Regular targeted support was given to PMTCT sites to improve Option B+ reporting. The Program trained sites in PMTCT Option B+ timely reporting, loaned 15 health facilities with mobile phones and made weekly reminder calls to them. The Program also collaborated with 24 districts to provide joint HMIS technical support supervision at Program partner sites and enter their data in the DHIS-2.
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Ms. Joyce Achan (Program M&E Specialist) at HMIS technical support supervision at Ayira Nursing Home in Lira District (left) and Agwata Maternity Home in Dokolo District (right) During the fourth quarter, the Program carried out Internal Data Quality Assessments (DQAs) and HMIS support supervision at 95 health facilities. Focus for the DQA was HCT, SMC, HIV Care and ART data. Through this activity, the Program noted that the key reasons for variances in reported and verified data, were; non-update of registers, lack of training in use of HMIS tools for new staff, misinterpretation of indicators, frequent change of staff and high work overload. To address these gaps, the Program will train more PHP staff on SMC data quality checks and data cleaning, introduce quality improvement activities and encourage facilities to make use of their data. After the DQAs, the Program engaged 24 districts (biostatisticians/HMIS focal persons) in HMIS technical support supervision. Through this activity, PHPs had the opportunity to interface with the respective district bio-statisticians and HIV focal persons where DHIS-2 reporting was discussed. The Program learnt that some facilities were not registered in the DHIS-2, while others do not keep copies of HMIS reports submitted to the district and majority do not make use of their data to inform services delivery. Some of the key outcomes of this exercise was that two facilities (Nytil and Living Water) that were not previously in the DHIS-2 were added. This will ease their future reporting. Finally, the Program embarked on improvement of data management systems at 11 facilities (Kakira Hospital, SCOUL Hospital, Community Health Plan, Family Health Resource Centre, Hima Cement Factory Clinic, Kinyara Sugar Factory Clinic, Ayira Nursing Home, Charis Medical Centre, Kyotera Medical Centre, Buzirasagama HC and Gwattiro Hospital). The facilities were availed with filing shelves, hanging files and suspension files in order to improve organization of data and records. Additionally, they were provided with on-site mentorship that included assigning patients numbers, update of patient forms and registers, how to prepare reports and data quality assessment. This resulted into quicker retrieval of patient files, and easier monitoring of patients since the data is more readily available.
1.4.3 Support private health facilities to offer comprehensive healthcare service package The Program has supported partner facilities to offer a comprehensive healthcare package to their clients. This package covers primary healthcare services under HCT, HIV/AIDS prevention and care, SMC, nutrition, TB, malaria, FP/RH, MCH and PMTCT Option B+. Since, comprehensive health care service package can only be provided effectively if supportive systems are in place and functional, the USAID/Uganda Private Health Support Program’s focus in this area included support to logistics and supply chain management, HMIS, and quality improvement and assurance.
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During the first year, Program staff underwent a CQI orientation training facilitated by the ASSIST Project. This training covered the principles, tools and methodologies used in CQI and equipped more Program staff to be able to take part in CQI activities. Following the training, the Program worked jointly with the USAID ASSIST Program to carry out CQI activities to improve service delivery for comprehensive HIV services at five selected sites. The five sites were Family Health Resource Center- Kiruhura, Kakira Hospital, SCOUL MEHTA Hospital, Kyotera Medical Center and Kinyara Hospital. The CQI activities mainly focused on HIV care especially provision of ART, PMTCT, EID and TB /HIV Integration. The Program approach for this activity was monthly QI coaching visits; monthly data collection on selected indicators in the continuum of response and biannual learning sessions that brought together all the five sites to share best practices. As a result, there has been a marked improvement in HIV continuum of response indicators in all health facilities where this program is taking place. The indicators which have seen marked improvement are: percentage of HIV+ clients linked to care; ART eligibility assessment among HIV + patients in care and percentage of clients on ART retained in care. During Quarter 4, the Program completed a Logistics Assessment and on-site mentorship. The goal of this activity was to improve private sector ART ordering and reporting through the WAOS in DHIS-2. 97 facilities were visited. 67 out of 73 sites that have computers also had internet connectivity but only six were making online orders through WAOS. Only 38% had good quality orders and 44% of the sites were not trained to manage ART logistics. From this assessment, the Program has learned that the reasons for poor logistics management include: PHPs unaware of the JMS ordering and reporting schedule, no information to put on the order forms, lack of stock cards, limited training in ART logistics, limited logistics support supervision, lack of standard operating procedures (SOPs) for completing the end of cycle form and no access rights to the WAOS. During the assessment facilities were mentored on the ordering and reporting processes and tools (both WAOS and paper based), the ordering schedule, provided with stock cards, and trained on how to take stock. Two facilities managed to make their orders for the first time since ART accreditation. By the end of the activity there was marked improvement in submitted orders and reports to JMS from 42% in June 2014 to 68% in August 2014. During Quarter 4, the Program carried out targeted support supervisions to Kakira Sugar Limited Hospital and Mehta Hospital-SCOUL private facilities. The purpose of this exercise was to assess facilities’ performance standards in line with MOH guidelines. Furthermore, in collaboration with ASSIST Project the Program carried out quality Improvement (QI) for SMC monthly coaching at five private facilities (Community Health Plan, Family Health Resource Centre and Kyotera Medical Centre and Ankole Tea Estate Clinic).The activity involved reviewing and discussing QI projects; documentation journals; and QI data collection for the QI indicators for the previous months with the purpose of addressing identified gaps. Health workers were mentored in areas such as documentation and use of data in identifying gaps; principles and steps of QI; problem analysis using fish-bone method; client retention and follow up and linkages to care. The Program made a targeted support supervision visit to Royal Van Zanten Clinic (Mukono) to follow up on comprehensive HIV and SMC activities and challenges noted by the M&E team. The Program recommended as follows: > Suspension of SMC activities until systems are streamlined to what is required for successfully implementing a quality program in line with the MOHMOH recommended guidelines. > Improve EID services by following up HIV exposed infants, counsel mothers and caretakers to stay in care as well as proper documentation.
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> Offer provider initiated testing and counselling (PICT) to all clients that seek services at the clinic. > Make use of the available MOH registers.
Table 12: Clinical Care
Indicator < 5 Years 5-14 Years 15+ Years Quarterly Total Cumulative Total Annual Target Number of new patients enrolled in HIV 14 18 629 661 2,914 2,105 care
Number of HIV positive adults and 7,880 children receiving a minimum of one 111 218 7,551 7,880 9,000
clinical service Number of HIV-positive patients diagnosed at assisted service outlets who are 153 224 100 eligible and are awaiting treatment Number of service outlets supported with clinical care 44* 70 * Since clinical care goes hand in hand with ART accreditation and therefore few sites offering ART meant fewer sites were offering clinical care.
Table 8: HIV/AIDS Treatment
Indicator < 1 Years 1-4 Years 5-14 Years 15+ Years Quarterly Cumulative Annual Target Total Total Number of new patients started on 5 8 19 405 437 2,300 ART during the year 2,306
Number of current patients on ART 33 71 190 6,015 6,309 6,309 6,937 Number of adults and children enrolled in ART cohort 12 months before the reporting period 530 2,256 Percent of adults and children known to be alive and on treatment 12 months after initiation of 92% 65% ART Number of health facilities that offer ART 44* 70 * Few sites met the MOH ART accreditation criteria. More sites have been identified to support for accreditation in Year 2.
Table 9: Tuberculosis (TB)
Indicator Quarterly Total Cumulative Total Annual Target Number of accredited service outlets supported to provide TB diagnosis and 37* 45 treatment according to NTLP guidelines *The Program is scheduled to conduct TB care services assessment for supported sites for accreditation and the budget has been approved.
Table 10: Maternal and Child Health (MCH)
Indicator Quarterly Total Cumulative Total Annual Target Number of service outlets providing FP counselling or services 51 100 Number of new acceptors to FP registered at health service outlets 8,716 75,096 10,000
Percentage of mothers attending at least 4 antenatal care visits during pregnancy 55% 49% 25%
Challenges > USAID requested that the OVC grantee program include greater focus on private sector participation after the first round of approval requests; this led to a slight delay to allow for
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refocusing. Therefore start-up of OVC activity implementation under the grants had a subsequent delay. > Poor private sector data collection systems and non-reporting through HMIS remain a challenge. Some PFPs are still not submitting reports to their respective districts even after support from the Program The contributing factors to this is the view that HMIS tools are many and complicated, and that some facilities do not have staff dedicated to data management and reporting. Some ART facilities do not have access rights to WAOS online ordering and reporting despite the facilities having the minimum requirements, i.e. computer equipment and internet access. > There has been general inconsistent delivery of HIV testing and SMC services at some of the potential high volume sites. This has been due to the facilities’ continued confusion regarding where to access commodities, and the Program continues to address this with the facilities, JMS and other implementing partners. > Demonstration of additionally of a DCA loan vis-à-vis other bank financial products is a challenge. > The DCA banks are operating in a tight macro-economic environment that has seen inflationary pressures on the cost of capital and the interest rates charged on loans. Despite lowering of the Central Bank lending rate to 11.5% the interest rates are still relatively high, with Centenary Bank charging 21% interest rates as a prime rate with a margin of 6%. > The Lands Office has issued a moratorium on the issuance of new land titles or registration of new titles. Since land is the immovable asset of choice by banks as an asset pledged for security, this will slow down lending to first time new borrowers. It is not known how long the moratorium will last and will also result in a slowdown in the registration of mortgages.
Recommendations > Year 2 OVC grant processes will be started early to avoid delayed activities’ implementation, in close collaboration with USAID. > For Year 2, the Program will be proposing a clinical grant for high volume ART partners that will ensure provision of comprehensive integrated services. > The Program has explored working directly with the district bio statisticians to support private sector data management and reporting. These teams will be part of the regular HMIS support supervision and will be responsible for ensuring that data from the PFPs is regularly reported through the district system. The Program M&E team will continue engaging and supporting the partners. Support will focus on training and mentoring staff from non- reporting facilities and also offer support for them to access the necessary tools (including reproduction of the tools where necessary). Together with MOH Resource Centre and District staff, the Program shall provide on-site HMIS mentorship in the new HMIS tools. Facilities were provided with soft copies of the tools and requested to print or request from the respective districts. > The Program has supported facilities to make regular requests and reports to JMS to ensure uninterrupted services delivery. It is hoped that provision of SMC kits to our partner health facilities will lower the cost of the service and facilitate uptake. > Some local governments like KCCA have taken a step to tie relicensing of clinics to regular reporting. The Program will promote such initiatives during its interactions with DHO’s in other target districts. > The inflation pressures in the country are easing and it is hoped that this will slowly translate into a reduction in the interests charged on loans under the DCA.
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Key planned activities for the next quarter > Develop a capacity building plan basing on the OVC capacity assessment and offer capacity building for the OVC grantees in M&E and other priority areas identified in the capacity assessment report undertaken by the Program. > Ramp up private sector partnership engagement activities through the prevention grantees. > Share and review the Jinja district PPPH desk officer’s job description and benchmark it against other job descriptions across the region. The Program will also work with the PPPH unit to endorse it. > Work with the District Health Management Team (DHMT) to assign PPPH desk officers in the 18 target districts where they are non-existent. > On-site mentorship on the new HMIS tools and HMIS support supervision at partner sites. > Identify and visit new partner sites (high volume targeted) to become part of the supported Program sites. > Assistance to DCA banks to improve their awareness, interest, and outreach to potential health sector borrowers. > Business strengthening support to health clinics who have either received a DCA loan or are potential clients.
Task 2: Increased affordability of private health services and products
Task 2.1 Examine and monitor current pricing of private sector services and products In the private sector, the cost of delivering health services is influenced by a number of interconnected factors, including: inefficiencies in the supply chain that increase the cost of drugs and related supplies particularly for remote areas; PFPs not having access to affordable and/or subsidized medicines; health workers not having access to continued training and incentives to prescribe cost-effective treatment; and lack of opportunities to participate in donor-supported programs. During the first year, the USAID/Uganda Private Health Support Program examined the cost drivers for providing health care in the private sector and identified cost-reduction strategies that are market-based and contribute to reducing structural barriers. High prices of health services and pharmaceuticals continue to present considerable barriers to access for middle and low income groups.
2.1.1 Assess cost drivers for drugs and health commodities During the first year, the Program commissioned and completed the aforementioned cost and pricing study. The purpose of the study was to determine factors that influence the costs and prices of selected health services in the private sector. The Program plans to use these findings to inform short and long term strategies to improve affordability of health services in its target districts. Indeed some have already been included in the Year 2 work plan. The study key recommendations included: > Engaging in partnership arrangements with other programs such as the USAID Strengthening Health Outcomes through Private Sector (SHOPS) project and the Accredited Drug Shops Initiative to collaborate on improving services in the private sector. > Conducting an inventory of available equipment especially for laboratories at the different levels of facilities, and establishing minimum standards for private sector facilities, e.g. a central laboratory hub for TB tests and other complicated tests.
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> Entering into long term purchase agreements with wholesalers/distributors in Kampala to reduce prices based on the economies of scale of the assured retail market. This would augment the previous efforts by projects such as the USAID/HIPS project. > Collaborating with other partners in the health sector to lobby for institution of recommended retail prices for particular health services and medicines. This is a common practice in Kenya where there are guidelines and recommended prices for procedures such as SMC agreed upon by private practitioners. > Working collaboratively with health insurance schemes and providers to promote their awareness to the general public to enable increases in utilization of health insurance services by consumers.
During the fourth quarter, the Program disseminated the cost and pricing study that was finalized in the previous quarter to private health stakeholders from two professional associations. These were the Uganda Medical Association and the Uganda Dental Association. The dissemination meeting was organized for and hosted by the Uganda Healthcare Federation (UHF). The stakeholders provided useful recommendations on reclassifying the raw data to show how the different health centre levels were categorized and highlighted the necessity of a follow-up report focusing on the two associations. The Uganda Medical Association has scheduled a follow-on dissemination session during its scientific conference scheduled for November 7th themed “Challenges in Medical Practice: The Role of Leadership”. The Program will follow this up by using some of the study findings to promote professional fee guidelines starting with the Uganda Medical Association.
2.1.2 Explore task shifting to lower cadres as a means to reduce costs During the first year, the Program held discussions with the USAID/CAPACITY project, USAID’s flagship project in Uganda on human resources for health (HRH), on how HRH systems could be strengthened under the private health sector. Following these discussions, the Program scheduled to have these task shifting activities channelled through the four councils through the process of updating their acts. This is one of the key activities in which the Program will engage the four professional councils, via an RFA for capacity building organizations/professional medical associations during Year 2. During the fourth quarter, the Program collaborated with the four professional medical councils, the MOH, and other key partners to ensure the private sector perspective was involved in redesigning the scopes of work for nurses, midwives and clinical officers. Specifically, the Program solicited for and received proposals from three professional councils with information on how they would address human resources for health shortages within the private health sector. These proposals will be part of the scopes of work of the capacity building organizations/medical associations that will be selected to work with the medical councils during Year 2.
Task 2.2: Examine health financing mechanisms to reduce the price of health services and drugs In Uganda, the health insurance market is small compared to other East African countries. Recently, there have been high-level discussions towards implementation of a national social health insurance scheme and National Hospital Insurance Fund (NHIF), but these are yet to materialize. The small number of private health insurance schemes that exist are only accessible by upper income groups. In absence of a viable health insurance market, donors have supported other financing mechanisms as ‘stepping stones’ to health insurance. During the first year, the Program worked with other USAID implementing partners to expand the
Year One Report: July 2013-September 2014 Page 34 USAID/Uganda Private Health Support Program scope of the voucher program, and approached one community health financing organization and one rural bank to explore micro-insurance and health savings opportunities respectively.
2.2.1 Expand the scope of the voucher program During the first year, the Program sought to leverage MSU’s expertise in using vouchers to increase uptake of MCH services and create demand for RH/FP services at Program partner clinics. The Program worked with Marie Stopes Uganda (MSU) to develop a mechanism to identify and include five Program supported clinics in MSU’s voucher scheme. The Program developed an MOU with MSU under which MSU will assess five clinics for viability to participate in its voucher scheme. The Program will closely monitor increases in uptake of these health services at the five selected sites. During the fourth quarter, the Program, through its collaboration with MSU approached two companies, SCOUL and Kakira Sugar, to expand the scope of health services they provided via MSU’s voucher program. Both companies requested for extra support in areas such as permanent family planning methods and cervical cancer screening. Both companies were also keen on having RH/FP services introduced to their large communities through MSU’s voucher – especially since both already have extensive community peer educator networks. During Year 2, the Program will work with MSU, if it will continue to receive USAID funding, to avail the necessary equipment, commodities, and trainings for long term family planning and permanent FP methods. The Program will also visit one more company, Kinyara Sugar Works, to interest in providing more RH/FP and MCH services at its facility.
2.2.2 Link health savings plans to USAID/ Uganda Private Health Support Program During the first year, the Program met with three PNFP hospitals (Namungoona Hospital, St. Stephens Mpererwe and Kibuli Hospital) to explore opportunities to link Opportunity Bank’s rural clients, via their bank savings plans, to the three health facilities. The facilities in return would receive guaranteed payments from Opportunity Bank and increased client volumes. The bank indicated interest in piloting this health savings plan with five PNFPs in Eastern Uganda under the Uganda Protestant Medical Bureau. The Program linked the Uganda Protestant Medical Bureau (UPMB) to Opportunity Bank to extend these services to the bank’s rural clients. During the fourth quarter, the Program approached the new PNFP Program partners inherited from the IRCU program to gauge their capacity to provide these services to interested private sector entities. Pending assessment of their proximity to existing health savings plans, the Program will link them to Opportunity Bank’s health savings plan, if the bank is still interested in extending this product to its savings clients. The Program approached the new PNFP Program partners inherited from the IRCU program because UPMB did not readily have the means to introduce this option to the bank’s clients yet the bank was keen on working with PNFPs (as opposed to PHPs).
2.2.3 Explore introduction of micro-insurance to larger organization networks During the first year, the Program met with one community health financing organization, Save for Health Uganda (SHU), to explore how best large formal health insurers could tailor products for smaller rural-based insurance organizations. SHU is a local NGO which supports various community health financing mechanisms amongst rural based organization networks. Specifically in rural areas, SHU encourages entire families to purchase health insurance to shield them from catastrophic health related expenditures. The Program found that over the past 10 years, the organization has built a base of member-managed health insurance schemes
Year One Report: July 2013-September 2014 Page 35 USAID/Uganda Private Health Support Program with some, e.g. in Luwero district, having as many as 25,000 members. During Year 2, the Program has proposed to link such populations to larger insurance providers not only for reinsurance but also for exposure to more health products and provider networks. During the fourth quarter, the Program approached three large health insurance providers, Sanlam, Liberty Health Insurance, and UAP, to explore their amenability to extending micro- insurance products to community based networks. The Program found that two of them, Sanlam and UAP, had both developed micro-insurance products in 2013 but the uptake was low as they faced a number of limitations. These include bureaucracies within the larger organization networks, lack of appropriate technologies at network health facilities to facilitate data capture and/or fraud prevention, and the small premiums typically afforded by such networks making them unviable entities for larger insurers. Liberty Health Insurance dealt with high end of the market and did not have plans to develop a micro-insurance product any time soon. All three expressed interest in providing reinsurance services if introduced to smaller insurance groups and allowed to conduct their own risk assessments.
Challenges > Smaller community based health insurance groups are scattered and few have come together to form larger networks to increase their negotiating power with suppliers and providers. > Identifying additional suitable PFP facilities to recommend for participation in the voucher scheme program will require rigorous assessment of their quality of services, accessibility to pregnant mother populations, and financial records keeping on the part of the Program. > The availability of free public services, even though they might not be as efficient as the health services provided in the private sector, provides a disincentive for bank clients to prioritize spending their savings on health services.
Recommendations > Work through strong existing non-governmental organizations such as Save for Health Uganda to mobilize and organize the existing fragmented networks. > Work closely with MSU, pending availability of continued funding/resources, to reach more PHP’s beyond the target five that were proposed in the agreement with MSU. > Work with other PNFP organizations and other banks to reach new clients with health savings products.
Key activities for the next quarter > Identify more private sector partners to assess for possible inclusion into MSU voucher scheme and for demand creating activities for MCH and RH/FP services. Submit both lists to MSU. > Disseminate cost and pricing study at the Uganda Medical Association organized event and work with association to develop professional fee guidelines.
Task 3: Improved quality of private health sector facilities and services The USAID/Uganda Private Health Support Program is collaborating with multiple stakeholders under this task that cut across the public and private sector to strengthen quality among its partner providers and facilities. Stakeholders are to include the four Professional Medical Councils (Uganda Medical and Dental Practitioners Council, Uganda Private Medical
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Practitioners Association, Uganda Nurses and Midwives Council, and Allied Health Professional Council), the MOH PPPH Unit and district coordinating committees, UHF and other private sector leaders. At present, most USAID implementing partners, including the Program, have been instructed not to provide grants, funding or other direct support to public institutions as the US Government is in the process of reviewing its relationship with the Government of Uganda. This has forced the Program to temporarily shift its approach, including putting many of the Task 3 activities on hold, as the Program evaluates alternative means of realizing these objectives while avoiding direct support to public institutions in Uganda.
Task 3.1: Assist the MOH to implement the PPPH policy to enable PFP providers to deliver quality services During the first year, the Program worked with the MOH PPP Unit, the PPPH Policy Technical Working Group, medical councils, and district governments to leverage the new policy as a way to improve the quality of health services. To this end, the Program COP and Contracting Officer’s Representative attended the PPPH technical working group quarterly meetings at the Belgian Technical Cooperation offices. Key items discussed included 1) progress on dissemination of PPPH policy, 2) implementation guidelines for the PPPH updates, 3) Primary Health Care (PHC) transfers to the private sector, and 4) access rights to DHIS-2 by the private sector. The Program used this platform to brief members of the technical working group on the RFAs for private sector programs that had been recently released by the Program and encouraged members whose associations had expertise in these areas to respond. However, resulting from the Ugandan and US government relations issue, most of these activities came to a standstill.
3.1.1 Analyse key stakeholder groups to inform USAID/Uganda Private Health Support Program activities During the first year, the USAID/Uganda Private Health Support Program conducted a series of consultative meetings with key stakeholders to identify key areas that will inform future performance-based grants and to prioritize the technical assistance needs for the first year work plan. The Program identified key stakeholder groups (approximately 50), secured all the necessary contact information to set up the stakeholder interviews, mapped out the interview schedule, undertook the interviews for each stakeholder group (MOH leadership and other policy makers, four Councils, and representatives from different areas on the private health sector). During the fourth quarter, the process of conducting a stakeholder analysis which started in Quarter 1 was concluded and the report was submitted. A dissemination workshop to key stakeholders was carried out on July 31st, 2014 and was attended by 69 stakeholders.
3.1.2 Create a regulatory and enabling environment to implement the PPPH policy During the first year, the MOH secured funding for seven staff in addition to the Director. The USAID/Uganda Private Health Support Program worked with the PPP Unit to build its capacity and systems in a bid to translate the PPPH Policy into action. The MOH has typically struggled to operationalize the PPP Unit, primarily due to a lack of investment (e.g. unit staff, operating budget, capacity building). In collaboration with the PPP Unit, the Program assessed the staff’s skills base and systems at the national and district levels. Based on the assessment, the Program designed a sustainability plan that identifies areas for technical assistance and activities requiring financial support to grow PPP capacity within the MOH. The Program also held multiple meetings with the PPP Coordination Unit’s Director, Dr. Timothy Musila. From
Year One Report: July 2013-September 2014 Page 37 USAID/Uganda Private Health Support Program these meetings, the Program mapped an action plan for assisting the PPP Unit in multiple areas that include: 1) raising awareness and promoting implementation of the PPPH policy, 2) building PPP Unit’s staff skills and designing systems needed to implement the PPPH policy, and 3) creating PPPH skills at the decentralized level. Also, the Program gathered existing documents (e.g. PPPH Policy, PPP descriptions, etc.) and met with IFC/IHA team to discuss respective scopes of work with the PPP Unit and agreed to coordinate resources and technical expertise. Other activities in this sub-task and others under task 3.4 (including 3.4.3 and 3.4.4) are on hold pending USAID guidance for engagement with the public entities (PPPH unit and Councils). During the fourth quarter, the Program submitted a proposal to IFC-Nairobi to fund some activities which include 1) conducting a high level workshop on the basic concepts of health PPPs for senior MOH, MOF, KCCA and directors of some of the large private hospitals in Uganda, 2) carrying out an inventory of existing health PPPs in Uganda, and 3) developing a PPP pipeline of potential health PPPs. The Program is currently awaiting feedback from IFC. Since it is still unclear as to how to deal with public entities, the Program held these discussions with the IFCIFC to provide an interim supportive collaboration to move some of the Task 3 activities forward. IFC has indicated that it will consider support while the Program awaits guidance from USAID on how to work with the Councils, MOH PPP Unit and other Government of Uganda entities. Sub-tasks 3.1.3, 3.1.4, and 3.1.5 are on hold pending USAID guidance for engagement with public entities.
3.1.3 Design a strategic investment plan for PPPs Activity 3.1.3 – 3.1.5 entailed working directly with the MOH PPPH Unit and the professional councils. Considering that these are public institutions, the Program consulted with USAID on the mode of engagement and the support that can be provided to these bodies in view of the USG response to the enactment of the Anti-Homosexuality Bill during the year. At present, USAID implementing partners have been instructed not to provide grants, funding or other direct support to public institutions as the US Government is in the process of reviewing its relationship with the Government of Uganda. This has forced the Program to temporarily shift its approach, including putting these activities on hold, as we evaluate alternative means of realizing these objectives while avoiding direct support to public institutions in Uganda. During the year, a draft investment plan for PPPs was developed in partnership with IFC and the PPPH unit at the MOH.MOH The Program went ahead and explored the possibility of pushing this activity forward through partnership with IFC and a proposal has been submitted.
3.1.4 Assess PPP Unit capacity to implement PPPH policy During Year 11, the Program carried out a capacity needs assessment for the PPP unit to implement the PPPH policy. One of the outstanding capacity needs of the unit is the low staffing level. The Program had envisioned a grant to the unit to support capacity building interventions. However, as explained above, this was put on hold. The Program continues to explore a partnership possibility with the IFC to build capacity of the PPP unit.
3.1.5 Work with the PPP Unit to raise awareness on the PPPH Policy During the year, the Program worked with the PPP unit to develop a policy brief of the National Policy. This is an easy to understand four-page brochure that would facilitate
Year One Report: July 2013-September 2014 Page 38 USAID/Uganda Private Health Support Program popularization of the policy among stakeholders. The policy brief has been finalized and awaiting sign off from the PPP Unit head. The Program will make copies for distribution alongside the national policy document. The Program has also held district meetings to disseminate the PPPH policy.
Task 3.2: Build District Health Management Team capacity to engage and partner with PFPs During the first year, the Program held district private sector stakeholder meetings in 13 districts of Kasese, Mpigi, Rakai, Serere, Mbale, Kabarole, Kyenjojo, Mityana, Mubende, Mukono, Hoima, Lira and Dokolo. Meetings were attended by the DHMTs and the PFPs. The Program is using these stakeholder engagement meetings to make DHMTs aware of the importance of engaging PHPs in health services delivery. It was important that the Program initially holds these meetings separate from the District Management Committees (DMCs). Going forward, the Program will attend DMC meetings starting with Kasese on July 22 and Bushenyi July 30, 2014. As requested, the Program will share a presentation highlighting its current quarterly progress report (April – June 2014) achievements and its activities work plan for July – Sept 2014 on the key interventions supported in each district.
Task 3.3: Build a more cohesive and capable private sector to promote standards of care for PFP providers
3.3.1 Grow the core group of champions to promote private sector issues During the fourth quarter, in addition, the Program through the UHF secretariat supported Uganda Medical Association to make a presentation of the Cost and Pricing study to their members. UMA is championing the formulation of uniform consultation and other related costs across their profession. They had no baseline and the cost and pricing study provided some insights worth sharing with their members. During the first year, the Program identified private sector champions: these include private sector leaders, private sector providers and public sector key decision makers in relation to health. The process of the stakeholder analysis classified the private sector into: Leaders, Providers and Regulators. The Program worked with the first group (Leaders) to identify among them, association members that were well placed to champion private sector issues. These leaders have started to advocate for the formation of the National Health Professions’ Authority using their respective platforms. See links on some of the work by the champions. http://www.monitor.co.ug/News/National/New-health-regulatory--body-to-be-formed/- /688334/1694754/-/2dskhvz/-/index.html and http://www.newvision.co.ug/news/654544-government- to-set-up-national-health-authority.html.
3.3.2 Build UHF’s capacity During the first year, the USAID/Uganda Private Health Support Program met with UHF to explore UHF’s technical assistance and resources needs and discussed the following: 1) strategies to unify PFP and not-for-profit sectors in advocacy and other policy related activities, 2) organizational development approaches to strengthen UHF’s governance and long-term financial sustainability, 3) membership services (government relations and advocacy, networking, professional development and training) that UHF could offer their members to help retain existing members and attract new ones and 4) creation of a voluntary accreditation system for private providers. Based on these discussions, the Program presented and received approval for a sole source solicitation for a performance based grant to UHF. The overall goal of the grant activity is to
Year One Report: July 2013-September 2014 Page 39 USAID/Uganda Private Health Support Program build UHF’s capacity as a sustainable umbrella association representing the private health sector. In addition to the grant, the Program offered technical assistance in key areas to strengthen UHF management and governance. During the fourth quarter, the Program supported UHF to draft job descriptions for Finance Manager, Program Officer and Executive Director Positions and as a result, UHF advertised the positions of Finance Manager, Project Officer/administrator and Membership Logistics Coordinator. Interviews were conducted and UHF recruited the three staff. However, the selected candidate for the Finance Manager (FM) position declined to take up the job, citing low pay, and they had to employ a part-time consultant instead. In addition, the Program supported UHF to finalize tools to conduct an organization assessment (member survey), and review and edit the report. The Program supported UHF to conduct their Annual General Meeting on July 31, 2014 where a new board of 13 (eight new and five old) members was elected. The Program also facilitated a UHF board retreat on 12th-14th September which was attended by 11 of the 13 board members. The purpose of the board retreat was: (1) to help the board as a whole to have a clearer picture of UHF’s strategic direction and a better understanding of their role in helping to realize that vision, (2) build the capacity of board members through an orientation of board members on governance issues and (3) to provide both the Board secretariat the opportunity to fully engage with the most important issues (or challenges) confronting the UHF. AA report is being compiled.
3.3.3 Build UHF and other organizations’ capacity to advocate and engage in dialogue on behalf of the private sector During the first year, through the performance based grant awarded to UHF, the Program was able to carry out specific activities aimed at building UHF capacity such as: a) providing training in designing an advocacy campaign (on-going); b) assisting UHF staff to design effective advocacy activities (e.g. policy seminars, e-newsletters, policy briefs, coalition building and networking and press releases); c) strengthening UHF governance function through the board training facilitated by the Program; d) supporting UHF to carry out, with the PPP Unit, awareness on the PPPH policy; and d) initiating a consultative process on how the private sector report data to the MOH during their Annual Members Conference. During the fourth quarter, UHF organized a board retreat during which its board members prioritized its advocacy and dialogue issues and developed a strategic and sustainability plan. UHF will develop a communication strategy during the next quarter.
Task 3.4: Strengthen Councils’ capacity to regulate and oversee quality of private health providers
3.4.1 Update the Council Acts During the first year, the USAID/Uganda Private Health Support Program held several meetings with three out of the four Councils earlier on to discuss preliminary ideas for areas for capacity building through performance-based grants. Later as the Program learnt it could not give grants directly to public entities for the time being, the Program held a brainstorming meeting on how to propel the Council activities. This meeting agreed that grants be given to professional associations or capacity building organizations to strengthen the councils’ capacity to regulate and supervise the private health providers. In addition, the USAID/Uganda Private Health Support Program also learned during these discussions that all four Councils are moving towards a uniform approach to professional and facility licensing as well as coordinating key functions common across all Councils (e.g. supervision visits, facility
Year One Report: July 2013-September 2014 Page 40 USAID/Uganda Private Health Support Program inspections, etc.). Towards that end, the four Councils have formed a Registrar’s Forum that meets monthly to discuss strategies to standardize activities. The Program also determined that all four Councils need assistance to: 1) finalize quality standards, 2) update and harmonize the Council’s Acts and implementation guidelines, and 3) develop new tools based on the updated quality standards. To prepare for this technical activity, the USAID/Uganda Private Health Support Program collected and organized all the existing Council Acts and implementation guidelines. Also, progress towards formation of the National Professional Health Authority (NPHA) was made during the year. The Program in collaboration with IFC/World Bank funded and facilitated a National Consultative Stakeholder meeting held at the Lake Victoria Serena Resort. This meeting was attended by more than 200 participants drawn from the medical councils, professional associations, health training institutions, National Drug Authority and MOH.MOH During this meeting, the structure, composition and functions of the authority were agreed upon and these were incorporated into the draft document. The document is currently at the MOHMOH- Senior Management Committee for further consultations. The Program is currently working in partnership with IFC to undertake an impact assessment of the Authority and debrief for the Parliamentary Committees on Health and Finance. Once this is done, the bill will then be forwarded to Cabinet. During the fourth quarter, the MOH Technical Working Group (TWG) on the draft Bill was prepared to present the bill to MOH senior management. However, the TWG is still doing some ground work because the exercise involves a lot of lobbying and advocacy. Therefore, aactivities towards formation of the National Health Professions’ Authority (NHPA) are on- going. As a result, the Program is working in partnership with IFC to undertake an impact assessment of the Authority. Once this is done, the bill will then be forwarded to Cabinet. Sub-tasks 3.4.2, 3.4.3, and 3.4.4 are on hold pending USAID guidance for engagement with public entities. In the interim, the Program has drafted an RFA for a grant to professional associations or a capacity building organization to strengthen and streamline the licensing process.
Task 3.5 Develop a voluntary accreditation program
3.5.1 Finalize standards and design the peer accreditation program During the first year, the USAID/Uganda Private Health Support Program in partnership with the KCCA organized a meeting to engage selected private health facilities in Kampala. At this meeting, results of the pilot study for the self-regulatory standards were disseminated. To move the process forward, the Program held discussions with the standards and regulations consultant (that previously worked on the self-regulatory standards for the private sector under the HIPS Project) to assess how best to engage going forward. During the fourth quarter, the Program drafted and sent out a Request for Proposals (RFP) through a competitive process. Six firms responded to the Expressions of Interest that was developed and shared with 20 potential consultancy firms. Out of the six firms, three were selected and requested to submit technical and financial proposals. However, two of the firms - Coalition for Health Promotion and Social Development (HEPS Uganda) and PS Consulting wrote back saying that they were not able to write the detailed technical and financial proposals for reasons they did not specify. Only one firm- Quality Health International Consultants Limited (QHIC) submitted the technical and financial proposals. The review team assessed the firm and found that it met all the selection criteria. The review team recommended that
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QHIC, having met all the selection criteria, be considered to complete this assignment. As a result, a local contracting agreement was developed and has been signed.
3.5.2 Pilot test the tool with USAID/Uganda Private Health Support Program partners During Year 1, the Program carried out a pilot of the tool kit within KCCA facilities in a bid to finalize the self-regulatory standards tool kit and design a VQIS and the system will be piloted with the Program partner clinics. This activity will continue in Year 22.
Challenges The Program continues to await final guidance from USAID on engaging with Councils/public institutions per the situation discussed above regarding USG/GOU relations. As such, implementation of activities may continue to be delayed or at a standstill until instruction is given or until the Program has found alternative means of working towards the objectives. Activities for the next quarter are contingent upon the Councils agreeing on how to proceed on the NHPA Bill and the Program resolving how to provide technical assistance and financial support to the Councils.
Recommendations > The USAID/Uganda Private Health Support Program will continue to work with partner District Health Offices and private sector sites to ensure coordination of interventions and reporting. > USAID and the Program should agree on a way forward for managing the grants with government entities. Until then, most of the policy work with the Councils and PPP Unit will remain at a standstill. In the interim, the Program has drafted an RFA for a grant to professional associations or a capacity building organization to strengthen and streamline the licensing process. With the RFA in place, it will present an opportunity to accomplish the pending policy work.
Key activities for the next quarter > Organize an entry/commencement consultative meeting with key project stakeholders. > Printing, distribution and dissemination of self-regulatory standards and guidelines. > Finalize RFA and solicit for potential professional associations or capacity building organizations to strengthen the councils’ capacity. > Finalize the member survey and board training reports. > Support UHF to develop content for e-newsletter.
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Year 1 Overview of Grants Program During the first year, the Program developed a grants manual to guide the granting processes. The granting processes kicked off in February 2014 after the grants manual had been approved by the USAID/Uganda Mission on February 6th, 2014. During the course of the year, the program secured approval from USAID/Uganda for the following performance based grants: 1. Through a sole source justification, $100,000 was approved for UHF to advocate for issues that affect the private health sector. The grant will run for one year for the period June 16, 2014 to June 15, 2015 and may be renewed depending on performance. The main objective of the grant is to broaden the base of private sector support and engagement with the public sector. It is hoped that this will lead to a forum that will unify all major private and non-state stakeholders to address policy and advocacy matters in particular sectors, as well as improve quality and standards of private health facilities through self-regulations. 2. Through a competitive request for applications, two grantees were issued grants to conduct HIV prevention activities that mainly target MARPs (fishers, commercial sex workers, bar attendants and truck drivers). The aim was to engage grantees to provide comprehensive knowledge of HIV prevention, increase safer sexual behaviors, and reduce risk-taking behaviors. Under this activity, it is expected that the Program will link clinical service providers skilled in HIV/AIDS, TB, SMC, malaria, MCH and FP to employers. The grantees will also identify large employers, particularly those employing youth and MARPs, to design and implement comprehensive HIV/AIDS prevention packages. The Program will expand work-based HIV prevention programs with medium-sized employers with the aim of improving delivery and ensuring quality of their programs. The two successful grantees were Federation of Uganda Employers, which will implement in 14 districts, and Uganda Manufacturers Association, which will implement in 20 districts. Each grantee was awarded $100,000. 3. Through a competitive process a request for applications was made for civil society organizations to apply for grants not exceeding $30,000 each to support innovative approaches for orphans and vulnerable children. The model of public-private partnerships was used as a vehicle for coordinating with non-governmental actors to undertake integrated, comprehensive efforts to meet community needs. It is aimed at taking advantage of the expertise of each partner, so that resources, risks and rewards can be allocated in a way that best meets clearly defined public needs. It is also hoped that the civil society organizations (CSOs) will be able to achieve their strategic objectives in collaboration with others, leverage new resources for public health, and gain experience with a highly feasible and sustainable approach to public health promotion. 10 successful grantees were awarded performance based grants to run for a period of one year from 15th August 2014 to 14th August 2015. The successful grantees were International Needs Network Uganda, FXB Uganda, Kakira Out growers Rural Development Fund, SOS Children’s Village Uganda, Action for Behavioural Change Tororo, Kiyita Family Alliance for Development, Fishing Communities Health Initiative, Caring Hands Uganda, Family Spirit Children Centre and Environment Conservation & Agricultural Enhancement Uganda. 4. Another competitive request for applications was issued to provide grants to two successful applicants that have capacity to train and mentor private health providers in business skills training and counselling. The grantees will help private health facilities improve their business and finance management skills to ensure that the services they are providing are comprehensive, of good quality and cost efficient. The two successful grantees were Private
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Sector Foundation Uganda to implement in Central and Western regions (110 private healthcare businesses) and Makerere University College of Health Sciences to implement in 75 PFP healthcare facilities in Eastern and Northern Uganda. Each of the grantees will access a maximum of $250,000 for a duration of one year.
Year 1 Overview of Monitoring and Evaluation Activities During the first year, to strengthen efficiency of service provision within the private sector and to ensure that the private sector’s contribution to healthcare delivery is adequately reflected by national data, the USAID/Uganda Private Health Support Program strengthened data collection and reporting within the private sector and worked to integrate private sector outputs in the National DHIS-2. The Program baseline assessment was carried out and results disseminated during a meeting held on 8th November 2013. The report was submitted to USAID on 12th November 2013. Based on the baseline findings and feedback from USAID, the Program PMP with revised targets was re-submitted together with a revised work plan and indicator reference sheets. Partner reporting through the DHIS-2 has improved since the baseline from 27% to 62%. This has been possible through continuous support supervision visits and on-site mentorship plus printing and distribution of HMIS tools. Quarterly visits were made to 101 partner facilities to provide on-site HMIS technical support and 24 districts (biostatisticians and HMIS focal persons) carried out HMIS support supervision. On 22nd January, 2014, an M&E Private Sector Partners’ meeting was held with participants from MOH, Districts and Private sector partners. The meeting discussed the challenges PHPs face in using the HMIS and reporting to districts and came up with recommendations that were implemented during the year. PMTCT Option B+ improved over the year from 33% to 51%. This was a result of targeted supported through in-class trainings for PMTCT that included a section on Option B+ reporting, two specific trainings held in Option B+ reporting and loaning of mobile phones to 15 health facilities.
Facility Reporting rate in DHIS2 70
60
50
40
30 Percent 20
10
0 Qtr1 Qtr2 Qtr3 Qtr4 Quarter
In addition, there were weekly SMS and reminder calls to the facilities. District coordination and M&E support was enhanced through several M&E private sector partners’ meetings that were held in each district. The meetings discussed challenges PHPs face in using the HMIS
Year One Report: July 2013-September 2014 Page 44 USAID/Uganda Private Health Support Program and reporting to their respective districts. The stakeholders came up with recommendations and agreed on a way forward that will be discussed in subsequent meetings. As above, the Program carried out a Logistics Assessment and on-site mentorship with the aim of improving private sector ART ordering and reporting through the web based ordering and reporting system (WAOS) in DHIS-2. 97 facilities were visited and mentored on the ordering, reporting processes, tools (both WAOS and paper based) and the ordering schedule, provided with stock cards, and trained on how to take stock. Two facilities managed to make their orders for the first time since ART accreditation and submitted orders and reports improved from 42% in June 2014 to 68% in August 2014. The Program carried out Internal Data Quality Assessments (DQAs) and HMIS support supervision at 95 health facilities. Focus for the DQA was HCT, SMC, HIV care and ART data. Key quality issues were noted and facility staff given feedback and actions for improvement agreed upon. Finally, the Program embarked on improvement of data management systems at 11 facilities. The facilities were availed with filing shelves, hanging files and suspension files in order to improve organization of data and records.
Cumulative males circumcised 12000
10000
8000
6000 Number 4000
2000
0 Qtr1 Qtr2 Qtr3 Qtr4 Quarter
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Cumulative new acceptors to FP 80,000 70,000 60,000 50,000 40,000
Number 30,000 20,000 10,000 0 Qtr1 Qtr2 Qtr3 Qtr4 Quarter
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Annex 1: DCA Baseline Survey Report – Executive Summary In 2013, USAID and the Swedish International Development Agency (SIDA) structured a Development Credit Authority (DCA) guarantee with Centenary Bank to expand access to financing for the private health sector. The program provides a 50% guarantee for health sector lending losses incurred by the bank. The purpose of this baseline survey was to gather data on each centenary bank DCA borrower. The baseline included 32 of the 36 private healthcare businesses which had borrowed under the USAID/SIDA Health DCA as of December 31, 2013. DCA borrowers came from across Uganda’s Western, Eastern, Central and Northern regions. The types of borrowers interviewed included stand-alone clinics (72%), pharmacies (18%), health equipment vendors (4%), and health training institutes (6%). The health clinic borrowers offer a diverse range of services including malaria prevention, diagnosis and treatment and HIV/AIDs counseling and testing. Loan sizes varied depending on business type: > Health clinics: 62,414,814 Uganda Shillings (US$ 24,476) > Pharmacies and drug stores: 32,166,667 Ugandan Shillings (US$ 12,614) > Equipment vendors: 780,000,000 Ugandan Shillings (US$ 305,882) > Training centers: 200,000,000 Uganda Shillings (US$78,431) Seventy eight percent of DCA borrowers interviewed stated that they had seen an increase in the number of clients served after they had received the DCA loan, while 17% saw no change. In general, most of the health service providers increased the diversification of their service offerings after the loan was disbursed, adding a wider range of services relevant to their community. Of significance, 8 clinics began offering HIV/AIDs related services (HIV/AIDS counseling and testing, HIV/AIDS prevention of mother to child transmission services- PMTCT) in rural areas where testing and support had been previously limited. Three new clinics began offering maternal child health (MCH) services in the Eastern region, and there was an 18% increase in clinics offering in-patient services. When asked about growth opportunities, 67% of the borrowers cited expanding service offerings including upgrading minor surgery theatres. 4747% cited partnering with other health providers as a key opportunity and this included establishing referral relationships with other health facilities. 4444% noted offering MCH, infertility treatment and the provision of antiretrovirals (ARVs) as key prospects for future growth. The baseline also highlights several opportunities for future support to the DCA borrowers. This includes: (1) encouraging Centenary Bank to reduce its interest rates and collateral requirements for DCA borrowers, approving loans more quickly, offering longer repayment periods for equipment financing, and better monitoring of loan use; (2) providing DCA borrowers with business and financial management skills; and (3) supporting DCA borrowers to report to the MOH’s HMIS. Over the next five years, assessments will be carried out with the same borrowers to determine changes over time. This will include a determination of any fluctuations in volumes of health care delivery, diversification of service offerings, and improvements in the borrower’s financial performance.
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Annex 2: Public-Private Partnerships for Health Survey Report - Extraction
Executive Summary The recently approved National Policy on Public-Private Partnerships in Health (PPPH) has greatly changed the dynamics of the relationship between the Government of Uganda and the private health sector. Although the policy outlines a framework for joint cooperation between the two, the private sector’s understanding of health public-private partnerships is still nascent. On the public side, many district health offices are still unaware of their role in operationalizing the policy. To better integrate district and private sector activities and to get a better understanding of existing PPPH coordination mechanisms, in February 2014, the USAID/Uganda Private Health Support Program conducted a PPPH survey in 14 districts. The survey further sought to determine which districts had functional PPPH desk officers and coordination committees. Survey respondents included the District Health Officers (DHOs), PPPH focal persons and PNFP coordinators. The survey revealed that only eight out of the 14 districts visited had PPPH Desk Officers. It also found that the presence of a PPPH desk officer did not necessarily imply PPPH desk office functionality: Nine districts reported having desk officers but only eight were functional to some extent. Out of the eight, only one officer was performing functions concurrent with those of a PPPH desk officer. In further examining the tasks the others performed, it was evident they all had different definitions or understandings of their roles and responsibilities. A key reason for this discrepancy was the lack of a clear, detailed job description. Many of the desk officers were not aware of the PPPH policy: those that were aware did not know whether it had been approved. For the small number of districts that had PPPH coordination committees (4/14), most did not engage the private sector within their respective districts. Although some periodically implemented joint one-off activities, the private sector hardly participated in district planning meetings or other MOH organized events. The survey showed that the primary factors contributing to the low capacity and knowledge on the National PPPH policy and district level PPPs were (1) limited number of functional PPPH desk officers, (2) little to no guidance from the central PPPH Unit (3) limited capacity to implement PPP’s (4) no basic tools and instruments, and (5) limited leadership or involvement of District Health Management Teams.. Despite these challenges, in Jinja district, the Program found a good model of an effective PPPH desk office. To help operationalize the National PPPH policy, the Program developed a number of recommendations that include setting up district PPPH coordination committees and supporting them to work closely with the existing district management committees. Specific Program recommendations were organized around short and medium term actions to address the knowledge and skills gaps of the PPPH desk officers. In the short-term, the Program will (1) foster a basic understanding of PPPH Policy, (2) establish PPPH structures in the districts without one, (3) create a minimum standard for PPPH desk officers’ roles and responsibilities, and (4) build basic PPPH skills. In the medium-term, the Program will (1) conduct additional training in core PPPH skills to desk officers, (2) support expanded DHMT’s (that will include the private sector) in district operational planning, and (3) mentor PPPH desk officers to start brokering PPPs.
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Background The approval of the PPPH Policy and the renewed interest of Health Development Partners in the role the private sector can play in the implementation of the Health Sector Strategic and Investment Plan (HSSIP 2010/11 – 2014/15) have drastically changed the dynamics of the partnership between government of Uganda and the private health sector. In fact, the MOH outlined the PPPH as one of the mechanisms to enable implementation of the HSSIP (Objective 5: Deepen health stewardship). The key objective during HSSIP was to: “Effectively build and utilize the full potential of the public and private partnership in the health sector.” To assist help the private sector facilities participates in the new opportunities presented by PPPH Policy, the USAID/Uganda Private Health Support Program is working with the target districts to ensure that private sector facilities are included in district level planning as well as assist districts to set up PPPH coordination committees. The objective of this initiative is to build PPPH coordination committees’ capacity to identify, design and implement PPPs. Additionally, the Program also liaises with the with District Management Committee meetings to ensure joint planning /execution of priority activities within PPPs. As a first step, the Program has assessed PPP capacity at district level (in addition to national level) to implement the PPPH policy. Assessment examines the PPPH staffs’ skills and systems to determine their skill level and organizational capacity in PPPs. The assessment, and subsequent interventions, will be done in collaboration with the PPP Unit at the MOH. Based on the findings of the assessment, the program will design a sustainability plan that identifies areas for technical assistance and activities requiring financial support to grow PPP capacity within the MOH. According to Dr. Musila2, PPPH Unit Director, the PPPH desk is charged with coordinating the partnership between the government and the private sector in health in terms of policy elaboration, planning, service delivery, monitoring and evaluation. It is also tasked with strategizing together with the private sector on how it can improve collaboration between the sectors in pursuit of a common goal: expanding access to quality health services to the population. The PPPH plays an important role in a stewardship and coordinating role in the partnership between the public and private sectors. Dr. Musila envisions the PPP Unit as a “one-stop center” for both the public and private sector stakeholders to make sure that it can be able to have the databases that are required to inform decision making about where resources are invested within the health system— whether in the public or private sector. The USAID/Uganda Private Health Support Program conducted an on-going assessment of the PPPH district coordination in line with its Year I work plan activity – Task1.4.1: Strengthen District PPPH Coordination. This review of current coordination mechanisms was done to establish which districts have existing and functional PPPH desk officers and coordination committees. The survey has been conducted in 14 out of the 18 planned districts. The respondents included District Health Officers, PPPH focal persons, PNFP coordinators and any other persons assigned to carry out this responsibility.
2 Dr. Timothy Musila on Mobilizing Private Sector Resources to Solve National Health Challenges in Uganda , Interview transcript, May 2013
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Methodology The objective of the survey was to identify the success stories and challenges faced by those districts with PPPH desk officers that are implementing the PPPH policy so that the Program can replicate the same strategies to other district. The survey was conducted in 14 districts of Jinja, Mukono, Kabarole Dokolo, Buikwe, Mpigi, Mityana, Mubende, Kyenjojo, Nakasongola, Lira, Masindi, Hoima and Rakai. Plans are in place to visit the remaining four districts of Masaka, Wakiso, and Kasese in the coming months to make up the planned 18 districts. The Program focused on these 18 districts as they directly correspond to the project’s target districts. In order to achieve the above objective, the survey team used multiple strategies to collect data including semi-structured questionnaires, district-level presentations and one-on-one discussions. Semi-structured questionnaires: The team developed a semi-structured question which was used as to guide interviews with MOH district leadership. The tool included sections on: i) respondent’s information, ii) PPPH background information, iii) PPPH dissemination and iv) capacity gaps. District presentations: Also during other ongoing activities/workshops/meetings, the DHO/PPPH focal persons have been given an opportunity to make a presentation on how they coordinate activities with the private sector, challenges they encounter in engaging the private health sector and the way forward. One-on-one discussions with districts staff: The survey team also talked to different district staff like the DHO, PPPH focal person, District Drug Inspectors, and PNFP coordinators to establish which districts have existing and functional PPPH desk officers and coordination committees. The team organized the data elicited from questionnaires, one-on-one discussions and district presentations along thematic areas on a simple Excel spreadsheet. The spreadsheet captured districts visited, whether the desk officer existed, whether the desk officer was functional, and existence of coordination committees, the survey team, appointment dates and venues of the activities/meetings. The survey team obtained consent of the respondents to participate in the survey. There was a high degree of openness regarding the objective of the survey.
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Survey Findings The report covers findings regarding the presence of PPPH desk officers and functionality, PPPH Coordination Committees, current roles in working with the private sector, challenges in working with private sector and training/capacity needs. Below is a summary table of the districts visited and key findings.
Program Target Site Visited PPPH Desk Officers PPPH Coordination Committee Districts Exists Functional Exists Functional Buikwe √ √ X X X Dokolo √ √ √ √ Hoima √ X X X Jinja √ √ √ √ Kabarole √ √ √ √ Kamwenge √ X X X Kyenjojo √ √ √ X X Lira √ X X X X Masindi √ √ √ X X Mityana √ X X X X Mpigi √ X X X X Mubende √ √ √ X X Mukono √ √ √ √ Nakasongola √ X X X X Rakai √ √ √ X X
Summary of districts visited and key findings
PPPH Desk Officers Presence of PPPH Desk Officers: The survey revealed that only eight out of the 14 districts visited had PPPH Text Box 1: Districts with PPPH Desk desk officers in place (See Text Box 1). The survey also Officers showed that the presence of a PPPH desk officer did not Buikwe Dokolo Jinja, Kabarole necessarily imply functionality. Six of the 8 were Kyenjojo Masindi Mubende Mukono partially functional while only one was performing Rakai according to common scopes of a PPP desk officer (see below). Buikwe is the sole district whose desk officer is completely non-functional. Level of functionality: There are a few East African countries (Malawi, Tanzania) that are in the process of building PPPH capacity at decentralized levels. These countries have draft scopes of work for the decentralized PPP Coordinator/Focal Person (See Table below). The Program team used these countries’ scope of work as a measure of functionality. In examining the tasks performed by the 7 PPPH desk officers, it is clear that they do not fulfill the same role or perform similar tasks. A key reason is the lack of a clear, detailed job description. The exemption is Jinja: the desk officer had job description - bullet format - prepared in 2008 by the former DHO in Jinja. Most notably, many of the desk officers are not aware of the PPPH policy; where they were aware, many did not know whether it was approved or not. Moreover, the PPPH desk officers
Year One Report: July 2013-September 2014 Page 51 USAID/Uganda Private Health Support Program did not have the tools and instruments needed to carry out their job, such as MOH priority areas for PPPH, guidelines to implement PPPHs, and a handbook and/or templates to guide identification, design and implementation of a PPPH. Despite these challenges, the Jinja desk officer was a good example of what an effective desk officer looks like. The table summarizes the main functions of a PPP focal person: promoting regular communication and exchange of information; foster formal, intentional dialogue among public and private sectors; involve the private sector groups in policy and planning; facilitating quality of private sector providers; and brokering PPPs. Below is an overview of the Jinja desk officer’s activities compared to PPPH desk officer’s scope.
Examples of PPPH Desk Officer activities Jinja Desk Officer activities Promote regular communication and sharing of › Maintain open and regular communication with private sector information Foster dialogue among public and private sector › Lead quarterly meetings with PNFP and PFP partners leaders › Involve private sector in multiple forums (e.g. HIV/AIDS partner forums, PPPH TWG on Malaria) › Continuously shares information with and invites PNFP and PFP partners to MOH events Involve private sector leaders in policy and planning › Involves private sector groups in annual DOP planning Facilitate quality of private sector provider › Recommends approval of licensing for PFP and PNFP facilities › Conducts quarterly supportive supervision visits of private facilities › Resolves licensure and disputes with the private sector. Broker PPPHs › Joint purchase of medicines and supplies with the private sector
PPPH Coordination Committee Number of PPPH coordination committee: A small number of the districts visited had a PPPH coordination committee: four out of the 14 districts. They included Jinja, Mukono, Kabarole and Dokolo. Of the four, only Jinja’s PPPH coordination committee was functional. Level of functionality: Most of the PPPH unit coordinating committees did not fully engage Text Box 2: Factors Contributing to a Functional Committee private sector players though some had some individual activities. Moreover, there was limited › Leadership by PPPH desk officer › participation of the private sector in district Active participation of all private sector partners › Openness and willingness of both sectors to work planning meetings and other MOH events. The sole together exception was Jinja district. Out of the 14 districts, › Open and regular communication Jinja was a prime example of a functioning and › Coordination mechanisms in place to build on effective PPPH Coordination Committee. Text Box › Concrete tasks identified for collaboration 2 shows the characteristics contributing to a functional PPPH Coordination Committee. Many of these factors could be replicated in the other districts. As noted, leadership was critical. In Jinja, the PPPH desk officer works tirelessly to bring in and integrate the private sector in all MOHs activities. In addition, the PPPH coordinating committee pro-actively involves a full range of private sector partners – both PFP and PNFPs – and uses not only the coordinating committee meetings but other existing forums. The PPPH desk officer ensures a clear flow of information. The Jinja district uses its five sub-districts, HIV/AIDS forum partners, and private sector leaders to disseminate information to PFPs and PNFPs. Mukono
Year One Report: July 2013-September 2014 Page 52 USAID/Uganda Private Health Support Program district conducted quarterly meetings with Private Association while Rakai district conducted capacity building programs for active PHPs that submit HMIS reports.
Analysis The 14 district PPPH desk officers require considerable capacity building. Although the Jinja desk officer was operating according to best practices from other East African countries, he still lacked direction and guidance from the central PPPH Unit. Moreover, he lacked some of the basic tools needed in order to fully realize his potential. Once again, the PPPH Coordinating Committee was the most active solely due to the leadership and energy of the PPPH desk officer. The primary factors contributing to the low capacity and knowledge on PPPHs are:
> Limited number of functional PPPH desk officers: Many of the districts visited still have not identified a MOH staff person to take on the PPPH role. In addition, the existing PPPH desk officers do not have a job description outlining their tasks as a desk officer. Even if the desk officers have a comprehensive job description, they may be limited in their ability to fulfil their scope. Almost all of the current desk officers are also responsible for other functions beyond PPPHs. > Little to no guidance from the central PPPH Unit: Almost none of the PPPH desk officers had a copy of the PPPH policy, nor were they aware if it has been approved. But even with the PPPH policy in place, the desk officers still need additional guidance on priority areas for PPPHs as well as guidelines on how to go about identifying and brokering PPPHs. Moreover, none of the PPPH desk officers had a work plan in place to align their activities to PPPH priorities or guide their efforts towards performance benchmarks. In addition, there is almost no regular communication from the central PPPH Unit, leaving the PPPH desk officers to operate in isolation. In fact, there is a “disconnect” between the districts and the PPPH Unit. > Limited capacity to implement PPPH: Few of the desk officers visited received training in basic PPPHs and therefore have partial understanding on PPPHs, what they are and how to do them. The PPPH desk officers not only misunderstand the PPPH policy, they also lacked competency in the most critical skills needed to be a successful PPPH desk officer: private sector engagement, coordination and communication, and basic contracting. Moreover, the desk officers did not understand the role of PPPHs in addressing health priorities and system gaps. Finally, desk officers lack resources – such as budget for consultants/experts, to convene stakeholder meetings, to regularly communicate and exchange information with stakeholders - to carry out activities needed to implement PPPHs. > No basic tools and instruments: The PPPH officers do not have the basics to perform their job: i) PPPH policy, ii) typology of PPPH mechanisms available, iii) implementation guidelines, iv) authority matrix, v) policies and procedures. In most cases, all of these would be contained in a handbook. > Limited leadership or involvement of District Health Management Teams: There were very few active PPPH Coordination Committees. There are many reasons why few have been created but the most important ones are: i) minimal District Health Officer, and their DHMT, buy-in or understanding of PPPHs, ii) limited leadership compelling the DHMT to involve the private sector in policy and planning, and iii) too many committees to manage.
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Recommendations The USAID/Uganda Private Health Support Program team recommendations are organized around short- and medium-term actions that the Program can support to address the knowledge and skill gaps of the district PPPH desk officers.
Short-Term (1 to 3 months) > Foster a basic understanding of PPPH Policy – Produce and distribute the PPPH Policy to all district DHOs, DHMT members and PPPH desk officers to create awareness of the policy and PPPHs. – Produce and distribute a brief (4 to 6 pages in layperson’s language) on the PPPH Policy and distribute it to the same audience to further understanding of the PPPH Policy. – Work with UHF to distribute and disseminate both the PPPH Policy and brief to the private sector groups in the target districts.
> Establish PPPH structure in the districts without a desk officer – For the districts without a desk officer, work with DHOs to identify a district health personnel to be appointed as PPPH focal person. – In all districts, use the DHMT as the coordinating committee for PPPHs. – Conduct stakeholder analysis to identify PFP and PFNP leaders to include in DHMT. – Convene initial meeting of all to explain PPPH coordination function and how it can feed into the Districts Operational Plan (DOP) mechanism. – Work with UHF and other private sector associations to mobilize the district level private sector to participate in the DOPs process.
> Create a minimum standard for PPPH desk officers roles and responsibilities – Update the Jinja job description. – Distribute the job description to all the PPPH desk officers in the Program target districts. – Share the Jinja desk officer’s work plan and activities with the other desk officers as example of the type of activities they should be managing.
> Build basic PPPH skills – Update the PPPH Unit’s training materials. – Conduct training of PPPH desk officers, DHMT and private sector groups. – Work with UHF to mobilize the private sector to participate in the PPPH workshops.
Medium-Term (3 to 12 months) > Conduct additional training in core PPPH skills for desk officers – Conduct additional workshops in stakeholder engagement, participatory planning and basic contracting. – Pair high performing desk officers with those with limited capacity. – Facilitate exchange and cross learning among desk officers in target regions.
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> Support expanded DHMT (includes the private sector) in DOP – Share information on private sector activities to be included in DOPs. – Share DHMT plans to align private sector activities to MOH priorities. – Identify opportunities for collaboration and cooperation. – Identify one to two simple PPPHs.
> Mentor PPPH desk officer to broker a PPPH – As the PPPH ideas emerge from the DOP process, help the desk officers use the guidelines and templates developed by the PPP Unit to implement a PPPH. – Help troubleshoot and problem-solve issues as they arise during implementation.
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Annex 3: Success Stories
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Success Story: Delivering and Scaling up HIV/AIDS and Health Access for Vulnerable and Geographically Isolated Groups in the Supply Chain of Nile Breweries Limited Program Overview: NBL, through the Incentive Fund applications, was awarded funding worth $385,000 for three years. USAID/Uganda contributed $130,000 while the Office of the Global AIDS Coordinator contributed $255,000. To date, the partnership has supported a broad spectrum of health services in 13 districts where NBL has operations. These district include; Dokolo, Katakwi, Lyantonde, Kapchorwa, Kasese, Hoima, Masindi, Nebbi, Lira, Soroti, Busia and Rakai. The program targets the NBL supply chain which includes the truck drivers, smallholder farmers and bar tenders (hospitality workers). The program supports two clinics to provide basic treatment and services to the target group. The clinics are private and operate in areas within NBL’s supply chain. Goal of the program: To contribute to the prevention of new HIV/AIDS infections as well as provide access to treatment and care among three vulnerable groups in NBL’s supply chain: truckers, bar workers and smallholder farmers. Purpose To increase the uptake of health services including HCT, Intermittent Preventive Therapy (IPT) and Reproductive Health (RH) among truckers, bar workers and smallholder farmers. Specific objectives > To increase access to and use of prevention interventions and HCT in the NBL supply chain. > To support the scale up of voluntary home-based couples counselling and testing for smallholder farmers. > To improve clinic capacity and provide training to health workers. > To implement community based peer education programs in support of prevention messages. > To scale up dissemination of anti- alcohol abuse messages of smallholder farmers in remote areas, bar workers, and truckers. Activity targets > Train 600 community based peer educators to provide prevention messages. > Provide HCT to 1250 truckers, 2000 bar workers and 3250 smallholder farmers a year, as well as to their partners. > Conduct health fairs to provide HCT and health information to community members through the four-tent model. > To support the scale up of voluntary home-based couples counselling and testing for smallholder farmers. > To scale up dissemination of anti-alcohol abuse messages to smallholder farmers in remote areas, bar workers, and truckers. > Provide treatment to at least 200,000 people in NBL’s catchment population, targeting the most vulnerable groups in their supply chain. > Provide welfare and nutritional support to People Living with HIV/AIDS.
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Peer Education HIV Counseling and Testing
Program achievements to date: KEY PERFORMANCE INDICATOR TARGET REACHED SO FAR GAP Training community based peer educators to provide prevention 600 390 210 messages and peer-education to truckers, bar workers and smallholder farmers as well as to their partners. People reached with health messages through peer education. 15,000 7,318 7,682 People reached with HIV messages through health fairs 34,000 6,713 27,287 Referrals made - 316 - Providing VCT/HCT services to truckers and bar workers 13,000 5,175 7,825 Scale up of HBHCT for small holder farmers (Dokolo) 12,000 5,884 6,116 Scaling up dissemination of anti- alcohol abuse messages to 9,000 2,120 6,880 smallholder farmers in remote areas Providing treatment to NBL’s catchment population targeting NBL’s 26 0 26 supply chain. Procuring and distributing of condoms 720,000 44,400 675,600 Providing IPT (ITNs) to pregnant women 10,000 2,000 8,000 Training of health workers from participating clinics 52 0 52 Providing nutritional support to HIV positive individuals 1,000 800 200 Purchasing drugs for opportunistic infections 1,000 0 1,000 Support supervision 13 6 7
Program achievements from the last quarter: > 5884 people have been tested through the home based HCT program in Adok parish in Dokolo district. > 5175 hospitality workers were tested through the four-tent model health fairs. > 6713 people have been reached with health information in the areas of HIV prevention, care and treatment, malaria, FP and TB.
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> About 800 people living with HIV/AIDS received welfare support in form of mattresses, blankets, mosquito nets and goats. > Clinical assessments were conducted for five clinics to be supported by the program. > Anti-alcohol abuse campaigns were conducted in Adok and Kakumbala as part of the HIV prevention interventions. > 44,400 condoms were distributed through the peer educators and also at Health Centres.
Challenges: > Referral of clients to clinics with minimal or no support. > Following up of peer educators to provide quarterly reports, is a challenge especially with limited resources. > Closure of the HIPS Project meant a reduction in TA available to the program and affected the funding and momentum of activities.
Recommendations: > Support private health facilities under the NBL/PPP with capacity building, linkages and access to financing to increase the range of services provided. > The USAID/Uganda Private Health Support Program will continue to support these program activities in conjunction with NBL during the PPP’s final year of operation.
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Success Story: USAID Continuing Quality Improvement (CQI) Support Improving Health Service Delivery at Sugar Corporation of Uganda Limited (SCOUL) Mehta Hospital The USAID/Uganda Private Health Support Program and the USAID ASSIST Project are working jointly to improve service delivery for comprehensive HIV services in five selected private sector sites. The focus areas are ART care, PMTCT, EID and TB/HIV Integration. SCOUL Mehta hospital needed CQI support to improve technical performance, service delivery, effectiveness of care to patients, interpersonal relations and efficiency of service delivery. Specifically, the facility lacked HMIS tools (e.g. pre-ART registers, appointment books and CD4 log books). Also, there was improper documentation in the TB register, improper monitoring of clients on ART, and poor linkage of clients that test HIV--positive. The hospital was initiating provider counselling and testing in their outpatient department. Together with SCOUL, an improvement plan was designed (see CQI journal below) with clear targets and timelines.
Table 4: CQI Journal
Indicator Improvement Changes Indicator Definition 13-Oct 13-Nov 13-Dec 14-Jan 14-Feb 14-Mar Objectives (Numerator, Denominator) % of To improve the Initiating PITC at all Numerator: Number of 5 4 6 6 5 2 newly % of newly entry points (OPD, HIV positive clients linked diagnosed diagnosed HIV General ward, and enrolled in Mehta HIV positive clients Maternity), health Hospital ART Clinic positive into HIV care education of patients clients from 50% (Feb. attending OPD daily, Denominator: Number of 5 4 6 6 10 2 linked to 2014) to 100% in ANC Monday, HIV positive clients linked chronic Sept. 2015. ongoing counselling of to Mehta Hospital ART care clients who are HIV clinic positive, integrated % 100% 100% 100% 100% 50% 100% outreaches to the community track lost clients and other services, timely requisition of HIV test kits from JMS, Departmental meetings to review performance every last Friday of the month % of To improve % of Health education of Numerator: Number of 2 2 2 3 0 2 exposed exposed infants pregnant mothers on HIV exposed infants who infants done 1st DNA importance of EID had their 1st DNA PCR done 1st PCR from 67% during ANC and done at 6 weeks DNA in Oct. 2013 to postnatal, community Polymera 100% in Oct. sensitisation on EID Denominator: Number of 3 3 2 3 0 2 se Chain 2014 importance, use of HIV exposed infants who st Reaction peer mothers to had their 1 DNA PCR (PCR) at conduct follow up and done 6 weeks participate in Health % 67% 67% 100% 100% 0 100% education, home visiting by HWs and peer mothers - sample collection at home In order to address these gaps, the program conducted a CQI coaching session in December 2013 and several onsite visits to the facility in January, February and March 2014, to execute CQI activities that included; (a) monthly QI coaching visits to the five selected sites, (b) bi-annual
Year One Report: July 2013-September 2014 Page 62 USAID/Uganda Private Health Support Program learning sessions, and (c) monthly data collection on selected indicators. With the monthly support supervision visits from the Program and the ASSIST Project, SCOUL’s progress has been monitored. The HMIS tools (pre ART appointment book, CD4 log book) were acquired from Buikwe district and others provided by the Program. Timely orders to JMS have been made for HIV test kits and other supplies, provider initiated counselling and testing is now offered in the outpatient department. ART status for co-infected patients is now documented in the TB register although there was still no record of Ms. Angellah Nakyanzi of USAID/Uganda Private Health Support Program and sputum results for two, five and eight Mr. Micheal Mwanga of USAID/ASSIST project coaching the medical team of months follow up. By March 2014, Sugar Corporation of Uganda Limited-Lugazi Buikwe District in the Continuing some of the clients had had their CD4 Quality Improvement activities on Friday 28th March 2014 cell monitoring done using support from the Protecting Families against HIV/AIDS (PREFA) Program, although the program has indicated that it will only support CD4 monitoring for pregnant mothers and exposed infants. An outreach program has also been supported to provide services in MCH, HIV counselling and testing, FP and nutrition. A team of “angels” comprising of 14 community volunteers is also helping in mobilizing the clients, following them up with phone calls and reminding them of their appointments. By March 2014, SCOUL had registered 100% newly diagnosed HIV patients linked to chronic care, and 100% of their exposed infants with DNA Polymerase Chain Reaction (PCR) done at six weeks.
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