USAID’s Maternal and Child Survival Program (MCSP) Uganda - Routine Immunization (RI) Program Quarterly Report January 1 to March 31, 2017 MCSP pre-visit to Mbarara District to sensitize district leadership on the REC-QI approach. USAID/Uganda Quarterly Progress Report (Quarter 2 of Program Year 3) Project Name: USAID’s Maternal and Child Survival Program (MCSP) Routine Immunization (RI) Program Reporting Period: January 1 to March 31, 2017 Obligation Funding Amount: $829,924 (Field Support) Project Duration: July 2014 – December 2018 Program Year (PY3): October 1, 2016 to September 30, 2017 Person Responsible for this Report: Dr Ssekitto Kalule Gerald – MCSP Chief of Party Project Objectives: 1. Strengthen UNEPI’s institutional/technical capacity to plan, coordinate, manage, and implement immunization activities at national level. 2. Improve district capacity to manage and coordinate the immunization program as guided by UNEPI leadership. 2 Acronym List ADs Auto-Disable Syringes CAO Chief Administrative Officer CBET Competence-Based Education and Training DPT Diphtheria, Pertussis and Tetanus DHMT District Health Management Team DTO District Technical Officer EC East Central EPI Expanded Program on Immunization EPCMD Ending Preventable Child and Maternal Deaths Gavi Gavi, The Vaccine Alliance Gavi PEF GAVI Partnership Engagement Framework HF Health Facility HSD Health Sub-District HPAC Health Policy Advisory Committee HQ Headquarters HRH Human Resources for Health ICHC Institutionalization of Community Health Practices Conference IIP Immunization in Practice IRB Institutional Review Board JSI John Snow Inc. MACIS Malaria and Childhood Illnesses NGO Network Secretariat MCH Maternal and Child Health MCHIP Maternal and Child Health Integrated Program MCSP Maternal and Child Survival Program MEL Monitoring, Evaluation and Learning MMEL Measurement, Monitoring, Evaluation and Learning MNCH Maternal, Newborn, Child Health MOH Ministry of Health NMS National Medical Store OPL Operational Level PDSA Plan-Do-Study-Act cycles PHC Primary Health Care PY Program Year QI Quality Improvement QRM Quarterly Review Meetings QWITs Quality Work Improvement Teams REC-QI Reaching Every Community using Quality Improvement techniques RED Reaching Every District RI Routine Immunization SAS Senior Assistant Secretary SW South West SS4RI Stronger Systems for Routine Immunization TWG Technical Working Group UNEPI Uganda National Expanded Programme on Immunization UNICEF United Nations Children’s Fund USAID United States Agency for International Development USG United States Government VHT Village Health Team WHO World Health Organization 3 Introduction The Maternal and Child Survival Program (MCSP) is a global U.S. Agency for International Development (USAID) cooperative agreement to introduce and support high-impact health interventions in 25 priority countries with the ultimate goal of ending preventable child and maternal deaths (EPCMD) within a generation. In Uganda, MCSP is working with the Ministry of Health (MOH) and the Uganda National Expanded Programme on Immunization (UNEPI) at national level to operationalize the Reaching Every Child/Community using Quality Improvement Approach (REC-QI) in ten districts. REC- QI focuses on district and health facility management processes and applies methods from the field of quality improvement (QI) to help increase coverage and reach every child with immunization services that are effective, safe, responsive to community needs and sustainable. MCSP Uganda continues work started by USAID’s predecessor project, Maternal and Child Health Integrated Program (MCHIP) and is implemented side-by-side with the Bill & Melinda Gates Foundation’s Stronger Systems for Routine Immunization (SS4RI) Project in 10 additional districts. REC-QI is one of the seven priority “innovations” that MCSP is introducing and studying as part of its global innovations and learning agenda. The REC-QI implementation process (shown in Figure 1 below) entails: 1) introducing the approach to the district and health facilities (Orient); 2) implementing REC-QI and determining its contributions to the routine immunization system (Establish and Strengthen); and, 3) adding it into the routine operations and plans of districts and health facilities (Sustain). REC-QI implementation from start to finish takes approximately 24 months in each district. Depending on which stage of REC-QI implementation a district is in, it receives differing amounts and kinds of support from MCSP (Figure 1). In general, MCSP supports the training of district managers, health workers and village health teams (VHTs) in immunization, microplanning, EPI management, and the use of key REC-QI tools. The program also trains supervisors in supportive supervision, and supports quarterly review meetings (QRMs) that are led by district health management teams (DHMTs). QRMs are the platform for health facility staff, DHMTs and district and sub-county political, religious and civic leaders to jointly reflect on the performance of routine immunization and other maternal and child health (MCH) services and to develop action plans to address challenges. Figure 1: REC-QI steps, inputs and timeline. 4 I. Summary of PY3 Quarter 2 Achievements During this reporting period, MCSP continued its efforts to strengthen the capacity of UNEPI and focus on promoting REC-QI practices in the districts, health sub-districts (HSD) and health facilities. MCSP phased out its support to the two PY1 (e.g., support initiated during PY1, October 2014 to September 2015) districts of Kanungu and Butaleja after 22 months of support. MCSP continued to provide support to the four PY2 districts of Ntungamo, Mitooma, Bulambuli and Kibuku. Additionally, MCSP initiated support to four PY3 districts of Mbarara, Bushenyi (South West region), Mayuge (East Central region) and Pallisa (Eastern region). Step one, “Orient”, was completed in the four PY3 districts, with the exception of a five-day REC-QI training to prepare the districts for Step two, “Establish and Strengthen”, which is planned for April 2017. The REC-QI approach encourages frontline health workers to “think outside the box” while addressing their RI challenges. For example, thinking of how to tap community, local government and private partners’ resources in the district instead of only relying on primary health care (PHC) grants from central government. Technical input to key national and global meetings MCSP attended and provided technical input to several important global and national level meetings, including the UNEPI EPI Technical Working Group (TWG), Inception Meeting for Immunization Financing Sustainability organized by MOH and partners, Gavi teleconference meetings, New RED Guide and Equity guide adaptation workshop, USAID’s Chief of Party & Communications meetings, Eastern and Southern Africa (ESA) EPI Manager’s Meeting held in Uganda from March 20-22, 2017, Institutionalizing Community Health Conference (ICHC) held in South Africa from March 27-30, 2017, and a WHO regional workshop to facilitate modification of the Home-Based Child Health Records for Immunisation. These meetings provided opportunities for MCSP to coordinate with other in-country and international partners and key players in immunization, share implementation experiences and results of MCSP’s work, and contribute to national and global knowledge in RED/REC and immunization in general. MCSP continued to support the EPI Newspaper Pull Out publication on district EPI performance that provides feedback to stakeholders and stimulates debate/attention to RI, and contributed to the mapping of the geographical distribution of EPI partners’ support to facilitate donor coordination, universal coverage and enhancement of synergies. Immediately after the ESA EPI Manager’s Meeting in Uganda, JSI held a one day meeting on March 23, 2017 that was dedicated to REC-QI work in Uganda with the aim of sharing lessons learnt for scale up within immunization and other health interventions. The meeting was attended by 38 participants, including 5 representatives from USAID (e.g., USAID/Washington, Africa Bureau, Uganda, and Mozambique), 2 senior staff from the Bill & Melinda Gates Foundation, the UNEPI Program Manager (PM) and Deputy PM, plus JSI immunization staff from eight countries. REC-QI “Sustain” step completed in two PY1 districts (Kanungu and Butaleja) MCSP conducted sustainability forum meetings, which is the last activity in the REC-QI timeline of activities, in both PY1 districts. During these meetings, results of REC-QI implementation were compared to baseline and a sustainability plan was developed. Notable results included an increase in the proportion of health facilities with completed REC microplans from 6% (baseline June 2015) to 67% (assessment conducted in October 2016), and a reduction in the Pentavalent (DPT1-3) dropout rates from 6.4% to 2.6% and from 21% to 14% for Kanungu and Butaleja districts, respectively. To close the remaining gaps and ensure sustainability of these improvements in RI service delivery, an action plan was jointly developed by MCSP and district health leadership with action points focusing on strengthening 5 cold chain maintenance, community mobilisation for RI services, and strengthening recording of children vaccinated in the MOH Child Register. Four PY2 districts in the “Establish and Strengthen” step (Ntungamo, Mitooma, Kibuku and Bulambuli) In the four PY2 districts, MCSP conducted Operational Level (OPL) trainings on immunisation practices