J.11_SDS_YEAR_7_Annual_progress_report_July_2016_to_March_2017.pdf

YEAR 7 ANNUAL PROGRESS REPORT

JULY 2016 – MARCH 2017

STRENGTHENING DECENTRALIZATION FOR SUSTAINABILITY (SDS)

PROGRAM

APRIL 2017

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.

ANNUAL REPORT

JULY 1, 2016 – MARCH 31, 2017

STRENGTHENING DECENTRALIZATION FOR SUSTAINABILITY (SDS)

PROGRAM

Submitted by:

Cardno Emerging Markets USA, Ltd.

Submitted to:

USAID/Uganda

Cooperative Agreement No:

AID-617-10-00003

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.

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page i

TABLE OF CONTENTS

ACRONYMS ........................................................................................................................................................ II

PREFACE

EXECUTIVE SUMMARY

Program Context

SDS ACHIEVEMENTS AND KEY DELIVERABLES FOR THE QUARTER (JANUARY-MARCH

2017)

SDS ACHIEVEMENTS AND KEY DELIVERABLES FOR THE YEAR

PROGRAM MANAGEMENT

OBJECTIVE 1: COORDINATE ACTIVITIES AT DISTRICT AND SUBCOUNTY LEVEL

1.1. Improve Implementation of the District Operational Plans

1.1.1. Institutionalization of District Coordination Mechanisms Efforts to promote and operationalize the DOP as a coordination mechanism have continued:

1.1.2. Foster Effective DMC Meetings

1.1.3. Continue Dialogue with USAID and District Leaders to Promote a CLA Approach to Improve Implementation of DOPs

1.1.4. Conduct Coordination and Planning Meetings with USAID IPs and CSOs in Northern Uganda

1.1.5. Continue to Support Districts in Northern Uganda to Coordinate Technical Meetings

OBJECTIVE 2: STRENGTHEN MANAGEMENT OF RESOURCES AND PROGRAM RESULTS AT

DISTRICT AND SUBCOUNTY LEVEL

2.1. Provision of Human Resource Support to Local Governments

2.1.1. HRH COP 15 Supplementary Recruitment

2.1.2. Support to improve institutionalization of performance management

2.1.3. Participate in Quarterly Meetings of PEPFAR HRH Implementing Partners

2.1.4. Strengthen Support Supervision Systems

2.1.5. Procurement and distribution of uniforms

2.2. Support the Renovation and Operationalization of Laboratory Hubs in Northern Uganda

2.2.1. Support the Renovation of Laboratory Hubs

2.2.2. Implementation Approach / Bid Solicitation

2.2.3. Strengthen Functionality and Operations of Lab Hubs

2.4. Service Delivery Activities in Northern Uganda

2.4.1. DREAMS Initiative

2.4.2. Gender norms training

2.4.3. HIV Prevention

2.4.4. Voluntary Male Medical Circumcision (VMMC)

2.4.5. Malaria Prevention and Control

2.3.6. MNCH and family planning activities

OBJECTIVE 3: IMPROVE LOCAL GOVERNMENT SUPPORT FOR SOCIAL SECTOR SERVICE

DELIVERY

3.1. Provision of Critical Service Delivery Activities in 43 districts in Eastern, Central, Western and Northern Regions through In-kind grants

3.2. CSO Grant Engagement in the Northern Region

3.3. Support Health Care Waste Management (HCWM)

3.4. Award Grants to Medical Bureaus under HRH

3.5. Close out of Grants

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page ii

3.5.1. Receipt and Review of the grant closeout packages

3.5.2. Financial Reviews

3.6. Sustaining Service Delivery in Suspended Districts

3.7. USAID/SDS Program Total Grants Disbursed to Grantees from 2011 to Dec 2016

OBJECTIVE 4: INSTITUTE INNOVATIVE APPROACHES TO SUSTAIN SOCIAL SECTOR

SERVICE DELIVERY

4.1. Provide strategic TA to partner districts

4.1.1. Strengthen Capacity of Local Governments to Implement the New PFM Act

4.2. Provide induction to newly elected District and Lower Local Government Councils– [LOGIC II]

5.0. MONITORING AND EVALUATION

5.1. Monitoring and Evaluation

5.1.1. Dissemination of Survey Findings

5.1.2. HMIS Data Validation and Updating the DHIS2

5.1.3. Dissemination and Printing of CSOs Data Collection Tools

5.1.4. Technical Support to Districts

ANNEXES

Annex I. DMC Meetings Success Stories

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page i

LIST OF TABLES

Table 1: Partner Roles on SDS Year 7 Program Extension Table 2: Financial Summary: FY 2017 Financial Analysis Report July, 2016- March, 2017 Table 3: Objective 1 – Key Deliverables Table 4: Summary of COP 15 supplementary recruitment progress by facility (Public) Table 5: PEPFAR absorption progress by district Table 6: Summary of Health workers transitioned to URC/SUSTAIN Table 7: Public and PNFP facilities visited by HRH team July 2016– March 2017 Table 8: HRH Public facilities Visited by ACLAIM during July– March 2017 Table 9: List of Renovated Laboratories Table 10: Sample transportation and result dispatch Table 11: Showing annual planned Targets vs. Actual Performance Table 12Showing Quarterly planned Targets vs. Actual Performance Table 13: Number of Enterprises by District and category Table 14: HIV status among tested AGYW Table 15: Number of Condoms Distributed by CSOs (Oct-Dec 2016) Table 16: Shows number of men circumcised versus target per district, July 2016 - Jan 2017 Table 17Number of VHTs trained per district Table 18: Coverage by Subcounty Table 19: Objective 2 – Key Deliverables Table 20: Districts Supported by each CSO Table 21: Total grants disbursed from 2011-Dec 2016 Table 22: Objective 3 – Key Deliverables Table 23: Objective 4 - Key Deliverables Table 24: Status of Planned activities

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page ii

ACRONYMS

ACT Artemisinin Combination Therapies AGYW Adolescent Girls and Young Women ART Antiretroviral Treatment ASSIST Applying Science to Strengthen and Improve Systems CAO Chief Administrative Officer CCI Children’s Chance International CDO Community Development Officer CHC Communication for Healthy Communities CLA Collaborating, Learning, and Adapting COP Chief of Party COW Children of the World Foundation CSO Civil Society Organization DBTA District-Based Technical Assistance partner DHMT District Health Management Team DHO District Health Officer DHS Demographic and Health Survey

DHT

DLG

District Health Team District Local Government

DMC District Management Committee DOP District Operational Plan DREAMS Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe DSC District Service Commission eDTPC Extended District Technical Planning Committee eDHMT

EMTCT

Extended District Health Management Team (Meeting) Elimination of Mother-to-Child Transmission

FP Family Planning

GBV

HoD

Gender-based Violence Head of Department

HCWM Health Care Waste Management HIV/AIDS Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome HMIS Health Management Information Systems HR Human Resources HRH Human Resources for Health ICOBI Integrated Community-Based Initiatives IDI Infectious Diseases Institute IEC Information, Education, and Communication IP Implementing Partner LLIN Long-lasting Insecticide-treated Nets LQAS Lot Quality Assurance Sampling M&E

METS

Monitoring and Evaluation Monitoring and Evaluation Technical Support Program

MNCH

MoFPED

Maternal, Newborn, and Child Health Ministry of Finance, Planning and Economic Development

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page iii

MoH Ministry of Health MoLG Ministry of Local Government MoU Memorandum of Understanding NMCP National Malaria Control Program NU-HITES Northern Uganda Health Integration for Enhanced Services NUDEIL Northern Uganda Development of Enhanced Governance, Infrastructure, and Livelihoods OVC Orphans and Vulnerable Children PEPFAR President’s Emergency Plan for AIDS Relief PFP Private For Profit PMP Performance Management Plan PMTCT Prevention of Mother-to-Child Transmission

PNFP

RRH

STF

Private Not-for-Profit Regional Referral Hospital Straight Talk Foundation

SCMS Supply Chain Management Systems SHRH Strengthening Human Resources for Health SOVCC Sub county Orphans and Vulnerable Children Committees TA Technical Assistance TASO The AIDS Support Organization TOT Training-of-Trainers TPC Technical Planning Committee UCMB Uganda Catholic Medical Bureau UGX Uganda Shilling UHF Ugandan Healthcare Federation UHSC Uganda Health Supply Chain UI Urban Institute ULGA Uganda Local Governments Association UMMB Uganda Muslim Medical Bureau UPMB Uganda Protestant Medical Bureau USAID United States Agency for International Development VHT Village Health Team VMMC Voluntary Medical Male Circumcision

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page 1

PREFACE

The United States Agency for International Development (USAID) requested that Cardno Emerging Markets USA, Ltd.—through the USAID Strengthening Decentralization for Sustainability (SDS) Program—continue to undertake ongoing and additional activities to increase access to skilled human resources (HR), particularly for the health workforce, and quality health services for the most vulnerable populations of women and children in underserved rural areas in Uganda. This extension of activities was also designed to meet a priority commitment under the President’s Emergency Plan for AIDS Relief (PEPFAR) to support the recruitment of health workers in Uganda and the scale-up of services for HIV prevention, interventions of Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) Initiative, Voluntary Medical Male Circumcision (VMMC), and support to laboratory functions in Northern Uganda. SDS also had to continue to support its core activities in 35 districts in the Eastern, Western, and Central Regions of Uganda. Lastly, SDS had to coordinate the delivery of critical, high-impact, and life-saving interventions in 15 districts in the Northern Region of Uganda.

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page 2

EXECUTIVE SUMMARY

Cardno Emerging Markets USA, Ltd. (Cardno) is pleased to submit this 3rd quarter and annual report for the USAID SDS Program.

This Annual report covers the period July 1, 2016 to March 31, 2017, and represents the 3rd quarter (Jan-March 2017) of the seventh program year. It incorporates the achievements, challenges, and recommendations of the following supported interventions: Human Resources for Health (HRH), HCWM (Healthcare Waste Management), DREAMS (Determined, Resilient, Empowered, AIDS-free Mentored and Safe) and direct service delivery.

During the reporting period, USAID extended the SDS program for an additional six months through March 31, 2017.

Per USAID guidance and effective August 9, 2016, SDS no longer disbursed grant funds to the district local government accounts, instead, the program was engaged in direct financial support for critical activities through: (1) Direct payment to service providers already used by districts; (2) Direct payment to vendors and beneficiaries through mobile money; and (3) Payments through district implementers (activity focal persons) via mobile money, for oversight and submission of attendance sheets and activity reports. This new funding model further strengthened the relationship with local authorities in addressing management issues that hindered effective planning, implementation, and monitoring of service delivery.

During the reporting period, as per the USAID request, the program also expanded its coverage to the districts previously served by the Strengthening HIV&AIDS and Tuberculosis Responses in East Central Uganda (STAR-EC) project and by December 1, 2016, officially transitioned these activities to the RHITES (EC) project implemented by URC.

Cardno serves as the prime contractor and supports the implementation through several local partners;

their roles for Year 7 are outlined in Table 1.

Table 1: Partner Roles on SDS Year 7 Program Extension

Partner Role on SDS Cardno (prime contractor) Program and grants management

Technical assistance to partner districts in management capacity building, leadership and governance, innovative programming

Coordination with District-Based Technical Assistance partners (DBTAs) and Implementing Partners (IPs)

ACLAIM Africa Human resource and payroll management for the public sector HRH health workers

Uganda Catholic Medical Bureau (UCMB) Uganda Protestant Medical Bureau (UPMB) Uganda Muslim Medical Bureau (UMMB)

Management of health workers for their affiliate Private Not-for-Profit (PNFP) health facilities

Civil Society Organizations (CCI, COW, STF, &TASO)

Building of demand and awareness in the three technical areas:

Malaria, VMMC, and HIV/AIDS prevention

Human Diagnostics and BD Laboratory equipment maintenance

Program Context Through Modification number 16 of the award agreement, USAID granted a six-month extension to the SDS Program to prevent an interruption in program activities. SDS continued to support core activities in target districts in the Eastern, Western, and Central Regions of Uganda, and coordinate the delivery of critical, high impact, and life-saving interventions in now 16 districts in the Northern region of Uganda including, the recently established district of Omoro, formerly part of Gulu District.

The SDS field and home office project management teams maintained regular and constructive dialogue on several programmatic and contractual matters, particularly in light of the scaling up of critical

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page 3 activities, and also in preparation for project closeout. Cardno’s home office provided short-term technical support to HRH, DREAMS, VMMC, closeout planning, and overall documentation/ communication efforts. At the field level, the team held weekly technical meetings, both in Kampala and Gulu, to plan and discuss critical program issues and to enable the prompt resolution of emerging issues.

In December 2016, the SDS Program initiated a three month closeout process that entailed:

Notification to districts, sub-grantees (CSOs), and medical bureaus that included any instructions regarding final payments and guidance on closeout preparations.

Preparation and submission of property disposition plan.

Notification to the first batch of SDS personnel whose contracts ended on January 31, 2017.

The second and last batches of staff contracts ended in February and March 2017 respectively.

In February 2017, the SDS Program held transition meetings for SUSTAIN (HRH support and VMMC); USAID/ASSIST (DREAMS, HIV prevention, Laboratory support); and AIDS-free (Health care waste management). The outcome of meetings helped develop a sustainability plan that has been shared with the various ministries Ministry of Local Government (MoLG), Ministry of Health (MoH), and district local governments (DLGs) during the 2017 regional closeout events held in Gulu (February 20th), Jinja (February 22nd), and Masaka (February 24th).

SDS ACHIEVEMENTS AND KEY DELIVERABLES FOR THE QUARTER (JANUARY-

MARCH 2017)

Held 8 District Management Committee (DMC) / extended District Technical Planning Committee (eDTPC) meetings in the mission-focused districts; the two planned for Gulu and Luwero districts did not take place due to the district offices’ conflicting schedules.

Obtained commitment from DLGs to harmonize and prioritize the execution of their sustainability action plans during the three regional closeout events held in February.

Through the district service commissions, successfully completed the recruitment of an additional 28 health workers who were posted to general hospitals and health center IVs.

In collaboration with the Ministry of Local Government (MoLG), organized a national HRH absorption review meeting on January 24, 2017, attended by the chief adminstrative officers (CAOs), district health officers (DHOs) and principal human resources officers (PHROs) for 32 district and key ministries to increase the absorption of HRH health workers onto the public payroll.

SDS-staffed teams visited approximately 60 health facilities (public and PNFP) in 40 districts.

Scaled up VMMC support at static and outreach activities in 11 priority districts, and as a result

8,356 clients were circumcised during the month of January.

Commissioned two renovated Lab hubs in Kalongo Hospital in Agago District and Namokora HC

IV in Kitgum District.

Oriented 460 peer educators (Gulu-205, Oyam-165, and Lira-90) under the DREAMS initiative. A total of 207 peer educators were trained on the Girl Roster tool to facilitate the mapping of Adolescent Girls and Young Women (AGYW) cohort.

Trained 26 peer educators, 18 health workers, 28 district local workers, 9 religious leaders, 9 cultural leaders and 2 police/law enforcement officers in the region on gender norms.

In January, a follow up refresher training on gender norms was held for 30 participants (from Lira, Gulu and Oyam) earlier identified from a previously trained pool of candidates.

Funded 95 business proposals as part of the economic empowerment for the AGYW.

Completed the Qualitative Study on the impact of DREAMS.

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page 4

Updated the DREAMS tracker Trained 926 village health teams (VHTs) on the use of Sayana Press (an all-in-one injectable contraceptive) for family planning outreach efforts.

The SDS monitoring and evaluation (M&E) team disseminated the Annual Citizens’ Survey fact sheets.

Completed the LOGIC II activity in 15 districts in Eastern and East-central Uganda Organized national SDS program closeout event on the 2nd of March.

Developed 50 district specific sustainability action plans that were shared with the MoLG, MoH, and DLGs during the regional close out events conducted in Gulu (20th February), Jinja (22nd February), and Masaka (24th February)

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page 5

SDS ACHIEVEMENTS AND KEY DELIVERABLES FOR THE YEAR

In addition to the quarterly achievements listed above, SDS had numerous achievements throughout the year.

Held 44 DMC/eDTPC meetings in mission focus districts and 22 biannual DMC meetings for the non-mission focus districts.

Developed 50 district specific sustainability action plans that were shared with the various ministries for local government, health, and district local governments during the regional close out events conducted in Gulu (20th February), Jinja (22nd February), and Masaka (24th February)

Up to 53% (COP 12 and COP 15) of the public PEPFAR supported health workers were transitioned into the mainstream public service.

654 health workers in public and PNFP facilities were transitioned to URC/SUSTAIN SDS team visited approximately 60 health facilities (Public and PNFP) in 40 districts.

Five laboratories were renovated and commissioned: Alebtong HC IV in Alebtong District, Namokora HC IV in Kitgum District, Kalongo Hospital in Agago District, Pajule HC IV in Pader District, and Lalogi HC IV in Omoro District.

Conducted 2 DREAMS IP coordination meetings and 18 monthly meetings across the four DREAMS districts.

132 peer facilitators and 5 community development officers (CDOs) were trained on Stepping Stones in Gulu and Omoro districts with peers coming from all the 16 subcounties.

A training of trainers (TOT) training on Stepping Stones was conducted in Kampala for CDOs, health workers, and peer educators from the 13 (non-DREAMS priority) districts of Northern Uganda in which 35 participants attended including 15 CDOs, 9 health workers, 7 CSO staff and 5 newly recruited SDS DREAMS officers. The list is attached in Annex VI

Four trainings were conducted for 150 participants on gender norms and Gender-based Violence (GBV), comprising of peer facilitators, CDOs, religious and cultural leaders, district officials in the Departments of Health, Community and Education along with the DREAMS officers and CSO staff. The training was to equip them with knowledge on the management and response to GBV in the community, more specifically in support of the girls.

1,903 AGYW have been supported with basic skills in business assessment and identified members of AGYW enterprise groups are now engaged in income generating activities.

More than 7,906 AGYWs accessed HIV testing services in Oyam, Omoro, Gulu, and Lira districts, out of which, 41 tested HIV positive and were linked to care.

1,769 young women and girls accessed family planning services.

Two trainings on gender norms were organized and held in August and December 2016.

From June 2016–January 2017, SDS supported 10 districts to provide VMMC services to eligible men through static and outreach activities. A total of 32,819 (73.4%) clients of the targeted 44,728 were circumcised in that period.

Beginning in late November 2016, SDS in collaboration with PATH and FHI 360, trained 926 out of the 3360 VHTs and peer educators in 11 out of the 16 Districts of Northern Uganda to administer Sayana Press and Depo at the community level.

The total number of grants due for closure are 184, that is, 169 Grant A, B and Cs, 8 Youth Group CSOs, 4 Northern CSOs and 3 HRH Bureaus.

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page 6

Technical assistance (TA) was delivered to all 50 partner districts.

SDS identified a local partner— ULGA—to host and carry on the SDS legacy through the Local

Government Knowledge Resource Center (LGKRC).

Under LOGIC II, a total of 241 local governments, both at district and lower levels participated in induction trainings, with approximately 4,391 councilors and 712 heads of departments (HoDs) trained.

Annual citizens survey results were disseminated in the 15 districts (Kumi, Bududa, Bugiri, Bukwo, Butaleja, Mbale, Busia, Kapchorwa, Pallisa, Sironko, Budaka, Iganga, Kaliro, Kamuli, & Mayuge) were LOGIC II was being implemented.

A total of 22 TOTs were conducted while 41 peer facilitators were trained with technical support from the Monitoring and Evaluation Technical Support (METS) Program.

SDS program, in collaboration with the ASSIST project rolled out the Open MRS system in the six pilot districts of Gulu, Nwoya, Kitgum, Apac, Dokolo, and Otuke.

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page 7

PROGRAM MANAGEMENT

The SDS field and home office project management team maintained regular and constructive dialogue on several programmatic and contractual matters. In fact, the senior management team held biweekly meetings with the home office project director to ensure coherent implementation of the work plan and uphold the quality of program delivery. At the field level, the team held weekly technical meetings to plan and discuss critical program issues and promptly address emerging issues given the program context.

In addition to management meetings, there were three major DREAMS regional conferences that took place over the course of this quarter. In July 2016, an SDS DREAMS Ambassador and an SDS staff member participated in the International HIV/AIDS Conference in Durban, South Africa. Then, from August 8–12, 2016, the Deputy Chief of Party for Programs, DREAMS coordinator, M&E specialist and representative of TASO took part in the DREAMS training in Johannesburg, South Africa, organized by Population Council. On September 21, 2016, in an event organized by Johnson & Johnson, six DREAMS Ambassadors and SDS staff participated in the DREAMS Ambassador Conference in Entebbe, to share success stories, challenges, and the impact that DREAMS has on girls’ lives.

While the successes of program implementation under SDS were many, challenges were also evident.

For instance, mitigating attrition rates was a major obstacle due to the short remaining performance period of the program. The program continued to engage STTAs for specific assignments such as behavioral change communication (BCC) support for the CSOs, SDS communications, and lab renovations.

In December 2016, in preparation for program closeout, SDS organized a one and half day all-staff meeting to discuss the closeout requirements, processes, and resource plans, as well as priority activities to be implemented and wrapped up during the remaining months of the project.

With the award of the new RHITES EC mechanism, the SDS program team held a series of meetings aimed at realizing an effective transition of specific bridge activities in the East Central region to RHITES EC by December 2016.

During the same period, SDS developed an environmental mitigation and monitoring plan, which was reviewed and approved by the USAID Mission Environment Officer (MEO). The MEO visited selected sites in Northern Uganda in December 13- 16, 2016 as part of the monitoring and approval process.

Table 2: Financial Summary: FY 2017 Financial Analysis Report July, 2016- March, 2017

Base Period Total Budget

Total Amount Obligated (as of June, 2016)

Total Amount Expended (as of June 30, 2016)

Remaining Obligation

Remaining Unexpended Funds

Direct Cost $27,630,237 $21,890,863 $5,739,374 Sub awardees $9,393,394 $6,482,963 $2,910,431 Grants $19,463,148 $15,287,907 $4,175,241 Construction $470,000 $266,364 $203,636 Indirect Cost $13,032,964 $10,692,636 $2,340,328 Total Program Cost

$69,989,743

$59,854,052

$54,620,733

$5,233,319

$15,369,010

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page 8

OBJECTIVE 1: COORDINATE ACTIVITIES AT DISTRICT AND SUBCOUNTY LEVEL

1.1. Improve Implementation of the District Operational Plans Objective 1 aims to eliminate duplication and improve complementarities among USAID implementing partners, and improve the collaboration and communication among local governments and other stakeholders working at the district level. It also aims to strengthen the districts’ and USAID’s joint coordination, implementation, monitoring and evaluation, and coordination with in-coming IPs— ASSIST, RHITES-SW, STAR-E and others— in planning, implementing, and monitoring activities at district, community, and health facility levels.

SDS continued to support districts to implement the District Operational Plans (DOP). Because of the strong partnership with districts, DOP agreements were not extended beyond September 30, 2016 by means of a formal MOU. With the release of the new USAID/Uganda Country Development and Cooperation Strategy (CDCS 2.0), the DOP based coordination and planning process will be elevated to the regional level with the use of regional based fora for coordination of donor support.

This regional strategy for development is being led directly by USAID and underscored in the new

CDCS.

1.1.1. Institutionalization of District Coordination Mechanisms Efforts to promote and operationalize the DOP as a coordination mechanism have continued:

SDS worked with partner districts to integrate the District Operational Plans (DOPs) and District Management Committee (DMC) meetings into eDTPC meetings.

The program further supported the MoLG and districts to encourage development partners to coordinate with districts’ local governments to ensure the following:

District-led stakeholder mobilization for the eDTPC or DMC meetings included several non-

USAID partners, many of which include other USG and UN partners District planners routinely updated the mapping of all IPs operating in non-SDS districts SDS cluster leads empowered district leadership and teams through direct mentorship to the DMC secretariats New IPs were provided orientation on the DOP strategy and given schedule to introduce their activities to the district leadership during the eDTPC meetings Integrated Planning and Budgeting (IPB) strategies are integrated into Budget Conferences, Budget

Framework Papers (BFPs) and DDPs Mapping of USAID IPs and development partners active in the respective districts completed The piloted DOP reporting templates have been adopted by the districts and are being used IPB tools developed and shared with the 35 partner districts and to be shared with MoLG through a proposal expected to be rolled out to the rest of the country List of current IPs shared and handed over to 19 focus districts for coordination

1.1.2. Foster Effective DMC Meetings

In Kasese and Gulu districts, field monitoring visits were initiated prior to the eDTPC meetings. These field visits have been replicated in other districts. This approach enables more focused and insightful discussions on the key issues affecting communities, resulting in more effective eDTPC/DMC meetings.

The performance in every eDTPC meeting was assessed using the DMC meeting evaluation form completed by each participant, and analyzed by SDS, and the Learning Contract, which is an activity

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page 9 that supports USAID’s Program and Policy Development office. The results of the evaluation, in the form of the DMC satisfaction survey report, will be presented during future meetings.

To strengthen local planning and support national ownership, SDS coordinated with USAID partners, enabling them to integrate their work plans into district-level health sector work plans. The SDS cluster leads for each district participated in all DMC meetings to foster joint coordination and planning at the district level. These meetings provided an opportunity to match technical support capabilities to the needs of local organizations through SDS-supported grants.

1.1.3. Continue Dialogue with USAID and District Leaders to Promote a CLA Approach to Improve Implementation of DOPs

Community listening events: The SDS Progam supported the community listening events conducted by USAID at the regional levels, as the events were held prior to the release of theUSAID Uganda Country Development and Cooperation Strategy (CDCS), which may provide clarity on the type of forum future IP coordination would take and whether the strategy would target the district or regional level.

1.1.4. Conduct Coordination and Planning Meetings with USAID IPs and CSOs in Northern Uganda

SDS continued to coordinate IPs and CSOs across 15 districts in Northern Uganda to strengthen local planning for optimal results. The meetings between SDS and individual IPs were conducted to clarify and address implementation challenges. The key IPs included ASSIST, CHC, IRS, SHRH, TRACK TB, USAID/Uganda Health Supply Chain (UHSC) Program, and Monitoring and Evaluation of Emergency Plan Progress (MEEPP). The CSOs included TASO, ICOBI, COW, and CCI. SDS conducted regular visits to meet with key district leaders, IPs, and CSOs leadership and staff to ensure prompt and quality implementation.

On October 20, 2016 SDS conducted one quarterly IP coordination meeting for performance review and planning. The major IPs that participated included ASSIST, CHC, MARIE STOPES, TRACK TB, JCRC, USAID/Procurement and Supply Management Project (PSM), Better Outcomes for Youth and Children, PATH/Advocacy for Better Health, and MEEPP. Among the CSOs were TASO, COW, and CCI. Overall, 19 participants discussed key issues, including the challenges of stock outs of basic supplies, HIV testing kits, and tetanus vaccines. The meeting engaged relevant stakeholders, specifically National Medical Stores (NMS), to plan for emergency (or out-of-schedule) deliveries.

Some IPs SDS, CHC, ASSIST, and MARIE STOPES also used the meeting to harmonize plans for family planning training of VHTs, peer educators, and health workers.

1.1.5. Continue to Support Districts in Northern Uganda to Coordinate Technical Meetings

SDS continued to support districts in their coordination role by extending grants for districts to hold technical meetings to review priorities and plans for service delivery in these areas: malaria prevention, care, and treatment; TB prevention and control; HIV/AIDS prevention, including DREAMS, HIV counseling and testing (HCT), elimination of mother-to-child transmission (eMTCT), and antiretroviral treatment (ART) services; maternal, newborn, and child health (MNCH) services; and laboratory services.

SDS supported districts’ performance review meetings through the direct financing mechanism. These included quarterly expanded District Health Management Team (eDHMT) meetings; other technical meetings to review priorities and plans for service delivery in the areas of malaria prevention, care, and treatment; TB prevention and control; HIV/AIDS prevention, including DREAMS, HIV counseling and testing (HCT), eMTCT, and antiretroviral treatment (ART) services; MNCH; laboratory services;

and health supplies related activities.

Annex 1 provides detailed information covering DMC meetings in mission-focused districts in Northern Uganda during the reporting period.

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page 10

The notable challenges that affect these coordination meetings are:

Delays by some IPs in submitting their reports to their line heads of department Uncertainty on the sustainable strategy for the DOP; the issue of whether or not to continue with the district fora or regional fora

Table 3: Objective 1 – Key Deliverables

Deliverable July – Sept 2016

Oct – Dec 2016

Jan- March 2017 Total

Number of integrated DMC/DTPC meetings in mission-focus districts

19 17 8 44

Number of eDHMT meetings in all SDS supported districts 43 43 0 86 Number of IP coordination meetings held 1 1 0 2 TA provided to partner districts in PFM and planning to further 90-90-90 goals

0 40 0 40

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page 11

OBJECTIVE 2: STRENGTHEN MANAGEMENT OF RESOURCES AND PROGRAM

RESULTS AT DISTRICT AND SUBCOUNTY LEVEL

Under this objective, as outlined in the SDS Program extension, SDS focused on the implementation of these major activities: expansion of the HRH activity to include approximately 401 new health workers; renovation and operationalization of the laboratory hubs in Northern Uganda; and support of direct service delivery in Northern Uganda in the areas of a) HIV prevention and DREAMS Initiative,

b) VMMC, and c) malaria prevention and control.

2.1. Provision of Human Resource Support to Local Governments During the year, USAID mandated SDS to hire 401 health workers for the Regional Referral Hospitals (RRHs), General Hospitals (GH), HC IVs and HC IIIs in both public and PNFP facilities in 26 districts.

Additionally, inductions of the newly recruited health workers were conducted, uniforms were procured and distributed, level of effort validation and support supervisions for both public and PNFP facilities were conducted, and the Uganda Healthcare Federation (UHF) conducted training of 200 health workers posted to both public and PNFP facilities.

2.1.1. HRH COP 15 Supplementary Recruitment

The SDS program undertook supplementary recruitment for the 56 positions that existed in the HC IVs, District Hospitals and RRHs. These recruitments were conducted through the district and health service commissions for the RRHs to address the health worker staffing gaps that were left vacant during the first round of COP 15 HRH recruitments.

The District Service Commission-led recruitments were conducted during the period from October to November 2016, however Health Service Commission-led recruitments meant for the RRHs have yet to be concluded. The apparent delay by the Health Service Commission to undertake these recruitments affected SDS program’s ability to meet the targeted number allocated under COP 15 HRH support.

Table 4: Summary of COP 15 supplementary recruitment progress by facility (Public)

District Site Vacancy Attracted Positions Filled Bugiri Bugiri General Hospital 2 2 1 Dispenser and 1 Medical Officer Iganga Iganga General Hospital 2 2 2 Dispensers Sironko Budadiri HCIV 1 1 1 Enrolled Midwife Namayingo Buyinja HCIV 1 0 Remained vacant Ntungamo Itojo General Hospital 2 2 1 Pharmacist and 1 Enrolled Nurse Kisoro Kisoro Gen Hospital 1 1 1 Laboratory technician Isingiro Rwekubo HCIV 7 7 All positions filled Buhweju Nsika HCIV 2 2 2 Laboratory technicians Sheema Kitagatta Gen Hospital 4 4 1 Pharmacist, 1 Laboratory technician, and

2 Midwives Alebtong Alebtong HCIV 2 2 1 Medial Officer and 1 Dispenser Lamwo Madi Opei HCIV 1 1 1 Laboratory technician Nwoya Anaka Gen Hospital 4 4 3 Midwives and 1 Enrolled Nurse Kitgum Kitgum Gen Hospital 1 1 1 Laboratory technician Amolatar Amolatar HCIV 1 1 1 Laboratory technician

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page 12

Table : Summary of COP 15 Positions not filled for RRHs in three districts

District Site Allocated In post Comments Gulu Gulu RRH 16 12 1 Medical Officer, 1 Dispenser, 1

Laboratory technician, and 1 Enrolled Nurses not recruited.

Mbarara Mbarara RRH 31 15 1 Medical Officer, ,2 Dispensers,1 Laboratory technician,4 Enrolled Nurses, 9 Enrolled Midwives remain vacant

Kabale Kabale RRH 28 16 2 Medical Officer, 2 Dispensers,1 Laboratory technician, 1 Enrolled Nurse , 6 Enrolled Midwives

The following challenges were met during the recruitment process:

Some district service commissions (e.g., Namayingo, Iganga and Bugiri) were not in place. This accounted for delays in undertaking supplementary recruitments It was challenging to attract some health worker cadres (e.g., dispensers and midwives) for some districts Delays by HCs to undertake some recruitments affected SDS program’s ability to meet the targeted number allocated under COP 15 HRH support.

Challenge of interpreting and implementing non-monetary benefits as stated in the COP 15 recruitment PEPFAR guidelines

2.1.2. Support to improve institutionalization of performance management

2.1.2.1. Transition of health workers to GoU payroll

The SDS program has made a number of engagements with district leaderships about plans to transition the HRH workers. Currently, 53% (COP 12 and COP 15) of the public PEPFAR supported health workers have been transitioned into the mainstream public service. However, less than 1% of PEPFAR supported health workers recruited under COP 15 have been transitioned to the mainstream public service. During the quarter, significant progress was seen in Namayingo, Iganga, Bugiri, Bullisa, Buyende and Otuke districts. However, in other districts Isingiro, Napak, Ntungamo, Amudat, Mitooma, Buhweju, Kole, Kiruhura, Pader, Kabale, and Mbarara are still facing wage bill related issues.

Table 5: PEPFAR absorption progress by district

Grouped % Absorption

Number of districts (frequency) Districts

100 % Absorption 22 Agago,Arua, Bukomansimbi, Bulambuli, Gulu, Iganga, Jinja, Kabale, Kamwenge, Kanungu, Kayunga, Kween, Moyo, Nebbi, Oyam, Seembabule, Serere, Sironko, Namayingo, Iganga, Bullisa

70-99% Absorption 20 Butaleja, Nwoya, Kapchorwa, Kitgum, Dokolo, Luuka, Alebtong, Ibanda, Busia, Lamwo, Kibuku, Mayuge, Sheema, Bukwo, Pallisa, Kaliro, Buyende,Amolatar, Nwoya, Namutumba

40 - 69% Absorption 7 Bududa, Amuru, Buikwe, Bullisa, Namayingo Kiruhura, Mbale, 1-39% Absorption 8 Bugiri, Kole, Kisoro, Lira, Ntungamo, Rubirizi, Budaka, Bushenyi

0% Absorption 14 Amudat, Buhwejju, Isingiro, Kabarole, Kalangala, Kamuli, Lwengo, Napak, Ngora, Otuke, Rukungiri, wakiso,Isingiro, Apac

Transition progress by cadre - Public only

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page 13

Cadre Absorbed Left Not Absorbed

Not eligible for absorption

# Recruited Transition Trend

Biostatistician 30 8 8 46 65%

Dispenser 1 2 7 10 10%

Enrolled Midwife 96 24 55 175 55%

Enrolled Nurse 121 21 82 224 54%

Laboratory Assistant 7 7 0%

Medical Clinical Officer 19 6 13 38 50%

Medical Laboratory Technician 19 16 38 73 26%

Medical Laboratory Technologist 7 11 14 32 22%

Medical Officer 7 6 13 26 27%

Nursing Officer Midwife 2 0 2 100%

Nursing officer Nursing 5 0 5 100%

Pharmacist 1 1 4 6 17%

Sample Transporter 4 0 14 18 0%

Grand Total 308 99 241 14 662

The table above indicates that 100% nursing officer midwifery and nursing officer were absorbed, partly because very few of them were allocated and recruited, The absorption rate of sample transporters on the other hand was at 0% because their positions are not included as part of the local government structure, and therefore not eligible for absorption. There were higher attrition rates among laboratory technologists and despite being recruited and posted to HCIVs, these HCs could not accommodate them into the current existing staffing structure/establishment.

In order to ensure that districts scale up the absorption of PEPFAR HRH supported health workers, SDS in collaboration with the MoLG, organized an HRH absorption review meeting on January 24, 2017. The meeting was attended by the chief adminstrative officers (CAOs), district health officers (DHOs), and principal human resources officers (PHROs) for 32 districts. The main purpose of the meeting was to review absorption progress and chart a way forward on fasttracking the process in light of the imminent program closeout. The below addresses key issues discusssed during the meeting:

HRH Policy and Strategic Issues: focusing on customizing local government (LG) critical posts staffing structures, such as hub riders and sample transporters, matters involving Wage Bill and staff ceilings, understaffing, salary disparities for medical officers in favor of those deployed to HCIVs versus those in hospitals, inadequate supply of cadres (e.g., pharmacists, dispensers, anesthetic officers), incentives for attraction and retention of staff, and performance management.

Key HRH Milestones: including a remarkable 98% of PEPFAR supported health workers were inducted and provided with uniforms, of which, more than 60% transitioned into mainstream public service. Furthermore, District Service Commissions (DSCs) were supported in the recruitment and regularization of staff, performance management and performance-based salary payment using timesheets was institutionalized, and lastly support supervision was strengthened in both Public and PNFP facilities.

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page 14

HRH Closeout Plan/Road Map: because the end date of PEPFAR HRH support was scheduled for February 15, 2017, formal close out letters were shared with districts on January 10, 2017. Later, the regional closeout and sustainability workshops took place from February 20-24, 2017. Lastly, the national closeout event was held on March 2, 2017.

Limited availability of health workers: the high absenteeism rate of health workers was also noted (currently at 55%), in addition to the already low health worker enagement. The limited staff that were available had high, impractical pressures placed on them.

Political interference: the recruitment and absorption of PEPFAR supported health workers was influenced by politics (competing priorities of politicians) in some districts.

These key challenges affected the achievement of health sector strategic plan goals and led to the below listed recommendations.

The following were the key recommendations of stakeholders attending the HRH absorption meeting:

Districts should prioritize the inclusion of PEPFAR supported health workers, who were not absorbed, into the district recruitment and retention plans.

MoLG should lead discussions over wage provisions to districts, in collaboration with the Ministry of Finance, Public Service and Health.

Lobby the office of the president to engage several ministries including Local Government, Public

Service, Finance and Health for additional wage bill provision.

SDS/ACLAIM should ensure that arrears due to health workers are cleared by February 15, 2017.

Districts were encouraged to prioritize the absorption of health workers onto another payroll mechanism, otherwise risk unfavorable contractual stipulations.

2.1.2.2. Transition of PEPFAR

supported health workers to

URC SUSTAIN

In preparation for the program closeout, SDS was instructed by

Dr. John Odaga- presenting on behalf of Intrahealth, during the PEPFAR HRH absorption review meeting organized by SDS program in collaboration with Ministry of Local Government.

Senior District officials following the proceedings during PEPFAR HRH absorption review meeting.

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page 15

USAID to transition PEPFAR supported health workers whom were not absorbed, to USAID/URC SUSTAIN project, effective February 15, 2017. Hence, a transition planning meeting was held by SDS on February 3, 2017 to ensure a smooth transition to the new mechanism covering these main points:

Brief SUSTAIN team on the HRH implementation modalities Share the list of non-seconded health workers and affiliated facilities with SUSTAIN, including district contact persons Brief SUSTAIN team on the key implementation challenges and jointly agree on the way forward Provide the status of absorption of PEPFAR supported health workers Provide formal communication from SDS to district leadership introducing SUSTAIN Ensure follow up from SUSTAIN on pending recruitments for the RRHs (Mbarara, Kabale and

Gulu) Continue supporting district service commission by SUSTAIN to undertake absorption of PEPFAR supported health workers

Table 6: Summary of Health workers transitioned to URC/SUSTAIN

Category No Districts Health facilities No of health workers Public 42 54 249

UCMB 35 50 224

UMMB 4 7 31

UPMB 23 39 150

Total 150 654

2.1.3. Participate in Quarterly Meetings of PEPFAR HRH Implementing Partners

During the year, SDS participated in the HRH IP coordination meetings held on August 19, 2016 and on November 25, 2016 organized by USAID, in conjunction with Strengthening Human Resources for Health (SHRH) Program. The meetings enabled PEPFAR funded HRH implementing partners to review the progress of HRH efforts, including the status of recruitments, share experiences and outstanding issues, and to discuss cross-cutting issues and district intervention packages. Among the specific items discussed were:

Update by the IPs on the 921 PEPFAR recruitments, including the progress of filling gaps Update on the absorption plans for COP 12 and COP 15 PEPFAR staff Update on the transition of sites between mechanism and IPs Monitor opportunities and provide TA to districts for absorption of new graduates and contract health workers Provide TA to District Health Supervisory Authorities to track compliance with licensure and registration of health workers Support the induction and on boarding of health workers to improve retention Support district level advocacy for increased financing of HRH interventions Support district planning processes to fully integrate HRH into district health plans and budgets IPs should maintain records of DSC-led recruitments for district hospitals and HCIVs under COP

IPs should prioritize the absorption of PEPFAR supported health workers recruited under COP 12 Emphasize the need to continue engaging districts and the PNFP facilities to undertake absorption efforts

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page 16

Advise HRH IPs on the need to undertake proper induction in order to retain PEPFAR supported health workers

In addition to the coordination and absorption-focused meetings, a number of meetings where also held with ACLAIM and the medical bureaus to discuss pending issues i.e., invoices, PEPFAR HRH implementation challenges, and absorption progress in the PNFPs. For the public sector on the other hand, the following were key issues and recommendations:

SDS should expedite the clearing of ACLAIM invoices for gratuity to pay to health workers; the finance team should review gratuity related documents intended for the public sector PEPFAR supported health workers and share them with the home office team.

Provide clarification for the USAID HRH technical working group on how non-monetary benefits can be effectively implemented.

Ensure that the districts and medical bureaus are involved in cadre identification and overall HRH planning in future programming.

Explore the possibility of local governments absorbing PEPFAR supported health workers and seconding them to PNFP facilities.

Revise timesheets for RRHs to include provisions for head of departments and hospital director.

2.1.4. Strengthen Support Supervision Systems

During the year, SDS, ACLAIM, and the medical bureaus undertook supportive supervision in both public and PNFP facilities. These supportive supervisions were meant to monitor the performance of HRH workers, ensure that performance appraisals are routinely conducted, validate PEPFAR HRH supported staff level of effort and participation during performance improvement meetings, and provide follow up on the district and PNFP plans and commitments for absorption of PEPFAR supported health workers.

The SDS team visited approximately 60 health facilities (Public and PNFP) in 40 districts. The table below shows specific districts and number of public and PNFP facilities visited.

Table 7: Public and PNFP facilities visited by HRH team July 2016– March 2017

Region District Public PNFP

Northern

Apac 1 0 Alebtong 1 1 Amolatar 1 0 Dokolo 1 1 Alebtong 1 0 Otuke 3 1 Lira 0 1 Kole 1 1 Oyam 0 1 Gulu 1 1 Nwoya 1 0 Amuru 1 2 Omoro 1 1 Pader 1 0 Kitgum 1 1 Agago 0 1 Napak 1 0

Uganda SDS Program Year 7 Annual Report: July 2016 – March 2017 Page 17

Region District Public PNFP Amudat 1 0

Kotido 0 1

Eastern

Kapchorwa 1 0 Budaka 1 0 Sironko 1 0 Butaleja 1 0 Busia 1 0

Western

Ntungamo 1 0 Mbarara 1 1 Kabale 1 0 Mitooma 1 0 Isingiro 1 0 Kiruhura 3 2 Sheema 1 0 Ibanda 0 1 Rukungiri 0 1 Kisoro 1 0 Rubirizi 1 0 Buhweju 1 0

Central Iganga 1 2 Namayingo 1 1 Bugiri 1 0

Total 38 22

During this reporting period, ACLAIM’s support supervision targeted three regions of northern, central, and western Uganda. The focus of this support supervision was to follow on pending issues emanating from quarterly support supervision and as well as participate during the district/ facility level performance review meetings.

ACLAIM did pay visits to over 21 public health facilities in 17 districts during the period under review.

This included visits paid to the offices of DHOs and the PHROs, to follow up on issues of performance management and absorption of PEPFAR supported health workers seconded to those districts.

Table 8: HRH Public facilities Visited by ACLAIM during July– March 2017

Region Districts visited Facilities

Western

Mbarara Mbarara RRH Sheema Kitagatta Hospital Ntungamo Itojo Hospital Kabale Kabale RRH Mitooma Mitooma HCIV

Northern

Dokolo Dokolo HCIV Kole Apalaobaro HCIII and Bung…