THE UGANDA STOP MALARIA PROJECT YEAR 6 WORK PLAN. October 1, 2013 September 30, USAID/JHU Cooperative Agreement No. CA 617-A

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1 THE UGANDA STOP MALARIA PROJECT YEAR 6 WORK PLAN October 1, 2013 September 30, 2014 USAID/JHU Cooperative Agreement No. CA 617-A Re-Submitted 08 October 2013 Johns Hopkins Bloomberg School of Public Health Stop Malaria Project Center for Communication Programs Plot 30B Impala Avenue Plot 15 Binayomba Avenue Kampala, Uganda P.O. Box 3495 Tel: Kampala, Uganda Tel: /183

2 Table of Contents I. Introduction... 3 II. IR 1 Malaria prevention programs in support of the national malaria strategy improved and implemented... 4 IR 1.1: Malaria related policies and guidelines operationalized... 4 IR 1.2: Access to IPTp increased... 5 IR 1.3: Access to LLINs increased... 7 III. IR 2 Malaria diagnosis and treatment activities in support of the national malaria strategy improved and implemented... 9 IR 2.1: Service providers capacity to manage severe malaria improved... 9 IR 2.2: Malaria diagnostic capacity and services improved IV. IR 3 NMCP capacity to monitor and evaluate interventions strengthened IR 3.2: Collection, processing and use of data from districts and implementing partners improved 1514 V. Cross cutting activities A. Support supervision/quality improvement (QI) activities B. Creating demand for malaria services and practices C. Project monitoring and evaluation D. Documentation E. Management Information System (MIS) F. Coordination among key partners improved G. Project management and coordination VI. Annex A: List of Year 6 project districts... 1 VII. Annex B: Year 6 Activity Implementation Plan... 4 i

3 List of Acronyms ACT Artemisinin-based Combination Therapy ANC Antenatal Care BCC Behavior Change Communication CCP Center for Communication Programs CDFU Communication for Development Foundation Uganda CHC Communication for Healthy Communities CPHL Central Public Health Laboratory DDU Data Demand and Use DHI District Health Inspector DHIS 2 District Health Information System 2 DHO District Health Officer / Office DHT District Health Team DLFPs District Laboratory Focal Persons DOTs Directly Observed Therapy - short course EQA External Quality Assurance GF Global Fund GFATM Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria GPRS General Packet Radio Service HA Health Assistants HCP Health Care Provider HIPS Uganda Health Initiatives for the Private Sector Project HMIS Health Management Information Systems HSD Health Sub District IDI Infectious Diseases Institute IEC Information, Education and Communication IMM Integrated Management of Malaria IP Implementing Partner IPTp Intermittent Preventive Treatment in pregnancy IR Intermediate Result ISS Integrated Support Supervision IVM Integrated Vector Management JHU/CCP Johns Hopkins University Bloomberg School of Public Health/Center for Communication Programs LLIN Long Lasting Insecticide Treated Net MCH Maternal and Child Health MDD Music, Dance and Drama MDGs Millennium Development Goals MEMS Monitoring and Evaluation Management Services MFPs Malaria Focal Persons MIP Malaria in Pregnancy MIS Malaria Indicator Survey MoES Ministry of Education and Sports MoH Ministry of Health MOP Malaria Operational Plan NMCP National Malaria Control Program NMS National Medical Stores PMI President s Malaria Initiative PMP Performance Monitoring Plan ii

4 PNFP QI RBM RC MoH RDT RHD SDS SMP SP SURE TA TASO ToT TWG UBOS UBTS UCSF UHMG UMIS USAID VHT WHO Private Not-for-Profit Quality Improvement Roll Back Malaria Resource Centre of the MoH Rapid Diagnostic Testing Reproductive Health Department Strengthening Decentralization for Sustainability Stop Malaria Project Sulfadoxine-pyrimethamine Securing Ugandan s Right for Essential Medicines Technical Assistance The AIDS Support Organization Training of Trainers Technical Working Group Uganda Bureau of Statistics Uganda Blood Transfusion Services University of California San Francisco Uganda Health Marketing Group Uganda Malaria Indicator Survey United States Agency for International Development Village Health Team World Health Organization iii

5 Executive Summary The Stop Malaria Project (SMP), funded by the U.S. President s Malaria Initiative (PMI), is managed by Johns Hopkins University Bloomberg School of Public Health Centre for Communication Programs (JHU/CCP), Malaria Consortium, the Infectious Diseases Institute (IDI), and Communication for Development Foundation Uganda (CDFU). SMP is designed to assist the Government of Uganda in reaching the PMI and Roll Back Malaria (RBM) goal of reducing malaria-related morbidity and mortality by 70% by 2015 (MOP FY 2012), and subsequently contribute to the attainment of the Millennium Development Goals (MDGs). SMP works in 34 districts across the Mid-west, Central and Teso Regions of Uganda, supporting 1,117 public and private-not for profit health facilities across these districts. During Year 5, SMP consolidated achievements gained in the previous four years of the project by providing the following key interventions in its implementation districts: Supported NMCP to develop the National Implementation Guidelines for Parasite Based Diagnosis of Malaria. These are pending endorsement by the Ministry of Health Senior Management Committee; Completed the Process Evaluation/Quality Audit of the antenatal care (ANC) long lasting insecticide treated net (LLIN) distribution system. The evaluation report is being finalized and will be disseminated in Q1 of Year 6. This report will be one of the key documents to guide future ANC LLIN distributions in Uganda; Provided technical assistance to the NMCP planning and distribution of 20.5 million LLIN through the universal LLIN mass distribution. Distribution of nets in the Eastern Region commenced in Q4 of Year 5. SMP will continue to support the distribution in the Central, Western and Northern Regions of Uganda; Conducted clinical audits in hospitals and HC IV focused on improving management and outcomes of severe malaria; revised the clinical audit tool, which the NMCP will adopt to roll out clinical audits for severe malaria throughout the country; Parasite-based diagnosis of malaria in outpatient cases reached 69% in SMP districts compared to the year s target of 50% and Year 4 achievement of 59% (District HMIS data, 2012/13); in Q1 and Q2 of Year 5 testing in SMP districts was 72% and 69% respectively compared to 47% and 51% in non SMP districts. IPTp2 uptake by pregnant women attending ANC was sustained at 53% in Q3 of Year 5, which was the same for year 4 (HMIS 2012/13); this is still below SMP target of 60%. SMP will collaborate with Malaria Consortium to strengthen BCC around IPTp2 through radio and interpersonal communications at the health facilities. SMP will work with districts to implement targeted innovations like mother-to-mother support groups, peer sensitizations in order to improve IPTp2 uptake. Timely HMIS reporting from district to national level was maintained at 83% in Q3 of Year 5, similar to the rate of 82% achieved in Q3 of Year 4 (HMIS Data 2012/13). This was above the Year 5 target of 80% of all SMP districts submitting HMIS data to the national level on time; 1

6 Complete HMIS reporting on key malaria indicators (new attendance, IPTp 1, IPTp 2, lab diagnosis, malaria admissions, and malaria mortality) was 98% in Q3 of Year 5 compared to the year target of 95% (HMIS Data 2013). This data enables the project to determine stock status of antimalarial commodities (ACTs and SP) and provide feedback to the districts and NMCP for redistribution within the districts and placing requests to the National Medical Stores. In this final, sixth year of implementation, SMP will continue to consolidate the achievements and lessons of the last five years, and work with the NMCP, districts, USAID/PMI and non USAID/PMI implementing partners (IPs) to support integration of activities in the districts in order to maintain the achievements and promote the sustainability of SMP activities after the project s end. SMP by design is a technical support project to the National Malaria Control Program and districts and is implemented within the existing structures of the Ministry of Health and districts. In its last year, the project will continue to mentor district health workers who should carry on with the provision of malaria services in their respective districts after the project closes. closes. In the districts supported by Strengthening Decentralization for Sustainability (SDS) where SMP is, the option of using grant A to facilitate on-going support supervision by districts will be explored. Ongoing documentation and consolidation of project achievements, and lessons learned will be completed in Year 6. These will be disseminated to NMCP and key stakeholders to inform future programming for malaria services in the country. 2

7 I. Introduction The Stop Malaria Project is designed to assist the Government of Uganda, in particular the National Malaria Control Program (NMCP) and the District Health Teams (DHTs), to scale up proven interventions for malaria prevention, diagnosis, and treatment over a period of five years. SMP interventions are targeted to reach 85% coverage of children under five years of age, pregnant women and other vulnerable groups by improving diagnosis and treatment of malaria with artemisinin-based combination therapy (ACTs), and by expanding prevention efforts through intermittent preventive treatment of malaria in pregnancy (IPTp) and long-lasting insecticide treated nets (LLINs). Over the 5 Years of the project in the 34 districts, coverage for IPTp 2 increased from an average of 39% in Year 2 to 53% in Year 5, quarter 3), proportion of pregnant women attending ANC who were provided with a net was 87% (average of Year 5 Q1,Q2 and Q3) and percentage of children under five with fever who received a diagnostic test (RDT or Microscopy) at the health facility before treatment increased from 38% in year 3 to 71% in Year 5 Q3 (HMIS data ). The project s achievements in regards to coverage for each of these interventions for Year 5 are indicated in subsequent sections under each of the intermediate results areas. The project activities are designed to meet three intermediate results (IRs): IR 1 Malaria prevention programs in support of the national malaria strategy improved and implemented. IR 2 Malaria diagnosis and treatment activities in support of the national malaria strategy improved and implemented. IR 3 NMCP capacity to monitor and evaluate interventions strengthened. SMP works in 34 districts across the Mid-west (5), Central (21 districts) and Teso (8 districts) regions of Uganda, supporting 1,117 public and private-not-for-profit (PNFP) health facilities across these districts (see Annex A: List of Year 6 project districts for a complete listing of districts, the number of health facilities supported in each district, and population estimates by district). As with previous work plans, the development of the Year 6 work plan was done with participation of all SMP partners, National Malaria Control Program (NMCP), and PMI. In a meeting with the NMCP, SMP shared the proposed activities for implementation in Year 6; NMCP provided input, and endorsed the activities. SMP organized a planning meeting with all SMP partners (JHU/CCP, Malaria Consortium, IDI and CDFU), PMI/USAID and NMCP. In the planning meeting, SMP and its partners reviewed project performance during Year 5 and identified priority activities for SMP support during Year 6. Among the priorities discussed for Year 6 was sustainability of the SMP-supported activities once the project comes to an end in September As per project design, most project activities are within the existing components of the health system (such as support supervision). From SMP s inception, project activities have been and will continue to be implemented by district health workers with mentoring from SMP. These health workers are expected to be a continued resource to keep up the provision of malaria services after the project closes. SMP will also engage with other USAID/PMI Implementing Partners (IPs) e.g. Strengthening Decentralization for Sustainability (SDS), to encourage districts to include priority SMP activities in the district work plans and budgets. During the regional review meetings held with the districts every quarter, the project will engage with the districts to agree on project exit and 3

8 sustainability plans for each district. Focus of SMP engagement with the districts will involve encouraging districts to increase their budget allocation to malaria services or integrate them in other district activities. In Year 6, SMP will also continue to focus on documenting and disseminating project best practices, success stories and lessons learned to inform future malaria activities in Uganda. Year 6 activities are organized into four sections by the three intermediate results (IRs) and crosscutting activities. In each section there is a brief review of the progress to date based on last year s achievements, lessons learned and remaining key issues, which have informed the design of planned activities selected to be implemented in Year 6. During Year 6, SMP will continue to support malaria services throughout the current 34 SMP districts, to a total of 1,117 public and PNFP health facilities. In order to ensure that the work plan addresses the country s malaria priorities, as mentioned above, the NMCP participated in the development of this work plan. The NMCP provided guidance and endorsement to the priority activities. Following PMI approval of this work plan, SMP will present it to the Director General Health Services/Ministry of Health (MoH) along with the Letter of Agreement between SMP and NMCP for MoH endorsement. Once the MoH endorses the Letter of Agreement and the approved work plan, SMP will share these with each of the 34 districts. This work plan will form the basis of SMP s areas of support to the districts. The MoH endorsement of the approved SMP work plan will be taken as MoH commitment to implementation of the work plan. II. IR 1 Malaria prevention programs in support of the national malaria strategy improved and implemented IR 1.1: Malaria related policies and guidelines operationalized Progress to Date Over the past five years, SMP has supported the NMCP in the development of various policy and strategic documents. These include Integrated Malaria in Pregnancy (MiP) Manual and ANC LLIN Distribution Guidelines, Integrated Management of Malaria (IMM) Training Manual, National Malaria Control Policy 2011, Malaria Program Review (MPR), NMCP strategic planning documents (Annual Work Plan 2011/12 and 2012/13, Strategic Plan 2010/15, M&E Plan 2010/15, Three-year Implementation Plan 2010/13), Data Quality Assessment Guidelines and Data Analysis and Use Training Manuals. In Year 5, SMP provided funding and participated in the workshop for the development of National Implementation Guidelines for Parasite Based Diagnosis of Malaria. In addition, SMP staff participated in a meeting convened by the NMCP to finalize the NMCP Strategic Plan 2010/15, M&E Plan 2010/15, and Three-year Implementation Plan (2010/13). Key Issues The NMCP Strategic Plan 2010/15, M&E Plan and the National Implementation Guidelines for Parasite Based Diagnosis of Malaria were finalized but not yet approved by MoH. As such, the planned printing and launch of these documents was not done in Year 5. The National Implementation Guidelines for Parasite Based Diagnosis of Malaria are pending approval by the MoH Senior Management Committee. The Strategic Plan and M&E Plan 2010/15 are under review by the World Health Organization (WHO) (the WHO review is led by the WHO Country Malaria Advisor). 4

9 Planned Activities Activity 1.1.1: Print and disseminate guidelines Support NMCP to print and disseminate the NMCP Strategic Plan 2010/15, the M&E Plan and the National Implementation Guidelines for Parasite Based Diagnosis of Malaria. The review and approval of these strategic documents are expected to be completed between October and December SMP will communicate reminders to NMCP through and during SMP and NMCP meetings to push the process forward, and then support the printing and dissemination of these documents once they are signed off by the MoH. SMP will support NMCP to deliver copies of the printed documents to the 34 SMP-supported districts. Dissemination of these documents will be done during the planned quarterly regional review meetings and district data use meetings. IR 1.2: Access to IPTp increased Progress to Date IPTp stock: During Year 5, in collaboration with the SURE project, SMP tracked stock levels of sulfadoxine-pyrimethamine (SP), the drug used for IPTp, SURE provided monthly updates of SP stock status at the national level, and SMP obtained SP stock levels at health facilities through integrated support supervision (ISS). SMP worked with the districts to relay this information to the NMCP to promote replenishment from National Medical Stores (NMS), or redistribution of SP within the districts. Over 90% of health facilities reached during ISS did not have any SP stock outs in Year 5 (HMIS data 2012/13). SMP held discussions aimed at identifying the most effective means through which the districts can track these items on their own, such as through mtrac (a government led initiative to digitize the transfer of Health Management Information System (HMIS) data via mobile phones) or DHIS 2 (district health information systems a computer-based electronic HMIS system). However, in most districts, ISS was recommended as the best method for tracking stocks of all malaria medicines; mtrac data was considered to be still of poor quality due to low understanding of the system by health workers, limited support supervision to the health workers using the system and lack of 033b standard forms in the facilities. SMP plans to work with the districts to improve mtrac data in Year 6, such that the districts can use this data, in addition to ISS, to track SP commodities). IPTp uptake: IPTp2 uptake averaged at about 53% during the year. While this reflects an improvement from 39% in Year 1, IPTp2 uptake remains below the SMP target of 60% (and MoH target of 85%), having stagnated around 51% at the end of Year 3 (HMIS data 2010/11). In Year 5, SMP printed and distributed 50,000 ANC cards to health facilities during integrated support supervision. SMP will work with districts to implement targeted innovations like mother-to-mother support groups, peer sensitizations etc. SMP will also work with the NMCP and districts to explore ways of strengthening the implementation coordination between malaria services and reproductive health services at the national and district levels. IPTp commodity distribution: In Year 5, SMP procured and distributed 4,612 packets of water purification tablets: each packet contains 80 tablets. Most health facilities were provided with IPTp commodities (jerry cans and cups) during Years 2 and 3 of the project to ensure that pregnant women who attended ANC received IPTp under directly observed therapy short course (DOTs); in Year 4 some jerry cans and cups were provided to replace those which were damaged, and to add 5

10 supplies to busy health facilities, such as hospitals and HC IVs. There was no additional procurement of jerry cans or cups in Year 5. However, as indicated below under section on activities, in Year 6, SMP will supply additional IPTp commodities to all health facilities providing ANC services to ensure constant availability of these commodities. Increasing the availability of safe drinking water commodities in the health facilities was done to promote IPTp DOTs as per MoH policy. Key Issues As mentioned above, although there has been progress in IPTp2 uptake by pregnant women in SMP districts from 39% in Q4 of Year 1 to 53% in Q3 of Year 5; uptake has stagnated at about 53% since Q3 of Year 3, below the SMP target of 60% and MoH target of 85%. The SMP has worked to improve the skills and understanding of health workers in administering IPTp through training on malaria in pregnancy in Year 2 and 3 of the project, and continuous emphasis on IPTp2 during support supervision. These activities should have addressed issues around inadequate staff numbers and skills, poor recording of SP administration in ANC registers, and myths about the safety of SP. SMP s provision of IEC materials and job aids on IPTp was also expected to improve uptake, along with provision of DOTs commodities and tracking of SP supplies. However, these have not succeeded in bringing rates of IPTp up to or beyond the target. Although not within the scope of the SMP, this suggests a need for research into what other factors affect IPTp2. A study being under taken by Malaria Consortium, Assessing and Addressing Barriers to IPTp Uptake, is expected to generate recommendations that SMP may provide to the NMCP and PMI on how to improve IPTp uptake. The preliminary results of this study are expected in Q2 of Year 6. In addition to collaborating with Malaria Consortium to implement the results of the study on improving IPTp uptake, SMP will work with the districts to implement an innovative approach e.g. mother-to-mother support group sensitization to improve IPTp uptake. SMP will employ experiences in SMP districts whichdistricts that are performing better in IPTP as well as lessons from other countries e.g. Zambia and Ghana to support IPTp improvement across the 34 project districts. Planned activities Activity 1.2.1: Track IPTp commodities SMP will continue to track stocks of SP and the availability of IPTp commodities in health facilities. In Year 6, SMP will increase its efforts to work with districts to take up some of these tasks through existing stock tracking mechanisms like ISS and mtrac. SMP will encourage districts to regularly report on stock status, which will be used to measure the extent to which the districts have taken up this task. Activity 1.2.2: Conduct ISS on IPTp Continue to conduct on-the-job mentoring during integrated support supervision to strengthen interpersonal communication of health workers with clients and reinforce the knowledge around IPTp DOTs and preventing malaria in pregnancy. In order to ensure that health facilities have health workers trained in IPTp, additional ANC providers will be trained as part of the Year 6 IMM training. Activity 1.2.3: Print and distribute ANC cards Print and distribute ANC cards and distribute to health units that conduct ANC in the 34 districts in order to document pregnancy events, including administration of SP for IPTp. 6

11 Activity 1.2.4: Provide water purification tablets, cups and jerry cans Procure water purification tablets, additional cups and jerry cans to distribute to health facilities to ensure availability of safe drinking water for IPTp DOTs. Additional cups and jerry cans will replace those that have been damaged or lost. To promote continuity of IPTp DOTs services after SMP closure, a specific amount of IPTp DOTs commodities will be left behind with each district. Activity 1.2.5: BCC to promote IPTp Implement BCC activities that target pregnant women to improve IPTp knowledge and IPTp uptake as part of the overall project BCC activities. Mother-to-mother support group sensitization will form part of IPTp BCC. SMP will explore possibilities of working closely with the Communication for Healthy Communities Project (CHC), other projects, and the Malaria in Pregnancy Technical Working Group, to host a consultative meeting to identify specific recommendations for the design and revision of IPTp activities including BCC to be carried out by other or future partners. IR 1.3: Access to LLINs increased Progress to Date ANC LLIN distribution: From 2011 to date, SMP has distributed 904,449 LLINs to all 34 districts for distribution to pregnant women through 1,025 ANC clinics (not all of the 1,117 health facilities provide ANC services). All of the 904,449 nets were given to pregnant women and most health facilities now have stock outs of nets. Out of the 904,449 LLINs, 268,804 nets were distributed in Year 5 (Year 5 target: 493,631 LLINs). Quarter 1 of Year 5 was 77% (70,025 out of 91,099), Q2 was 95% (104,747 out of 109,698) and Q3 was 89% (71,149 out of 79,963). In order to address some of the challenges related to ANC LLIN distribution, like poor record keeping and irregular reporting, SMP, in collaboration with the NMCP developed and printed an ANC LLIN distribution record book and LLIN monthly reporting forms for the health facility and district levels. A total of 1,200 record books, 816 district monthly reporting forms and 12,960 health facility ANC LLIN monthly reporting forms were printed in Year 4 and distributed to the 1,025 health facilities distributing LLIN through the ANC. The record books and reporting forms were distributed to the health facilities during integrated support supervision. Availability of these record books and monthly reporting has improved ANC LLIN distribution data recording and reporting. In Q2 (January March 2013), there was a remarkable improvement in the number of pregnant women attending ANC who received a net; 90% of women attending ANC 1 received a net (118,880 pregnant women out of the 131,711 pregnant women recorded attending ANC 1 in the same period, compared to 77% in Q1). This was attributed to improvement in record keeping and reporting on ANC LLIN distribution following the supply of ANC LLIN distribution registers, monthly reporting forms to the districts and continued on-job mentorship of health facility staff. In addition, the process evaluation on ANC LLIN distribution has been completed. The final report is ready for dissemination to PMI, NMCP and partners. Specific attention will be made to ensuring that the recommendations resulting from the study are shared with The AIDS Support Organization (TASO), the agency primarily responsible for ANC LLIN distribution under Global Fund (GF) Round 10. 7

12 In Year 5, SMP provided technical assistance to the NMCP and MoH in the planning and implementation of the Global Fund,PMI/DFID and World Vision funded universal LLIN mass campaign distribution. PMI, through SMP, supported the official launch of the LLIN distribution in May 2013, which coincided with national World Malaria Day Celebrations. The launch was officiated by the H.E. President of the Republic of Uganda, Yoweri Museveni. SMP supported the event planning process, providing technical assistance in organizing the event, and supported the cost of the event. SMP has also provided funding and input into the MoH s planning and budgeting process, as well as technical assistance at central and district levels to the entire distribution exercise, including the distribution of 500,000 LLIN in Soroti and Busia Districts, led by World Vision. Key Issues In Year 5, all of the LLIN available in the SMP central stores (268,804) for ANC LLIN distribution were distributed to the districts for distribution to pregnant women through ANC. This number was lower than the target (493,631) because PMI did not procure nets for ANC LLIN distribution in Year 5 due to the pending universal LLIN distribution campaign, originally targeted to have begun in Q1 of Year 5. As a result of the stock out at central level, a large proportion of health facilities (approximately 40%) experienced stock outs of LLINs especially during Q3. This means that many pregnant women have not had access to nets through ANC for some time. However, Global Fund bought 586,000 nets to be distributed by TASO throughout the country for the January December 2013 period. This is supposed to address the gap until nets procured by PMI for ANC LLIN distribution arrive (expected in February 2014). SMP planned to support the NMCP GF Round 7 Phase 2 LLIN universal distribution in Year 5. However, there were delays and the universal LLIN distribution has only recently begun (in Q4 of Year 5). The exercise is expected to take approximately 6 to 8 months. In Year 5, SMP planned to provide technical assistance to the NMCP for the assessment and design of a continuous distribution system in four eastern districts (Serere, Kaliro, Bugiri and Mayuge) drawing on lessons learned from the ANC distribution in the 34 project districts. However, this activity was not implemented; instead the project concentrated on completing the process evaluation of the ANC LLIN distribution system. As mentioned above under section on progress to date, specific attention will be made to ensuring that the recommendations resulting from this evaluation are shared with TASO, the agency primarily responsible for ANC LLIN distribution in the country under Global Fund (GF) Round 10, in order to inform a robust ANC distribution system. Planned Activities Activity 1.3.1: Continue ANC LLIN distribution SMP will continue ANC LLIN distribution in all 34 SMP districts once PMI procures ANC nets in Q2 of Year 6 by transporting the nets to the districts and working with the districts to distribute nets to the health facilities. SMP will also explore the possibility of piloting distribution of LLIN through drug shops. Activity 1.3.2: Support universal LLIN distribution 8

13 SMP will provide technical and financial support to MoH for GF Round 7 Phase 2 universal LLIN distribution across all districts in Uganda. Malaria Consortium/SMP was identified by the MoH as the lead agency to support the universal LLIN distribution throughout the country. The MoH signed a Memorandum of Understanding (MoU) with Malaria Consortium/SMP as a lead agency. The MoU spells out the responsibilities and roles of the lead agency and MoH. The details of this activity are in a separate work plan, which has been approved by PMI and MoH. Activity 1.3.3: Promote net use Promote net use through the Stop Malaria in your Community Campaign (see details under BCC section) as well as interpersonal communication between providers and pregnant women to encourage women to sleep under LLINs (to be promoted as part of integrated support supervision). Activity 1.3.4: Print and distribute ANC LLIN registers While smaller health facilities still have room remaining in their ANC LLIN Registers, health facilities with a larger numbers of ANC clients are already running out of space in their ANC LLIN Registers. Therefore, SMP will print and distribute 1,200 additional ANC LLIN registers to facilitate continuity after the project closes. Activity 1.3.5: Fund and participate in Integrated Vector Management Technical Working Groups During Year 6, SMP will closely work with MoH to fund and participate in 3 Integrated Vector Management Technical Working Group (IVM TWG) meetings. This is expected to improve coordination between the NMCP and partners in this intervention. The IVM TWG is expected to review guidelines and policies, for adaptation by the MoH. III. IR 2 Malaria diagnosis and treatment activities in support of the national malaria strategy improved and implemented IR 2.1: Service providers capacity to manage severe malaria improved Progress to Date Support supervision: During Year 5, SMP provided on-job support and mentorship to health workers previously trained in integrated management of malaria (IMM). In health facilities reached during ISS, most health workers trained in IMM were found to manage malaria according to National Malaria Treatment Guidelines; this was attributed to IMM training, regular ISS and clinical audits. Clinical audits: SMP provided technical and financial support to district clinical audit teams to carry out clinical audits in 89 health facilities (35 hospitals and 54 HC IVs), and selected HC IIIs that manage severe malaria. Improvements in clinical practice relating to treatment of malaria were observed in most health facilities where clinical audits were conducted. For example, patients are fully assessed by clinicians and emergency cases attended to immediately with relevant laboratory investigations done (blood slide for malaria, blood sugar and hemoglobin). The quality of in-patient records has also greatly improved, e.g. filling relevant information in the patient observation forms including prescribed treatment, treatment outcomes and follow up notes. 9

14 In Year 5, SMP emphasized reviving the health facility audit committees so that clinical audits can be conducted by health facility staff, and therefore centered at the health facility. Through this, we hope that the implementation of clinical audits will be less reliant on the district teams, and there will be less need for funds to transport the district health teams to health facilities to do the clinical audits. The health facility clinical audit teams are required to send reports of their clinical audits to the district clinical audit team. This way, the district clinical audit teams can monitor the performance of the health facility audit teams. The clinical audit tool was also reviewed to make it shorter, and therefore cheaper for health facilities to reproduce. This is expected to encourage sustainability of the clinical audit process in the health facilities. SMP, together with NMCP/MoH and other stakeholders (Makerere University, Mulago Hospital, Gulu University, Uganda Blood Transfusion Services [UBTS]), completed the review. The tool will be used by the NMCP and districts to carry out clinical audits in the health facilities. The NMCP is planning to conduct clinical audits under the Global Fund Round 10 grant. Availability of anti-malarial medicines: During quarterly integrated support supervision conducted with the district teams, SMP tracked availability of ACTs (ACTs are considered a tracer medicine for antimalarial medicines). In subsequent ISS, SMP will work with the NMCP to track parenteral quinine and artesunate and the related supplies needed to give these medicines. In Year 5, ACTs were available in over 90% of the health facilities reached during ISS. SMP relayed information about the stock levels to the districts to ensure timely requests to NMS as well as redistribution within the districts. Further, SMP held discussions with the districts aimed at identifying the most effective means through which the districts can track these items. In most districts, ISS was recommended and mtrac data was considered to be still of poor quality (under IR 3, SMP has planned to work with the districts to improve mtrac data). Other: SMP, NMCP and UBTS also discussed key aspects of collaboration to improve the availability of blood for transfusion for the treatment of severe malaria at HC IV and hospitals in the 34 SMP districts. In addition, in Year 5, the project printed 55,000 in-patient observation forms and distributed these to hospitals and HC IVs, which provide in-patient services. The forms are used by the health facilities to document in-patient records. Key Issues A number of districts have recruited new health facility staffs, which have not been trained in IMM. Preliminary data indicate there are about 2,260 new health workers recruited in the 34 districts that need to be trained in IMM. In addition, the clinical audit tool reviewed with the NMCP and other stakeholders needs to be field-tested prior to finalization, so that a robust tool is availed to the NMCP and partners. There has been a shortage of transfusion blood in many health facilities; the UBTS indicated a need for additional consumables (e.g. donor + recipient sets, gloves, cold boxes) as well as support supervision for transfusion services in the health facilities with blood transfusion services. Revision of job aids on severe malaria was not done in Year 5, pending the availability of IV artesunate in health facilities. IV artesunate began being supplied to health facilities just recently (in 10

15 Q3 of Year 5) and the NMCP plans to maintain a steady supply of this medicine with support from partners. Planned Activities Activity 2.1.1: Conduct clinical audit in hospitals and HC IVs SMP will provide financial and technical support to district clinical audit teams to conduct clinical audits in hospitals and HC IVs. SMP will print the revised clinical audit tool endorsed by MoH and distribute to the districts and health facilities. The health facilities should be able to reproduce and use this less bulky clinical audit tool in order to continue with clinical audits in the health facilities after end of SMP support. During clinical audit, follow up of any adverse events associated with IV artesunate for treatment of severe malaria will be included in the clinical audit forms and procedures. Activity 2.1.2: Revise and produce job aids on severe malaria and uncomplicated malaria SMP will support meetings of NMCP and partners to update the job aids on severe malaria and uncomplicated malaria to reflect the new malaria treatment policy, and then reprint and distribute the revised job aids to health facilities in 34 districts. SMP will work in collaboration with the NMCP and the Malaria Consortium Severe Malaria Project (funded by UNITAID). Activity 2.1.3: Support blood banks to increase capacity for transfusion for severe malaria SMP will conduct an assessment of blood bank needs at the district level for the SMP districts and procure consumable supplies for the National Blood Bank for use in the health facilities, which provide blood transfusion services in the 34 SMP districts. SMP will also facilitate staff of the blood bank to conduct supervision of the transfusion services in the health facilities as part of ISS. The expected output of this activity will be reduction in mortality related to severe anemia. SMP will work with health facilities providing blood transfusion services to monitor trends of availability of transfusion blood, number of patients transfused, as well as deaths attributed to severe anemia. SMP will work with the Blood Bank and health facilities to collect the numbers of malaria patients with hemoglobin < 5 (as well as the total number of hemoglobin) to determine whether they were transfused or not. For the patients requiring transfusion and do not get transfused, reasons for no transfusion will be documented (e.g. lack of blood, lack of transfusion set etc). SMP will collaborate with Uganda Malaria Surveillance Project on their severe malaria project to track transfusions, availability of blood, and anemia. Activity 2.1.4: Track and when needed, redistribute ACTs, RDTs, IV and rectal artesunate SMP will encourage districts to redistribute anti-malaria medicines (SP and ACTs) from highly stocked to low stocked health facilities and this will form part of the ISS plan for the quarter. SMP will endeavor to work with UNICEF and a telecom provider to create an incentive structure for regular weekly reporting to mtrac (such as receipt of two free SMSs after submitting a report to mtrac). SMP will continue to track stocks of these commodities through ISS and mtrac and the information will be shared with the districts and NMCP for re-distribution or timely requests to the NMS. Activity 2.1.5: IMM training for new health facility staff 11

16 SMP will conduct IMM training of newly recruited staff in the districts. Four day trainings will be conducted for all cadres of staff (nurses, clinical officers, doctors, laboratory staff, records officers) at HC II, HC III, HC IV and hospitals using the existing NMCP/MoH IMM training curriculum. There will be a follow up post training supervision visit to the newly trained health workers. The follow up will also target the health workers previously trained in Year 4. A comprehensive report on the follow up assessment of performance with recommendations on potential value of future additional trainings will be prepared and shared with NMCP and PMI. Follow up is designed as part of the training and will focus on IMM trainees to reinforce knowledge and skills on job. Activity 2.1.6: Reprint and distribute in-patient observation forms Reprint and distribute in-patient observation forms to all hospitals and HC IVs in order to improve documentation and collection of in-patient data. Activity 2.1.7: PIP investigation in Kumi Documentation of extent of adverse events related to reports of inappropriate quinine injections especially in the private health facilities. Activity 2.1.8: Support NMCP, Resource Centre MoH review of HMIS tools to facilitate capture of patients treated with antimalarials who received a diagnostic test and the result of the diagnostic test Advocate to Resource Centre MoH for the review of HMIS forms 105 and 033b to include data on patients treated with antimalarials who received a diagnostic test, as well as the results of the test. This will provide information on adherence to the parasite-based diagnosis of malaria before treatment. IR 2.2: Malaria diagnostic capacity and services improved Progress to Date To date, SMP has trained 1,357 laboratory healthcare workers (143 ToT and 1,214 cascadecascades). This has been achieved through building teams of trainers in each of the 34 SMP districts who have in turn carried out cascade training within the districts. To support laboratory diagnosis of malaria, SMP has also procured and distributed a total of 48 microscopes and has implemented a continuous external quality assurance (EQA) program in over 170 health facilities. By June 2013, the average accuracy of malaria slide readings at these health facilities was 80%. Key Issues Although SMP has procured and distributed 48 microscopes during the past three years, these microscopes need to be well maintained by districts to keep them functional. As the project nears its end, there is a need for the faulty microscopes to be repaired and for the district teams to be trained in basic equipment maintenance so as to ensure the continued use of the equipment. 12

17 As mentioned elsewhere, the Government of Uganda recently recruited many new health staff and has been in the process of upgrading numerous health facilities (e.g. from a HC II to HC III). Many of the newly recruited staff are not well versed in malaria microscopy and RDT use. During integrated support supervision visits, it was discovered that the District Laboratory Focal Persons (DLFPs) rarely supervise or support lower level staff. Consequently some sites have consistently performed poorly in the external quality assurance program. During EQA, some DLFP s delay to collect, read and submit discordant slides to the Central Public Health Laboratory for tiebreak reading. This delays dissemination of EQA results. MC is currently providing EQA for VHTs and HF in five districts through Pioneer. We are also providing RDTs to VHTs for ICCM in nine districts. ICCM as a project is in nine districts in the Midwest and is ending in September SMP will take forward the EQA work in health facilities, which have been supported under the Pioneer project. Planned Activities Activity 2.2.1: Train laboratory personnel on malaria diagnosis This is a three-day training that equips laboratory personnel with competencies for accurate diagnosis of malaria using microscopy and RDTs (although clinicians also perform RDTs, their training in RDT use is under IMM). It also covers skills for implementation of external quality assurance and quality control. The training follows a cascade training model and is facilitated by the district trainers (ToT graduates) with technical assistance from IDI. The target group for the training is laboratory technologists, technicians and assistants working in government and PNFP health facilities in the SMP districts. Three laboratory technologists, one from each of IDI, NMCP and Central Public Health Laboratories, will conduct one follow up support supervision visit six weeks after training, to each of the graduate trainees. The purpose of this onsite support will be to ensure knowledge and skills retention after the training. Activity 2.2.2: Strengthen district capacity to conduct EQA To ensure accuracy of malaria blood slide microscopy readings among trained laboratory personnel, a total of 173 health facilities have been facilitated to participate in EQA. Participating laboratories have been supported to collect a sample of blood slides, which are re-checked by the district trainers. Until now, discordant slides have been sent to the Central Public Health Laboratories for confirmation of the results. During the final year of SMP, the process of confirmation of discordant results will be transferred to the districts such that the EQA process can be completed at the district level, ensuring quick turnaround times for EQA results. SMP will work with the districts to include these activities in the district work plans. Activity 2.2.3: Strengthen equipment maintenance and supply 13

18 In order to ensure availability of properly functioning microscopes, SMP will train laboratory technologists at the district level to carry out routine maintenance of microscopes at their health facilities. SMP will also facilitate the carrying out of repairs that cannot be handled at the district level. SMP will also procure and distribute new microscopes to a selected number of health facilities that have been upgraded from HC II to HC III. Activity 2.2.4: Strengthen supply of malaria diagnostic consumables. In order to ensure availability of EQA supplies, SMP will supplement efforts by the MoH to supply laboratory consumables for malaria diagnosis; IDI will give buffer supplies of consumables like Giemsa stain, EQA record books and microscopy slides to health facilities within the 34 implementing districts. IV. IR 3 NMCP capacity to monitor and evaluate interventions strengthened IR 3.1: Technical resources and skills of M&E unit improved Progress to Date To support NMCP s role in coordinating the Roll Back Malaria (RBM) Partnership, SMP funded quarterly RBM meetings. Three meetings were held in Year 5. These RBM meetings provided a forum to share information, review HMIS data and partners data and study findings, provide updates to policies and the 2013 LLIN universal mass campaign to partners and to review progress made in the implementation of key malaria control interventions. Key Issues SMP has been planning to support the development of a database for several years, so that all malaria indicator data are readily available to NMCP. This activity was meant to be done with support from a WHO consultant. Unfortunately, development of the NMCP database was not done in Year 5 due to failure to secure a WHO consultant. Planned Activities Activity 3.1.1: RBM coordination meetings Coordination of malaria partners is crucial for streamlining malaria interventions throughout the country. SMP will continue to provide financial support to NMCP for coordination of this activity. In this final year, we will work with NMCP to transition SMP support to another RBM partner to ensure continuity of the RBM coordination mechanism when SMP ends. Activity 3.1.2: Malaria technical working groups SMP will provide financial and technical support to the different technical working groups (TWGs) (e.g. case management, malaria in pregnancy, integrated vector management, research monitoring and evaluation, and social and behavior change) to hold quarterly meetings with the aim of having vibrant and coordinated malaria interventions. TWGs provide a forum for providing technical 14

19 support to the NMCP for quick decision-making. SMP will work to ensure that each meeting is minuted with follow on actions and due dates allocated to members. Activity 3.1.3: Develop the NMCP malaria database In past years, non-availability of the WHO consultant hindered previous plans to establish this database. In Year 6, NMCP has committed to working with WHO to secure the consultant to develop the database. In Year 6, SMP will hire a local consultant and provide accommodation for WHO consultant to modify the NMCP database. After the database modification, the consultants are expected to train NMCP staff on the use and management of the database. The database will act as a one-stop centre for malaria data in the country for NMCP staff, researchers and implementers. The WHO consultant will lead on this activity supported by the local consultant; and the local consultant will continue to provide needed support when the WHO consultant leaves the country. Activity 3.1.4: Support NMCP in the development of the annual work plan 2013/14: Provide TA and financial support to NMCP to develop the annual work plan 2013/2014. SMP support to development of the 2013/14 NMCP consolidated work plan is aimed at institutionalizing the annual planning process within the NMCP. IR 3.2: Collection, processing and use of data from districts and implementing partners improved Progress to Date In Year 5, timely HMIS reporting from district to national level was maintained at 83% in Q3, similar to the rate of 82% achieved in Q3 of Year 4 (HMIS Data 2012/13). This was above the Year 5 target of 80% of all SMP districts submitting HMIS data to the national level on time. In addition, complete HMIS reporting on key malaria indicators (new attendance, IPTp 1, IPTp 2, lab diagnosis, malaria admissions, and malaria mortality) was 98% in Q3 of Year 5 compared to the year target of 95% (HMIS Data 2013). This data enables the project and districts to determine the stock status of antimalarial commodities (ACTs and SP) and provide feedback to the districts and NMCP for redistribution within the districts and placing requests to the NMS. In Year 5, SMP supported all 34 districts to conduct two rounds of data quality assessment in selected health facilities. In Q1 and Q4, 579 and 301 health facilities of all levels (hospital, HC IVs, HC IIIs, and HC IIs) were reached, respectively. The data quality assessment involved selected indicators (LLIN distribution, ANC1, ANC2, total ANC, malaria cases, malaria tests done and ACT balances reported through mtrac). RC-MoH was also supported financially to provide technical support during DQA exercises. The SMP M&E team, RC-MoH and DHT also provided mentorship on proper recording and tallying to the facility health workers during the DQA exercise. SMP also supported districts to conduct data use meetings with the participation of different cadres (facility in-charges, nurses, midwives, records and laboratory personnel) from a selection of health facilities. The purpose of the meetings was to give feedback regarding the performance of HMIS/mTrac indicators from different health facilities and to suggest ways of further improving data 15