THE UGANDA STOP MALARIA PROJECT ANNUAL PERFORMANCE REPORT YEAR 5

Transcription

1 THE UGANDA STOP MALARIA PROJECT ANNUAL PERFORMANCE REPORT YEAR 5 OCTOBER 1 ST, 2012 SEPTEMBER30 TH, 2013 Submitted to USAID on October 30 th, 2013 USAID/JHU Cooperative Agreement No. CA 617-A

2 Table of Contents LIST OF ACRONYMS... 3 EXECUTIVE SUMMARY... 4 BACKGROUND... 6 RESULTS FRAMEWORK... 7 PROJECT ACHIEVEMENTS... 8 IR 1.1: MALARIA RELATED POLICIES AND GUIDELINES OPERATIONALIZED... 8 IR 1.2: ACCESS TO IPTP UPTAKE INCREASED... 8 IR 1.3: ACCESS TO LLINS INCREASED PLANNING AND COORDINATION OF THE 2013 LLIN DISTRIBUTION CAMPAIGN LLIN DISTRIBUTION CAMPAIGN LAUNCH NATIONAL LEVEL ADVOCACY IR 2: MALARIA DIAGNOSIS AND TREATMENT ACTIVITIES IN SUPPORT OF THE NATIONAL MALARIA STRATEGY IMPROVED AND IMPLEMENTED IR 2.1: MALARIA DIAGNOSTIC TREATMENT AND REFERRAL SERVICES IR 3: NMCP CAPACITY TO MONITOR AND EVALUATE INTERVENTIONS STRENGTHENED IR 3.1: TECHNICAL RESOURCES AND SKILLS OF M&E SUB-UNIT IMPROVED IR 3.2: COLLECTION, PROCESSING AND USE OF DATA FROM DISTRICTS AND IMPLEMENTING PARTNERS IMPROVED CROSS CUTTING ACTIVITIES SUPPORT SUPERVISION CREATING DEMAND FOR MALARIA SERVICES AND PRACTICES PROJECT MONITORING AND EVALUATION COORDINATION AMONG KEY PARTNERS IMPROVED LESSONS LEARNED CHALLENGES RECOMMENDATIONS CONCLUSION USAID/JHU Cooperative Agreement No. CA 617-A

3 List of Acronyms ACT Artemisinin-based Combination Therapy ANC Antenatal Care BCC Behaviour Change Communication CCP Johns Hopkins Bloomberg School of Public Health Centre for Communication Programs CDFU Communication for Development Foundation Uganda CMD Community Medicine Distributor CSO Civil Society Organizations DHS Demographic Health Surveys DHT District Health Team DMIS District Management Information System DOTS Directly Observed Therapy DQA Data Quality Assessments FP Focal Person HCP Health Communication Partnership HMIS Health Management Information Systems IDI Infectious Diseases Institute IEC Information, Education and Communication IPTp Intermittent Preventive Treatment in pregnancy IR Intermediate Result ISS Integrated Support Supervision ITN Insecticide Treated Net LLIN Long Lasting Insecticide Treated Net LQAS Lot Quality Assurance Survey MC Malaria Consortium MDGs Millennium Development Goals M&E Monitoring and Evaluation MIS Malaria Indicator Survey MoH Ministry of Health NMCP National Malaria Control Program OPD Out Patient Department PMI President s Malaria Initiative PMP Performance Monitoring Plan RBM Roll Back Malaria RDT Rapid Diagnostic Testing SMP Stop Malaria Project SO8 Strategic Objective eight SP Sulfadoxine-pyrimethamine SURE Securing Ugandan s Rights for Essential Medicines ToT Training of Trainers UBOS Uganda Bureau of Statistics UHMG Uganda Health Marketing Group UMEMS Uganda Monitoring and Evaluation Management Services USAID United States Agency for International Development VHT Village Health Team WHO World Health Organization USAID/JHU Cooperative Agreement No. CA 617-A

4 EXECUTIVE SUMMARY The Stop Malaria Project (SMP) is a President s Malaria Initiative (PMI)-Uganda funded project, which has recently completed its fifth year. The project works closely with the National Malaria Control Program (NMCP) and district local governments to provide comprehensive malaria programming in 34 districts. This annual report focuses on activities implemented in Year 5. It also shares successes, lessons learned, challenges and recommendations. Performance Highlights IR1: Malaria prevention programs in support of the National Malaria Strategy improved and implemented. In Year 5, the percentage of pregnant women attending antenatal care (ANC) who received at least 2 doses of Sulfadoxine-pyrimethamine (SP)increased from 52% in Year 4, Quarter4 to 60% in Year 5, Quarter 4(District Health Management Information Systems (HMIS) ). SMP provided technical support to the NMCP during the LLIN mass distribution campaign. IR2: Malaria diagnosis and treatment activities in support of the National Malaria Strategy improved and implemented. Blood slide reading accuracy for parasites was sustained at an average of 93 %( SMP Reports 2013). Recorded number of under fives with fever who received a diagnostic test (RDT and microscopy) at the health facility level increasedfrom 71% in Year 4to 84% in Quarter 4, Year 5(Integrated Support Supervision (ISS)data 2013). A graph on the wall in a health center III in IR 3: NMCP capacity to monitor and evaluate Kumi district shows the total number of interventions strengthened. blood smears conducted each month and 100% of district health teams received a number that were positive. Photo Credit: Kim Burns Case supervisory visit from national or zonal NMCP personnel in the past year. 100% of districts conducted data quality assessment on HMIS data in the past year. HMIS reporting from district to national level improved from (81% and 98% for timely and complete respectively). Cross Cutting Support Supervision Conducted ISS in health facilities in all 34 districts with the DHTs: 672 (Q1), 782 (Q2), 538(Q3) and 274 (Q4) (SMP ISS records 2012/13). 4

5 Cross Cutting: Creating Demand In Year 5, 3,912 school outreaches conducted by the health assistants (HAs) reached484, 029 pupils. Supported national level music, dance and drama competition, reaching out to 20,000 schools and approximately 18,000,000 primary school children. Conclusion SMP has sustained achievements from previous years. In the next year, SMP will focus on wrapping up its activities and supporting their transition to other implementers and the district and national governments. SMP will also shareits achievements, lessons learnt and recommendations with malaria partners. Above is a photo of one of the performers during the 2013 Music Dance and Drama (MDD) competition. Photo Credit: Tine Frank. Left above: A group of students listen intently to the MDD competition. Left below: One of the groups that was in the finals that entered an original composition that focused on malaria. Photo Credits: Kim Burns Case 5

6 BACKGROUND Stop Malaria Project is designed to assist the Government of Uganda, in particular the NMCP and District Health Teams (DHTs), to achieve its five year goal of reaching 85% of children under five years of age and pregnant women with proven preventive and therapeutic malaria interventions, including: Artemesinin-based Combination Therapy (ACTs) for treatment of uncomplicated malaria, IPTp and distribution of LLINs. The project activities are designed to meet three intermediate results, namely: Malaria prevention programs in support of the national malaria strategy improved and implemented Malaria diagnosis and treatment activities in support of the national malaria strategy improved and implemented NMCP capacity to monitor and evaluate interventions strengthened. The project activities are implemented in close collaboration with the NMCP and district local governments. The project currently covers 34 districts in three regions: Central Region: 21 districts Hoima Region: 5 districts Teso Region: 8 districts Activity implementation during the quarter was based on the results framework below; the framework provides a foundation for the expected project results and activities that contribute to the project intermediate results. Children during the MDD competition Photo Credit: Tine Frank PMI Director, Adm. Tim Zimmerman signing the guest book in the District Health Office in Kumi Photo Credit: Kim Burns Case 6

7 RESULTS FRAMEWORK Malaria related policies and guidelines operationalised Development Objective 3: Improved Health and Nutrition Status in Focus Areas and Population Groups Program Objectives 3.1.1: Reduce Malaria Mortality Critical Assumptions Availability of Funds Health workers available at HF Availability of drugs and nets IR1: Malaria prevention improved IR2: Malaria diagnosis and treatment improved IR3: NMCP Capacity strengt h ened IR 1.2: Access to IPTp increased IR 1.2.1: Services providers knowledg e and skills for IPTP improved IR Community Knowledge and perceptions of IPTp and LLIN improved IR 1.3: Access to LLINS increased IR 2.1 Malaria diagnostic treatment and referral services improved IR 2.2 Increased access to ACTS (Not doing this, Policy changed) IR 2.3 Communit y knowledg e,, perception s and behaviors of febrile illness improved - IR 3.1 Technical resources and skills of M & E sub-unit increased IR 3.2 Collection, processing and use of data from districts and implementing partners improved. Program Activities to affect the Results IR Distribute IPTp commodities for IPTpuptake 2. Collaborate with SURE and Districts to track SP stock on a monthly and quarterly basis in 34 SMP districts 3. Print and distribute Cards IR On job mentorship to strengthen skills and improve interpersonal communication 2. Support PNFP to quantify SP needs IR Facilitate Health Assistants to conduct outreaches on malaria prevention 2. Support radio talk shows and radio spots. 3. Support school outreaches - : IR Secure LLIN storage Warehouse at national level 2. Conduct LLIN distribution quality audit 3. Distribute LLINs in 34 districts through ANC Program Activities to affect the Results - IR Conduct TOT in integrated management of malaria (severe and uncomplicated), for district supervisors in 34 districts 2. Carry out orientation of health workers at HC II - hospitals in integrated management of malaria (severe and uncomplicated), 3. Provide financial and technical support to district teams to carry out clinical audits at hospitals and HC IVs and monitor performance of district clinical audit teams and health facility clinical audit teams 4. Print and distribute Uganda clinical guidelines to health facilities 5. Print and distribute (during support supervision) in-patient forms to Hospital and HCIVs 6. Carry out external quality assessments in conjunction with CPHL 7. Train district trainers (TOTs) in malaria diagnosis using microscopy and RDTs 8. Train laboratory staff (qualified staff &microscopists) from both public and private including for profit through district based malaria diagnosis by microscopy training 9. Reprint and distribute Malaria laboratory diagnostic charts to all functional laboratories IR Facilitate Health Assistants to conduct community outreaches on malaria prevention and treatment 2. Support HAs to conduct school outreaches. - Program Activities to affect the Results. IR Support and provide technical assistance in the finalisation of the NMCP M&E plan Provide Technical Assistance in the finalization of the NMCP strategic plan, national malaria communication strategy 3. Print and disseminate in the 34 districts 4. Support information sharing through NMCP quarterly and annual reports IR Organize and financially support quarterly national level RBM coordination meetings 2. Consolidate and analyze data from the districts 3. Train Malaria, HMIS FPs and biostatisticians at district, records staff at hospitals and HCIVs and records staff/health workers at health facility in data quality assessment, utilization and management 4. Facilitate the training of the records staff/health workers at health facility in data utilization, management, analysis and utilization through a cascade model 5. Facilitate RC-MoH in printing of HMIS Tools for 5 districts. Crossing cutting program activities 1. Finalize NMCP Strategic plan, M & E Plan and National Malaria Communication Strategy 2. Incorporate lessons learnt into the LLIN guidelines for ANC distribution 3. Print and disseminate policy documents 4. Conduct Quarterly Support supervision to districts and health facilities( JHU, Malaria Consortium, IDI, CDFU) 5. Conduct IEC/BCC mass media campaign to increase LLIN usage and IPTp uptake( JHU, Malaria Consortium, IDI, CDFU) 6. Hold quarterly review meetings with stakeholders at regional level( JHU, Malaria Consortium, IDI, CDFU) 7. Conduct LQAS in 6 districts 7

8 PROJECT ACHIEVEMENTS IR 1.1: MALARIA RELATED POLICIES AND GUIDELINES OPERATIONALIZED In Year 5, SMP provided financial support for the workshop for the development of National Implementation Guidelines for Parasite Based Diagnosis of Malaria. The workshop brought together malaria specialists from the Ministry of Health, Makerere University, Mbarara University of Science and Technology, professional institutions, donor agencies, WHO, regional and district level participants. The guidelines are awaiting approval by the MoH s Senior Management Committee. SMP provided financial support to NMCP to hold two Roll Back Malaria (RBM) meetings. These meetings have strengthened the RBM partnership and have been used to advocate for malaria issues. These meetings have been regularly attended by most of the malaria partner organisations. NMCP did not hold the RBM meeting in Quarter 3 and 4 because they were preoccupied with the LLIN universal distribution exercise. Although, the NMCP Strategic Plan 2010/15 and M&E Plan were finalized in Year 4, MoH has not yet approved these documents. As such, they were not printed and launched in Year 5. SMP asked NMCP to fast track the approval process by following up with top management. IR 1.2: ACCESS TO IPTp UPTAKE INCREASED During Year 5, the proportion of pregnant women attending ANC that received IPTp2 increased to 55% from 53% the previous year. As per the graph below, there was a rise in IPTp2 trend, especially in Q4 of Year 5 where the project achievedthe target for IPTp2 of 60%. In order to increase IPTp2 uptake, SMP, through ISS, mentored health workers to ensure they provided IPTp DOTs. In previous years, SMP supported training of health workers in IPTp as part of malaria in pregnancy (MIP) and integrated management of malaria (IMM) trainings. The proportion of health facilities with atleast two health workers oriented in IPTp was 72% (annual target: 80%). Some of the health workers who were trained with SMP support have since left in search of better jobs. There has been a shortage of In a health center III in Kumi district, a nurse counsels a woman during ANC with job aids and equipment for DOTs in the background. Photo credits: Kim Burns Case health workers for the past years. The government recruited a substantial number of health workers during Year 5. In Year 5, SMP procured and distributed 4,612 packets of water purification tablets to increasethe availability of safe drinking water in health facilities to promote IPTp DOTs. Most health facilities were provided with jerry cans and cups during previous years; as such, no additional procurement of jerry cans or cups in Year 5 was done. 91% (range for Q 1 to Q4 was 88% to 94%) of health facilities were fully equipped with the three IPTp commodities (water purification tablets, jerry cans and cups), which was significantly above the annual target of 80% (SMP ISS data). SMP procured and distributed to health facilities 100,000 ANC cards (target: 493,631) during ISS. This was intended to helphealth facilities to 8

9 capture data on pregnancy including IPTp. Fewercards than planned were procured because most districts still had cards supplied in Year 4. During the year, in collaboration with the SURE project, SMP tracked stock levels of sulfadoxinepyrimethamine (SP), the medicine for IPTp. Over the year, the proportion of health facilities that did not have stock out of SP was 94% (range for Q1 to Q4 was 94% to 96%) (HMIS data 2012/13). This was a marked improvement compared to 90% for Year 4 and marginally below the SMP Year 5 target of 95%. SURE provided monthly updates of SP stock status at the national level, and SMP obtained SP stock levels at health facilities through 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. 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. Although there has been progress in IPTp2 uptake by pregnant women in SMP districts from 53% in Year 4 to 55% in Year 5,uptake has generally stagnated at about 53% to 55% over the past 2 years, which is below the MoH target of 85%. However, according to HMIS data, SMP has realized a great improvement in IPTp from Q4, Year 1 (39%) to attaining the Year 5 target of 60% in Q4, Year 5, as per the chart below. Trend in IPTp uptake in health facilities since inception of the project to Year 5 (HMIS Data ) 9

10 The Stop Malaria Project worked to improve the skills of health workers in administering IPTp through training on malaria in pregnancy and continuous emphasis on IPTp2 during support supervision and during quarterly review meetings. In Year 4, SMP had proposed to conduct research into what other factors affect IPTp2 uptake, but it was not approved by PMI. This year, Malaria Consortium, a partner on SMP project sourced for funds to conduct the research, 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. According to Malaria Consortium, the preliminary results of this study are expected in Q2 of Year 6. SMP will work with the districts to implement an innovative approach e.g. mother-to-mother support group sensitization to improve IPTp uptake. In addition, as part of the test and treat campaign, a counselling tool was developed for health workers and village health teams (and other community health workers) that has integrated content for all the malaria prevention, testing and treating messages, including emphasising the importance of ANC and uptake of IPTp. This was developed in close collaboration with the Uganda Health Marketing Group. Below is the indicator table for tracking progress for the year. Indicator Percentage of facilities equipped with IPT commodities Percentage of health facilities with at least 2 health workers oriented in IPTp quality improvement approach Percentage of pregnant women attending ANC who receive at least two doses of SP Percentage of health facilities reporting no stock out of SP Data Source Target Actual Comments ISS 92% 91% This proportion increased from 89% last (940/1,02 (932/1,0 year. IPTp commodities were replenished 5) 25) during the quarterly ISS visits. ISS 80% 72% The frequent transfers of health workers from one district to another hamper the performance of this indicator. The indicator dropped by a percentage point from last year (73% in Year 4). This is due to high staff turnover. SMP will continue conducting onthe-job mentorship in IPTp improvement for health workers every quarter during ISS visits. HMIS % 55% This was a slight increase from previous year s performance of the indicator from 53% to 55% and achieving the target of 60% in Q4 of Year 5. ISS 95% 94% SMP will continue to collaborate with SURE, NMCP and districts to ensure availability of SP in all health facilities providing ANC services. 10

11 IR 1.3: ACCESS TO LLINS INCREASED ANC LLIN Distribution During the year, SMP distributed 268,804LLINs (55% of Year 5 target: 493,631) to all 34 districts for distribution to pregnant women through 1,025 ANC clinics. Not all of the 1,117 health facilities in SMP s districts provide ANC services. Most health facilities had stock outs of nets especially byq3 and Q4 of the year. On average, the proportion of pregnant women attending ANC who received a net during the year was 57% (282,999/493,631), ranging from 52% to 90% (SMP ISS data 2012/13). PMI has planned to procure ANC LLINs for distribution by SMP in February 2014 in order to address the current stock outs of LLINs in the health facilities. Once these nets are available, SMP will deliver them to all the 34 districts. SMP through ISS monitored ANC LLIN distribution data recording using the ANC LLIN distribution record book and monthly reporting forms developed by SMP in Year 4in collaboration with the NMCP. Availability of these record books and monthly reporting forms improved ANC LLIN distribution data recording and reporting. In Q2 of Year 5(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 (118,880pregnant women out of the 131,711 pregnant women recorded attending ANC 1 in the same period, compared to 77% in Q1) (ISS data).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-the-job mentorship of health facility staff. 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. As such SMP conducted an ANC LLIN process evaluation; attention will be made in 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. This will ensure sustainability of the activity. Universal Distribution of LLIN In Year 5, SMP provided technical assistance (TA) to the Ministry of Health in the planning and implementation of the Global Fund, PMI/DFID and World Vision funded universal LLIN mass campaign distribution. Specific activities supported included: macro-planning, coordination, the national launch, national and regional advocacy / mobilization initiatives, and the district community activities up to final distribution of LLINs to beneficiaries. These activities led to the distribution of nets in 6 wave 2 districts of eastern Uganda namely: Bukwo, Kaberamaido, Bukedea, Kapchorwa, Bulambuli and Sironko. Although district level activities up to registration of households and LLINs allocation were completed in all 16 wave 2 districts, distribution was completed in only 6 districts. The key challenge was due to the slow pace of transporting nets from Kampala stores to the districts due to loading capacity at the warehouse. As such, distribution in the 10 districts was deferred to October Planning and coordination of the 2013 LLIN distribution campaign A National Coordination Committee (NCC) chaired by the Director General Health Services was constituted including Ministry of Health and NMCP staff, SMP and Malaria Consortium technical staff and other LLIN specialists. The role of the NCC is to oversee, monitor and support the entire campaign. It hasthree committees: operations, logistics and advocacy / social mobilization. 11

12 LLIN distribution campaign launch World Malaria Day is commemorated every year to evaluate and recognize global efforts to control malaria in Uganda. This year it was delayed from 25th April to the 10th May 2013, to coincide with the national launch of the universal distribution of LLINs, to energize commitment to the fight against malaria and raise the profile of LLINs in the control of malaria.the launch was presided over by His Excellency Yoweri Kaguta Museveni, the President of the Republic of Uganda in Soroti District. Soroti District was selected because it had received nets from World Vision, had completed registration of households and was ready to distribute them to the community. Funding for the launch was provided by PMI/DFID through SMP. National level advocacy As part of the LLIN distribution advocacy activities, the Ministry of Health and the partners engaged the Members of Parliament at a breakfast meeting at Imperial Royale Hotel on 22 nd August The purpose of the meeting was toincrease the involvement of parliament members, provide key details of the LLIN distribution campaign and solicit their support in mobilizing the masses to register, acquire and consistently use the mosquito nets every night. In total, the event attracted 125 Members of Parliament who pledged their full support and commitment to the universal coverage LLIN distribution campaign. Above: Bobi Wine entertained the high level guests with a Malaria Song commissioned by SMP. Below: President Museveni and high level representatives from USAID, DfID and Global Fund officially launch the distribution. Photo credits: Kim Burns Regional level advocacy (regional meeting in Mbale) A regional sensitization meeting was held on August 30 th, 2013 at Mt Elgon Hotel, Mbale. The purpose of this forum was to bring together political, civic and key opinion leaders from Eastern Region to introduce the design and implementation of the Universal Coverage Campaign, sensitize leaders to support the campaign and equip them with information for effective community mobilization. The meeting was presided over by the Ministry of State for Health (Primary Health Care), Hon. Sarah Opendi. 12

13 Distribution of nets In total, the Ministry of Health distributed 660,652 LLINs in the 6 wave 2 districts. SMP also provided input into the MoH s planning and budgeting process, as well as technical assistance at Central and District levels to the distribution of 500,000 LLINs led by World Vision. The nets procured by World Vision were earmarked for Soroti and Busia Districts. SMP will continue to provide technical assistance to the Ministry of Health to distribute nets in the remaining districts. Performance Indicator Number of LLINs distributed to districts Number of ANC clients receiving free LLINs Proportion of pregnant women provided with LLINS through ANC distribution Proportion of ANC clinics distributing LLINs Data Source Project and partner records Project and partner records Project and partner records Project and partner records Target Actual Comments 493, , , ,804 and 660,652 LLINs were distributed to districts for ANC distribution (34 SMP districts) and universal distribution in the 6 wave 2 districts. 493, ,999 Most of the health facilities experienced LLIN stock out. 100% (1025/102 5) 95% 78% The indicator was affected by the stock out of ANC LLINs. 91% 933/1025) Some facilities run out of stock during quarter 4 of Year 5. IR 2: MALARIA DIAGNOSIS AND TREATMENT ACTIVITIES IN SUPPORT OF THE NATIONAL MALARIA STRATEGY IMPROVED AND IMPLEMENTED IR 2.1: MALARIA DIAGNOSTIC TREATMENT AND REFERRAL SERVICES During Year 5, SMP focused on reviewing the clinical audit tool to make it less bulky and more user-friendly. The clinical audit tool was reviewed to make it cheaper for health facilities to reproduce and use during district initiated clinical audits. 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 countrywide.nmcp plans to conduct clinical audits under the Global Fund Round 10 grant. I can say that the audits have supported us very much. They would help us identify our own problems, suggest solutions and come up with action points. These action points would keep us engaged after the audit exercise, and this led to performance improvement. It is really more of a mentoring exercise identifying gaps within your operation and how to bridge them. --Namwanga, Edwige, Senior Nursing Officer, Kinoni HC IV in Lwengo district 13

14 SMP continued to provide technical and financial support to district clinical audit teams to carry out clinical audits in targeted 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 and treatment outcomes, as well as follow up notes). In Year 5, emphasis was put on reviving the health facility audit committees so that health facility staff can conduct clinical audits, and therefore,be centered at the health facility. As a result, it is hoped that the implementation of clinical audits will be less reliant on the district teams, and require less fundsfor the district health teams to be transported to health facilities to carry out 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. In Year 6, SMP and the district teams will use the revised clinical audit tool to carry out clinical audits in the health facilities and any lessons learnt will be incorporated to improve the tool further. During the year, SMP staff together with MOH/NMCP/CPHL provided technical support to district trainers that conducted district-based training of the newly recruited laboratory staff. The training covered use of microscopy and RDTs in laboratory diagnosis of malaria as well as External Quality Assurance and Control (EQA/QC) procedures and the purpose of the training was to equip laboratory personnel with competences for accurate diagnosis of malaria using microscopy and RDTs and skills for implementation of EQA/QC. The training targeted 316 lab health workers out of which 314 attended the training Trainees came from the public (95%), private not-for-profit (2%), and private for profit (3%) facilities. Malaria diagnostic knowledge among the trainees increased from a 52% average score before training to 72% after training (assessment based on pretest and posttest results). Above is a lab technician using his microscope in Kumi District. Photo credit: Kim Burns Case Above is a lab technician show the job aids that he uses in his work. Photo credit: Tine Frank 14

15 IR 2.2: MALARIA DIAGNOSTIC CAPACITY AND SERVICES IMPROVED During the year, SMP supported three external quality assurance (EQA) re-orientation meetings for district laboratory staff from the Teso region, Central region and Midwestern region. Each district was represented by three laboratory personnel including two existing district level slide readers and one other senior laboratory person with experience in malaria microscopy. The purpose of the orientation meeting was to review the external quality assurance activities and to prepare the region for EQA scale up that was expected to start off immediately after the meeting (Jan- March 2013). A new scale up plan was also introduced which will increase the number of health facilities participating in EQA from the current 136 to 238 in the 34 districts. EQA sites scaled up from 4 to 7 health facilities per district. New EQA coordinators were selected from each district. The district EQA coordinator will be responsible for coordinating EQA activities, collecting slides from all EQA health facilities and transporting EQA discordant slides to IDI/CPHL. The district EQA coordinator will not be involved in slide reading to ensure effective blinding of slide readers at all levels. A lab technician entering data has he has been trained in Luwero district. Photo Credit: Tine Frank Above a lab technician is showing the rapid diagnostic test that he is waiting for the results for in Soroti Hospital. Photo Credit: Kim Burns Case During Year 5, SMP conducted EQA each quarterin each districts 108 health facilities participated in the 1 st quarter, 171 in the 2 nd quarter, 214 in the 3 rd and 4 th quarter respectively. Analysis of data for the 1 st, 2 nd and 3 rd quarters has been completed. There was consistency in slide reading accuracy averaging at 92% in all three quarters, although there was a slight drop in Q2 as per the chart below.data for the 4thquarter is yet to be submitted by the district EQA coordinators. EQA results have held steady at 92-93% per quarter during Year 5. During the year, SMP procured and supplied 70 microscopes to poorlyequipped health facilities; lack ofquality microscopes has been identified as a major constraint to provision of laboratory diagnosis of malaria in the target districts. An assessment of health facilities was done and those with most need identified were supplied with the new microscopes. During Q4 of Year 5, SMP did not conduct stand-alone post-training follow-up support supervision to the malaria diagnosis using microscopy and RDT course graduates due to limited funding for Q4 of Year 5. The SMP team, NMCP and CPHL use the opportunity to assess and suggest solutions to factors like 15

16 equipment and supplies management at the district laboratories, which may affect the quality of services at the district laboratories. Indicators Number of health workers oriented in case management of severe malaria Percentage of health facilities carrying out clinical audits for the management of severe malaria Proportion of health facilities with no stock outs of ACTs Data Source Project and Partners records SMP Clinical Audit Report Target Actual Comments 100% of HC IVS and hospitals 0 0 No training was planned for this year. 56% (50/89) SMP provided technical and financial support to district teams to carry out clinical audits at hospitals and HCIVs. More focus was on reviewing the clinical audit tool. HMIS 95% 90% SMP will continue to work with districts to redistribute drugs during ISS and clinical audits. Proportion of children under five referred for further management of malaria who are first given pre-referral treatment at HC II & III ISS 80% 70% Indicator affected by lack of rectal artesunate in the lower level health facilities. Improvement is anticipated once rectal artesunate becomes available in the lower level health facilities. During Year 5, there was a rise in the number of children under five years with a fever who were tested for malaria using microscopy and RDT as per the chart below.testing rates in SMP districts improved when MOH supplied RDTs to health facilities and reduced when stock outs occurred. 16

17 IR 3: NMCP CAPACITY TO MONITOR AND EVALUATE INTERVENTIONS STRENGTHENED IR 3.1: TECHNICAL RESOURCES AND SKILLS OF M&E SUB-UNIT IMPROVED During the year, SMP supported Dr. Denis Rubahika, M&E Specialist at NMCP, to attend the M&E Training by MEASURE Evaluation in Ghana. Denis is expected to use the knowledge acquired from the training during the planning process of the Uganda Malaria Indicator Survey scheduled for During the quarter, SMP identified a consultant to conduct M&E training for NMCP staff; however, due to the busy schedule of the NMCP staff the training did not take place. The training has been rescheduled for Year 6. IR 3.2: COLLECTION, PROCESSING AND USE OF DATA FROM DISTRICTS AND IMPLEMENTING PARTNERS IMPROVED During Year 4, SMP continued to support districts to submit their HMIS reports to MoH RC; timely reporting of HMIS data was at 81% from district to national level and exceeded the target of 70%. Complete reporting of HMIS data was at 98%, achieving Year 5 target. Performance Indicator Percent of SMP-supported districts that provided complete data (Complete means data submitted should cover IPTp uptake, case management and mortality due to malaria) on malaria indicators to national HMIS database Percentage of districts providing accurate data (accurate data means the summary of the data at the health facility should match the data in the district HMIS data that was submitted to SMP and the national level) Number of malaria, HMIS focal persons, biostatisticians and health workers at facility level trained in data quality assessment, management and utilization Percentage of districts submitting HMIS data to the national level on time (before the 28th of the following month) Proportion of health facilities utilizing data for decision-making. (numerator = number of health facilities in SMP-supported districts visited by ISS team with evidence Data Source HMIS Target Actual Comment 98% 98% SMP will continue to send e- mail reminders to districts to submit timely and complete data. ISS 70% 69.4% This may be attributed to the data quality assessments and data use meetings conducted in the quarter. Project and Partners Records HMIS No training is planned for the year. SMP will continue to mentor HMIS focal persons, biostatisticians and health workers at facility level in data quality, accuracy, management and reporting during the DQAs and quarterly ISS visits. 70% 81% ISS 50% 52% The indicator increased from 37% in Quarter 4, Year 4 to 46% in Quarter 3, Year 5. SMP will continue to mentor 17

18 Performance Indicator of plotting trends on key malaria indicators and using the data for planning in the quarter divided by / denominator = the number of health facilities visited by the ISS team during the same quarter) Number of Roll Back Malaria partner meetings Data Source Project and Partners records Target Actual Comment health workers to utilize data through data quality assessments and quarterly ISS. 4 2 This indicator was not achieved due to the LLIN distribution campaign that had the key people to convene the meetings heavily involved in the field. CROSS CUTTING ACTIVITIES SUPPORT SUPERVISION During Year 5, SMP conducted four rounds of malaria specific integrated support supervision focused on IPTp, ANC LLIN distribution, diagnosis and treatment, health education, community mobilization, malaria commodities management and records in all 34 districts to improve performance of health facilities in the delivery of malaria prevention and treatment services. The health facilities reached included all hospitals, HC IVs, HC III and selected HC II. District supervision teams led the activity with financial and technical support from SMP. The ISS teams provided on-site support and mentorship to the health facility staff to help them maintain good performance and to improve performance in areas of weakness. Regular ISS helped health facility in-charges and staff to identify gaps in the services at their health facilities and developed facility-based actions to address the gaps. SMP shifted from use of paper-based ISS tools to use of portable computers (PDAs). District supervision teams have been trained in the use of PDAs. SMP is encouraging districts to procure some PDAs for use when the project closes. As a result of using PDAs, the process of supervision including data collection and submission from the districts to SMP greatly improved. Data collection using PDAs is fast; this saves ample time for districts teams to better support the facility health workers. Although the national support supervision guidelines require districts to conduct ISS to the health subdistricts/health facilities, and the NMCP to districts at least once per quarter, SMP s experience is that neither the districts nor NMCP are able to execute this mandate without SMP funding. SMP continued to encourage the districts to identify alternative sources to carry on with this valuable activity. CREATING DEMAND FOR MALARIA SERVICES AND PRACTICES During the course of the Year 5, the project continued to strategically utilize communication and community outreach approaches in order to create demand for malaria service and practices. Some of the approaches and activities included: Universal Long Lasting Insecticide Treated Nets Campaign, the Test and Treat campaign, the roll out of the Primary School Music, 18

19 Dance and Drama competitions, and Net Care & Repair pilot campaign in Serere District and also the conclusion of the Stop Malaria in Your Community Campaign. The section below provide key highlights for the mentioned campaigns. A) Test & Treat Campaign: During Q4, SMP, working closely with the Uganda Health Marketing Group, supported NMCP to implement the Test and Treat campaign, which went by the theme of Don t Guess, First Test. Media activities included monthly talk shows and radio spots that started running in September. Provider training materials were completed and disseminated. Thirteen national trainers were trained in IPC skills for managing children with fever. They conducted 3 trainings for 68 district trainers/supervisors from the 18 central districts. After the exercise, district trainers with supervision from the national trainers conducted IPC trainings for 130 health providers from 9 of the 18 targeted districts. Billboards were erected at 15 major road points covering the 18 districts. Overall, the campaign has been embraced by relevant national and district partners. The campaign communication and training materials were endorsed by NMCP. NMCP program manager proposed a meeting to endorse the provider training materials as institutional for responding to provider interpersonal communication (IPC) training needs regarding malaria diagnostic and treatment services for public health facilities. Pretesting of the Test and Treat campaign materials in Luwero district. Photo Credit: Tine Frank B) Net Care & Repair Campaign: The Net Care & Repair campaign under the theme Silent Nights; Happy Days in Serere District was launched on 18th June 2013, with the participation of the district leadership and all the stakeholders. The campaign relies on interpersonal communication and mass media approaches. Under interpersonal communication activities, 58 VHT members executed 90 communication dialogues attracting a total of 1800 people. VHTs visited 1740 homes to provide the demonstration support for the net care and repair practices hence approximately 6090 people. During 19

20 the home visit interactions household members were able to attach an addedbenefit of net care and repair in that it saved resources that would have beenutilized to buy a new net. In addition to the above, the 29 villages engaged in song contests which enhanced the community dialogues, a total of 33 activations were executed which approximately 9000 people. The campaign also worked with 30 schools with a pupil population of 18,000 participating in the net care and repair campaign activities. The schools have been able to develop their own specific programming for the net care and repair campaign. 55 households have been directly contacted by the schools trying household outreach activities. The schoolteachers have expressed interest in leading the community dialogue activities in the instances where the VHTs have not been so active. Mass media has been utilized to complement the interpersonal communication activities mentioned above by executing 9radio talk shows, radio spots, 120 ABS boards placed in the trading centers and 2000 posters distributed. C) Primary Schools Music, Dance & Drama Competitions 2013 SMP worked closely with the Ministry of Education & Sports and UNICEF to implement this year s Primary Schools Music, Dance & Drama competitions under the theme Effective Learning for Malaria-Free Children in Zero Violence Schools. The competition aimed at attracting 18,000 primary schools with approximately 7,200,000 pupils. The project has supported the national training of 675 trainers across the country. Trainers then conducted district-level trainings for music Music, Dance and Drama competition Photo Credit: Tine Frank teachers which was imperative to the successful conduct of in-school, zonal, district, regional and national competitions based on this year s them. The project also fundedthe printing and dissemination of 50,000 competition syllabus brochures to all the schools through the District Education Offices. The project has also supported 1288 radio announcements and 2 radio talk shows. Its face book page attracted participation from775 people. The competitions were concluded with the national-levelevents, which wereheld the week of 26th 31st August 2013 at the National Theatre. D) Stop Malaria in Your Community Communication Platform During this Year 5, the project concluded the Stop Malaria in Your Community dialogue recordings. Groups comprising of approximately 20 people that included: Local Council Leadership, Health Unit Management Committee, Opinion Leaders, household 20 Mrs. Anopheles wanted to spread malaria. Then she met someone sleeping under a mosquito net. She tried, she tried, she tried, but she could not spread malaria. --Nora, age 13, remembering the campaign

21 members met on a monthly basis at the health facility to discuss malaria control issues. The recordings were broadcast on the radio stations and key issues were identified and discussed on radio by district leaders. To date, a total of 30 radio dialogue meetings and 13 radio talk shows have been held in 10 districts. In addition, 27,000 inserts that include radio presenter endorsements and radio spots by popular artistes Bobbi Wine and Samalie Matovu were aired. During Year 5, HAs were actively involved in facilitating the health facility-based recorded community dialogue sessions under the Stop Malaria In your Community campaign. 60 sessions were facilitated, recorded and later aired on the district-based radio stations for further discussion and technical input by the District Health Team members and for wider listenership. The sessions not only provided a platform for the community members to discuss and collectively agree upon local solutions to address the malaria challenges raised, but also created a link between the health facility and the communities. The school malaria program continued to empower pupils in 610 primary schools in the 10 districts with the knowledge on malaria control and how to apply this knowledge into action among themselves, their peers and household members. Through child-friendly activities like songs, poems, drama/skits and debates; pupils with support from the HAs, head teachers and class teachers acquired knowledge on the control of malaria and appreciated their role in the fight against malaria. Nakafeero Harriet (HA Kasasa s/c, Masaka district) reports that During preparations for the National Music Dance and Drama school competitions, I was able to get 3 pupils report to me that their parents had bought for them a net after they had talked to them. This shows me that the pupils understand what I tell them during assemblies and it also shows that the message is taken back home. Health Assistants:Kayinda Sylvia, NamusisiMadrine and NankumbaModester (in white t-shirts) demonstrating LLIN usage to the children of Kkindu Primary school, Masaka district. The table below shows the status of the indicator-tracking table. Performance Indicator Data Source Target Actual Comments Integrated Materials Project and Billboards: The project maintained the Partners current outdoor presence in the records partner districts. Number of radio spots Project and 47,450 50,726 Additional Radio Inserts (Spots & DJ 21

22 Performance Indicator Data Source Target Actual Comments (Stop Malaria in Your Community) Number of radio pots (Test & Treat Campaign) Number of radio spots aired (Net & Care Repair pilot campaign) Number of radio talk shows (Stop Malaria in Your Community) Net Care & Repair Radio Talk Shows Number of radio talk shows (Test & Treat Campaign) Number of support supervisory visits by project staff to HA conducting malaria control activities Number of school outreaches conducted by HA Partners records Project and Partners records Project and Partners records Project and Partners records Project and Partners records Project and Partners records mentions)and the revised Media Strategy to cater for the Music, Dance & Drama Competitions and some bonus inserts and make goods from the previous quarter Media campaign commenced during the month of September upon completion health worker training activities The campaign is jointly funded by SMP and the Networks Project These ones focused on the Stop Malaria in Your Community dialogue meetings. Additional radio talk shows were requested from the radio stations to support the music, dance and drama competitions Increased the frequency of the radio talk shows to weekly basis instead of the bi weekly basis as initially planned Increased the number of radio talk shows on the 8 radio stations. Provide targeted support supervision visit to Health Assistants Conduct school outreaches in 610 primary schools. Number of pupils reached through the school outreaches Number of Health Education Sessions conducted at health facility 366, ,029 Provide support to schools towards implementation of school based malaria prevention activities Provide technical support to health assistants to conduct health education sessions at the health facilities. PROJECT MONITORING AND EVALUATION During the quarter, data entry into the HMIS database was done on a monthly basis, which involved tracking timely and complete submission of reports from districts to the national level. The SMP M&E team continued to provide feedback to districts on the status of their reports (District Health Information System (DHIS2) and mtrac), which contributed to improved reporting to the national level. 22