THE UGANDA STOP MALARIA PROJECT ANNUAL PERFORMANCE REPORT

THE UGANDA STOP MALARIA PROJECT ANNUAL PERFORMANCE REPORT OCTOBER 1 ST SEPTEMBER 30 TH 2014 Submitted to USAID on October 30 th, 2014 USAID/JHU Cooperative Agreement No. CA 617-A-00-08-00018-00 1

Table of Contents LIST OF ACRONYMS... 3 EXECUTIVE SUMMARY... 5 BACKGROUND... 7 RESULTS FRAMEWORK... 8 PROJECT ACHIEVEMENTS... 9 IR 1.1: MALARIA RELATED POLICIES AND GUIDELINES OPERATIONALIZED... 9 IR 1.3: ACCESS TO LLINS INCREASED... 12 IR 2: MALARIA DIAGNOSIS AND TREATMENT ACTIVITIES IN SUPPORT OF THE NATIONAL MALARIA STRATEGY IMPROVED AND IMPLEMENTED... 15 IR 2.1: MALARIA DIAGNOSTIC TREATMENT AND REFERRAL SERVICES... 15 IR 2.2: MALARIA DIAGNOSTIC CAPACITY AND SERVICES IMPROVED... 17 IR 3: NMCP CAPACITY TO MONITOR AND EVALUATE INTERVENTIONS STRENGTHENED... 19 IR 3.1: TECHNICAL RESOURCES AND SKILLS OF MONITORING AND EVALUATION (M&E) SUB- UNIT IMPROVED.... 19 IR 3.2: COLLECTION, PROCESSING AND USE OF DATA FROM DISTRICTS AND IMPLEMENTING PARTNERS IMPROVED... 19 CROSS CUTTING ACTIVITIES... 21 SUPPORT SUPERVISION... 21 CREATING DEMAND FOR MALARIA SERVICES AND PRACTICES... 22 PROJECT MONITORING AND EVALUATION... 25 COORDINATION AMONG KEY PARTNERS IMPROVED... 26 LESSONS LEARNED... 26 CHALLENGES AND PLANS TO ADDRESS THEM... 27 CONCLUSION... 28 USAID/JHU Cooperative Agreement No. CA 617-A-00-08-00018-00 2

List of Acronyms ACT Artemisinin-based Combination Therapy ANC Antenatal Care BCC Behavior Change Communication CDFU Communication for Development Foundation Uganda CHC Communication for Health Communities CME Continuing Medical Education CPHL Central Public Health Laboratory DDU Data Demand and Use DEO District Education Officer DHI District Health Inspector DHO District Health Officer / Office DHIS2 District Health Information System 2 DHT District Health Team DFID Department for International Development in UK DLFPs District Laboratory Focal Persons DO3 Development Objective 3 DOTs Directly Observed Treatment ECAMM External Competency Assessment in Malaria Microscopy EPI Expanded Program on Immunization EQA/QC External Quality Assurance/Quality Control GF Global Fund GPRS General Packet Radio Service HMIS Health Management Information Systems IDI Infectious Diseases Institute IEC Information, Education and Communication IMM Integrated Management of Malaria IP Implementing Partner IPC Interpersonal Communication IPTp Intermittent Preventive Treatment in pregnancy IR Intermediate Result ISS Integrated Support Supervision JHU CCP Johns Hopkins University Center for Communication Programs LLIN Long Lasting Insecticide Treated Net MC Malaria Consortium MCH Maternal and Child Health MDD Music, Dance and Drama MFPs Malaria Focal Persons MIP Malaria in Pregnancy MIS Malaria Indicator Survey MoH Ministry of Health MOP Malaria Operational Plan MPR Malaria Program Review MRS Malaria Reduction Strategy USAID/JHU Cooperative Agreement No. CA 617-A-00-08-00018-00 3

MSH Management Science for Health MTR Midterm Review mtrac Mobile Tracking of Essential Medicines NDA National Drug Authority NMCP National Malaria Control Program NMRS National Malaria Reduction Strategy NMS National Medical Stores OPD Outpatient Department PHC Primary Health Care PMI President s Malaria Initiative PMP Performance Monitoring Plan PNFP Private Not-for-Profit Q1 Quarter 1 QI Quality Improvement QC Quality Control RBM Roll Back Malaria RC MoH Resource Centre of the MoH RDT Rapid Diagnostic Testing SDS Strengthening Decentralized SystemsSMP Stop Malaria Project SP Sulfadoxine-pyrimethamine ToT Training of Trainers UMIS Uganda Malaria Indicator Survey USAID United States Agency for International Development VHT Village Health Team WHO World Health Organization USAID/JHU Cooperative Agreement No. CA 617-A-00-08-00018-00 4

EXECUTIVE SUMMARY Stop Malaria Project (SMP) is designed to assist the Government of Uganda to reach the RBM goal of reducing malaria morbidity and mortality by 70% by 2015. Project implementation started in September 2008 with JHU.CCP, the lead partner, Malaria Consortium, the technical lead, Communication for Development (CDFU) and Infectious Disease Institute (IDI). During the year, Stop Malaria Project (SMP) focused on three intermediate results: 1) Malaria prevention programs in support of the national malaria strategy improved and implemented. 2) Malaria diagnosis and treatment activities in support of the national malaria strategy improved and implemented. 3) NMCP capacity to monitor and evaluate interventions strengthened. During the year, SMP made progress towards meeting Year 6 targets. These include: IR 1: Malaria Prevention SMP as a lead agent for the universal net coverage campaign provided technical assistance (TA) to Ministry of Health in the planning and implementation of the Global Fund, PMI/DFID and World Vision funded universal LLIN distribution. Over 22 million bed nets were distributed and Uganda achieved Universal coverage. SMP provided financial and technical support to NMCP to commemorate the World Malaria day that was held in Mubende district under the theme Invest in the future, defeat malaria. The Guest of honor was the Vice President of the Republic of Uganda, Hon. Ssekandi Edward accompanied by the Minister of Health, Hon. Rukahana Rukunda. SMP strengthened health workers knowledge and skills to ensure they provide IPTp - DOTs and have interpersonal communication competence to influence clients health decisions. Over the years the proportion of pregnant women receiving two doses of IPTp has increased from 40% in Year2, quarter 1 to 57 % in Year 6, Quarter 4. IR 2 Malaria treatment and referral services improved SMP provided financial and technical support to districts and health facility teams to conduct clinical audits for severe malaria in hospitals and HC IV. Triaging - 77% of (48 out of 62) facilities, had a system for triaging patients, 96% (60 out of 62) of facilities had a thermometer, 60% (37out of 62) had a timing device, 85% (53 out of 62) had a BP 5

machine, 65% (40 out of 62) had a glucometer, 42% (26 out of 62) had a patient trolley and 55% (34 out of 62) had a wheel chair, 93% of the assessed clinicians were able to use the ABCD strategy and take appropriate action, 90% of the clinicians assessed patients for all emergency signs for malaria, 68% of the HCIVs and 65% of HCIIIs assessed patients for all emergency signs. Increase in the percentage of children under five who received a diagnostic test (either microscopy or RDT) (Numerator = Tests done for children U5 and Denominator = Malaria cases of children U5) at the health facility increased from 84% in Year 5, quarter 4 to 94% in Year 6, quarter 4 On average, 71% (18 out of 25) of the lab trainees responded to the SMS quiz questions shared with them and, 75% of all trainees that responded submitted the correct response. IR 3: Strengthen the capacity of the NMCP M & E Unit to monitor and evaluate malaria interventions. SMP provided financial and technical support to NMCP to conduct the Midterm Review (MTR) of the National Malaria Strategic Plan 2010/15. The MTR informed the review and revisions to the National Malaria Reduction Strategy 2014-20. SMP provided technical support in reviewing the HMIS tool and participated in the stakeholders meeting that discussed the roll out plan of the new revised HMIS tools. SMP supported NMCP to hold meetings for M & E technical working groups. Submission of HMIS reports from the district to the national level that were timely (actual 94% target = 80%), and complete (actual = 99%: target = 98%). Increase in data utilization at health facility level from 46% in Year 5, Quarter 3 to 57% in Year 6, Quarter 4. (HMIS 2013-2014). The denominator is the number of health facilities visited by ISS team during the same quarter and the numerator is Number of health facilities in SMP supported districts with evidence of plotting trends on key malaria indicators visited by an ISS Team in the quarter Increase in Health Management Information Systems (HMIS) data accuracy from 71% in Year 5, Quarter 4 to 74% in Year 6, Quarter 4. Successful organization of the Project close out Event in the Teso Region with National Malaria Control Program (NMCP), President s Malaria Initiative (PMI), District Leadership and Implementers partners and sharing the projects achievements and sustainability plans. 6

However, SMP encountered some challenges including delays in receiving LLINs from the vendor, clearance of the nets by National Drug Authority (NDA), delays in receiving funds from the donor,that hampered timely activity implementation. BACKGROUND Stop Malaria Project (SMP) is designed to assist the Government of Uganda, in particular the National Malaria Control Program (NMCP) and District Health Teams (DHTs), to achieve its six year goal of reaching 85% of children under five years of age and pregnant women with proven preventive and therapeutic malaria interventions, that include: Artemisinin-based Combination Therapy (ACTs) for treatment of uncomplicated malaria, Intermittent Preventive Treatment (IPTp) of malaria in pregnancy, and Long-lasting Insecticide Treated Nets (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; and NMCP capacity to monitor and evaluate interventions strengthened. The project activities are implemented in close collaboration with the NMCP and district local vernments including district health team. SMP will endeavor to seek avenues to engage the Regional Performance Monitoring Teams (RPMTs). The project has been coverings 34 districts in three regions but beginning of July 2014, the project phased out Teso Region, as a result of scaling down project activities in the final year of implementation and change in regional focus by the donor. Central Region: 21 districts Hoima Region: 5 districts Teso Region: 8 districts Activities for Q1-Q3 were implemented in all 34 project districts while activities for Q4 were only in 26 districts excluding the 8 Teso region districts that were phased out on June 30 th, 2014. In addition, SMP closed out activities with two of its partners CDFU at the end of June 2014 and IDI at the end of August 2014. Activity implementation during the year 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. 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 strengthened IR 1.1: Malaria policies & guidelines operationalised IR 1.2: Access to IPTp increased IR 1.3: Access to LLINS increased IR 2.1 Service providers capacity to manage severe malaria improved and implemented IR 2.2 Malaria diagnostic capacity and, services 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 Program Activities to affect the Results Results - IR 2.1 IR 1.1 1. Print and disseminate guidelines IR 1.2 1. Track IPTp Commodities 2. Conduct ISS on IPTp 3. Print and distribute ANC cards 4. Provide water purification tablets, cups, and jerycans 5. Print and distribute Cards 6. BCC to promote IPTp IR 1.3. 1. Continue ANC LLIN distribution 2. Support Universal LLIN distribution - : 3.. Promote Net Use 4. Print and distribute ANC LLIN registers 5. Fund and participate in Integrated Vector Management Technical Working groups 1. Conduct Clinical Audit in Hospitals and HCIVs 2. Revise and produce job aids on severe malaria - and uncomplicated malaria 3. Support blood banks to increase capacity for transfusion for severe malaria 4. Track and when needed, redistribute ACTs, RDTs and IV and rectal artesunate 5. IMM training for new health facility staff. 6. Reprint and distribute in patient observation forms 7. Support review of HMIS tool to facilitate capture of patients treated with antimalarials who received a diagnostic test and result of the diagnostic test Program Activities to affect the Results. IR 3.1 1. RBM coordination meetings 2. Financial and Technical support to Malaria Technical Working Groups 3. Support NMCP development of Annual Work plan IR 3.2 1. Conduct DQA and DDU 2. Fund Internet Subscriptions IR2.2 1. Train Laboratory personnel on malaria diagnostics 2. Strengthen NMCP capacity to conduct EQA 3. Strengthen equipment maintenance and supply 4. Strengthen supply of malaria diagnostic consumables Crossing cutting program activities 1. Support NMCP to conduct ISS 2. Support districts to conduct ISS 3. Liaise with SDS to sustain ISS 4. Test, Treat and Track campaign 5. Net care and Repair campaign 6. Conduct Community Outreach activities 7. Conduct quarterly review meetings 8. Compile and share ISS reports 8

PROJECT ACHIEVEMENTS IR 1.1: MALARIA RELATED POLICIES AND GUIDELINES OPERATIONALIZED During the year, SMP provided financial support for three RBM. meetings. held on 10 th January, 6 th March and 13 th August 2014. The key issues discussed in the meetings included the updates on the universal LLIN distribution, and support to NMCP in developing the annual work plan 2013/14. One Technical Working Group (TWG) per thematic area was held during the year. One of the notable achievements registered in the year was the Midterm Review (MTR) of the National Malaria Strategic Plan 2010/15, which was supported by SMP financially and technically. The MTR informed the review and revisions to the National Malaria Reduction Strategy (MRS) 2014/20 which was finalized. The Development of the GF grant proposal/concept for 2014/17 was based on the MRS 2014-2020 In addition, SMP provided financial and technical support to NMCP to commemorate the World Malaria day that was held in Mubende district under the theme Invest in the future, defeat malaria. The Guest of honor was the Vice President of the Republic of Uganda, Hon. Ssekandi Edward accompanied by the Minister of Health, Hon. Rukahana Rukunda. Stop Malaria participated at the World Malaria Day by showcasing Information, Education and Communication (IEC) materials developed by the project, demonstration of proper LLIN usage and carried out onsite testing of people using malaria Rapid Diagnostic Test kits (mrdts). IR 1.2: ACCESS TO IPTp UPTAKE INCREASED During the year, the proportion of pregnant women attending first Antenatal Care (ANC) that took two doses of sulfadoxine-pyrimethamine (SP) increased to 58% from 55% the previous year (HMIS data Oct 2012 Sept 2013). This year, data on health facilities reporting no SP stock outs and proportion of health facilities equipped with IPTp commodities slightly decreased from 94% to 88% and 91% to 90% respectively. This was as a result of delay in supplying medicine to the districts. Some facilities had less number of cups in ANC clinics than distributed because some cups were being used in in-patient wards. SMP has discussed with the district leadership the need to ensure that cups are taken back to ANC clinics to support IPTp administration. SMP supported integrated support supervision (ISS) on IPTp to strengthen health workers knowledge and skills of IPTp - DOTs and interpersonal communication of health workers with clients. 71% of health facilities were reached during ISS and had at-least 2 health workers trained in IPTp quality improvement approach this was slightly below year 5 achievement of 72%. This may be attributed to the newly recruited health workers; however these will be mentored during the IMM mop on Job in the next quarter. In addition, SMP will support the 9

districts to improve health worker interpersonal communication skills for increased IPTp uptake during next quarter s ISS visit. In order to better understand factors affecting uptake of IPTp2, Malaria Consortium, conducted a study Assessing and addressing barriers to IPTp Uptake. The study revealed both supply and demand barriers to improving IPTp uptake: this includes, inconsistent IPTp guidelines; poor quality IPTp data in some health facilities and weak community mobilization. In a bid to address the identified gaps, SMP in next quarter will support NMCP to hold a stakeholders workshop to revise the Malaria in Pregnancy guidelines based on the new WHO guidelines, support community level mobilization activities for the VHTs and strengthen interpersonal communication skills for ANC health workers. The chart below shows IPTp uptake in the 34(HMIS data 2009- June 2014) and 26 SMP supported districts (HMIS data July -semptember-2014). The indicator stands at 50% at national as per the AHSPR 2013-2014. Below is the indicator table for tracking progress for the year. 10

Indicator Percentage of facilities equipped with IPTp commodities Percentage of health facilities with at least 2 health workers oriented in IPTp quality improvement approach Percentage of pregnant women attending ANC who received at least two doses of SP Percentage of health facilities reporting no stock out of SP Data Source Target Actual Comments ISS 95% 90% Some facilities had less number of cups in ANC than distributed. In some facilities cups are used in inpatient wards. SMP has reemphasized the purpose of n ot removing the cups from the ANC clinics. ISS 75% 71% This drop is due to high staff turnover in health facilities and the newly recruited health workers have not yet been trained. SMP will continue to provide on job mentorship to new staff during the quarterly support supervision. HMIS 60% 58% This achievement is an increase in IPTp uptake from 55% in the previous year although this falls short of this years target. ISS 96% 88% Some PNFPs experienced SP stock out. SMP through the DHO will continue to engage the PNFPs to stock SP, 11

IR 1.3: ACCESS TO LLINs INCREASED ANC LLIN distribution During the year, the proportion of pregnant women attending ANC who received an LLIN was 33%, on an average for Q1 to Q4 (range: 16% to 49%) [HMIS data 2013/14]. This was significantly below the year 6 SMP target of 95%. Over the year, SMP did not have ANC nets in its stores to distribute to the districts. By the request of MOH and partners, PMI procured nets for SMP ANC distribution were diverted to cover the country gap for the SMP lead universal bed net coverage mass campaign distribution in Kampala and Wakiso Districts. As such, the only bed nets that were available in the health facilities for ANC distribution were provided by The AIDS Support Organization (TASO) under the Global Fund Round 10 grant. Although TASO provided bed nets to health facilities, the quantities delivered were less than the need, and most health facilities had stock outs of bed nets over the year. SMP through ISS continued to encourage health workers to provide interpersonal communication with pregnant women so that pregnant women consistently sleep under the bed net received by universal net campaign every night during pregnancy and after delivery along with their babies. Interpersonal communication messages also involved advising pregnant women to care for and repair their bed nets so that the bed nets can last for a long time. SMP hopes that in the long run bed net use culture will be developed among pregnant women and in the community as a whole. Although SMP planned to explore the possibility of using private sector transporters to deliver bed nets to health facilities in anticipation of improving value for money for this activity, this activity was not done because SMP did not have bed nets for ANC distribution during the year because of the universal net campaign approach ( a strategic shift from targeted to universal ). Performance Indicator Number of LLINs distributed to ANCs in districts from SMP Kampala stores Data Source SMP Records Target Actual Comments 493,632 0 No ANC nets were available in the SMP stores for ANC distribution. PMI ANC nets arrived in country in June 2014 but were channeled to Universal coverage distribution. The nets distributed in the ANC clinics during the year were from TASO Number of ANC HMIS 493,632 151, 829 This data was drawn from national 12

Performance Indicator clients receiving free ITNs Proportion of pregnant women provided with LLINs through ANC distribution Proportion of ANC clinics distributing LLINs Data Source Data HMIS Data ISS Data 100% (1025/1025) Target Actual Comments 95% 33% (151829 /460,08 9) 58%(595 /1025) HMIS database. (DHIS2) Numerator 151,829 (Pregnant women (PW) who received LLINs as reported in DHIS); denominator 460,089 (PW attended ANC 1st visit in SMP districts as reported in DHIS2). 595 out of 1025 health facilities distributed LLINS. The rest had no nets for distribution. Universal Distribution of LLIN Over the course of the year, SMP as a lead agent for the universal net coverage campaign, 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 in Uganda. Specific activities supported included: macro-planning, coordination, the national launch of the campaign in Soroti District in May 2013, national and regional advocacy/mobilization initiatives with the district leaders; district pre-distribution activities as well as actual distribution of nets to household beneficiaries. District pre-distribution activities included training of district task forces, sub-county task forces, and Village Health Teams (VHTs). VHTs carried out registration of households to determine the number of people in the households upon which allocation of nets to each household was done using the universal LLIN distribution formula of 1 net for every 2 persons. Following the launch of the campaign in May 2013 by H.E the President of the Republic of Uganda, implementation of distribution activities was done in phases (waves). Each wave consisted of a grouping of districts (2 to 18 districts) selected based on geographical closeness and burden of malaria. There were 8 waves in total. 13

The President flags off the truck with nets. beneficiaries in Soroti The President hands over nets to the In all the waves, a total of 22,289,644 1 nets were distributed to a registered population of 41,034,354 achieving distribution coverage of 109% (22,289,644x2/41,034,354). The UCC registered population is higher than the preliminary national census result for reasons that are not clear for SMP. A successful close out event for the universal LLIN distribution campaign was held in Kampala on 16 th August 2014. H.E.the President of the Republic of Uganda, the Minister of Health, the US Ambassador, the UK High Commissioner, the Head of High Impact Africa II Department, PMI Deputy Coordinator, Malaria Consortium Chair Board of Trustees, World Vision Country Director, other Government of Uganda officials and implementing partners graced the close out event. The President of Uganda handing a net to a A beneficiary at the close out event The President of Uganda receiving a net from the British High Commissioner and US Ambassador at the close out event 1 This number includes PMI 651,860 LLINs distributed in September 2012 in four eastern Uganda districts (Bugiri, Kaliro, Mayuge and Serere) as a pilot for countrywide universal LLIN distribution. 14

SMP is working on a lessons learned documentation report, which is aimed at providing reference for future distribution in Uganda and other countries that are planning universal coverage distribution. A final report is expected in November 2014. MoH and partners are preparing a final campaign distribution report, which will highlight the processes at the different levels: national, regional, district, sub-county and community levels. The report will be shared with stakeholders once it is finalized. In the meantime, PMI commissioned a process evaluation of the campaign. A draft report of the process evaluation is available. 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 6, SMP provided financial and technical support to districts and health facility teams to conduct clinical audits for severe malaria in hospitals and HC IV. The aim of clinical audits is to improve severe malaria case management. Clinical audit was conducted using the revised clinical audit tool. SMP provided technical and financial support to review the clinical audit tool in year 5. Most districts that did not conduct clinical audit as scheduled were occupied with the universal LLIN distribution activities. SMP s focus in year 7 will be on strengthening facility clinical audit teams so that the facilities can continue to conduct clinical audit on their own with technical support from the districts. Since the start of the clinical audit approach, severe malaria case management in health facilities has improved: e.g. in most health facilities, there was timely recognition of danger signs, triage by health workers and administration of emergency treatment to patients. Nurses in the wards also monitored patients at-least twice in a day; and recorded vital findings in the patient charts. Health workers had also adapted the current recommended treatment of severe malaria using IV Artesunate. NMCP has planned to scale up clinical audits across the country under the recently awarded Global Fund grant for 2014 to 2017. In addition, SMP generated a list of performance monitoring indicators below for severe malaria case management. Some improvements, which may be attributed to regular clinical audits were as follows: 15

Triaging - 77% of (48 out of 62) facilities, reportedly had a system for triaging patients in their outpatient department. Availability of triaging equipment - nearly 96% (60 out of 62) of facilities had a thermometer, 60% (37out of 62) had a timing device, 85% (53 out of 62) had a BP machine, 65% (40 out of 62) had a glucometer, 42% (26 out of 62) had a patient trolley and 55% (34 out of 62) had a wheel chair. Application of the ABCD strategy - overall 93% of the assessed clinicians were able to use the ABCD strategy and take appropriate action. Assessment of danger signs for malaria - 90% of the clinicians assessed patients for all emergency signs for malaria, 68% of the HCIVs and 65% of HCIIIs assessed patients for all emergency signs. During the year, SMP provided financial and technical support to districts to roll out integrated training on malaria case management (IMM). Between April and June 2014, SMP trained 1,156 (52 %) health workers (target: 2230) in 19 out of 34 planned districts. SMP s and districts focus was on completion of the universal LLIN distribution; as such training in all 15 districts could not be completed as scheduled District trainers led the training with technical assistance from SMP and MoH national trainers. Training mainly targeted newly recruited health workers and health workers at hospital, HC IV, HC III and HC II that missed the earlier training conducted by SMP and NMCP in 2012. The training was conducted according to the four-day MoH IMM training curriculum. The aim of the training was to equip health workers at the health facilities with the knowledge, understanding and skills to effectively manage malaria within their health facilities. In order to ensure availability of antimalarial medicines, as is the case for SP under IPTp section above SMP through support supervision conducted in Q1, 2 & 4 tracked the availability of ACTs in the health facilities. ACTs were available in 88% of the health facilities reached during ISS. This was below the year 6 target of 95% and year 5 achievement of 90% (ISS data: Q1, 2 & 4). SMP encouraged districts to re-distribute ACTs from facilities with higher stocks of ACTs to those with low stock and this stabilized the stock levels in health facilities in the districts. Now that Artesunate is available, tracking of the artesunate will be done next quarter. As per year 6 work plan, SMP supported the revision of the jobaid on uncomplicated malaria and severe malaria. The draft job aids were submitted to NMCP for finalization and approval. MoH has not yet approved the job aids. SMP will engage NMCP to include this on the agenda of the next meeting for Case management Technical Working Group (TWG). 16

IR 2.2: MALARIA DIAGNOSTIC CAPACITY AND SERVICES IMPROVED During the year, a total of 176 (85%) of the targeted 205 newly recruited laboratory Health workers from 28 districts were trained in diagnosis of malaria using microscopy and RDT. SMP introduced an innovation regarding regional proficiency testing for facility laboratory staff. SMP piloted the clustered proficiency testing for trainees at central venues nearest to their districts. During this pilot testing trainees were given a set of slides to examine, they were observed while performing tasks in sample collection smear preparation and staining. Gaps noted in performance of the tasks were discussed and corrective measures agreed upon, and discrepancies in slides results were corrected by reviewing the slides together with the trainees. SMP working in collaboration with IDI through Learning Innovation Centre (LIC/ATIC) established an innovative approach, offering laboratory post training support using SMS. This was intended to assess innovative and cost effective ways of determining how much knowledge trainees have retained from trainings in Malaria Diagnosis using Microscopy and RDT, and to determine whether or not this form of follow-up (SMS quiz questions) is appropriate for rollingout to the rest of the Stop Malaria Project trainees. This follow-up of 95 laboratory trainees was conducted via SMS quiz questions. The trainees received questions via text messages on their phones and the trainees sent in their responses to a toll free reply center which would immediately acknowledge receipt of response and also give feedback whether the response was correct or not. A total of 25 questions were sent out, two per week. On average, 71% (18 out of 25)of trainees responded to the SMS quiz questions. Out of all the trainees that responded to the questions, 75% submitted the correct response. The SMS follow up was concluded with a face to face meeting held at regional centres nearest to their districts for competency testing.. The accuracy results were the same for both methods however the SMS follow up was more cost effective in terms of duration for the activity. In order to ensure improved malaria microscopy diagnostic accuracy, SMP procured ten binocular microscopes and distributed them to laboratories within the SMP districts in a bid to improve laboratory diagnosis. The microscopes were distributed to health facilities, which have been upgraded from health Centre II to III and also replaced monocular microscopes in some health facilities that had faulty microscopes beyond repair. SMP through IDI in collaboration with NMCP organized a 5-day WHO external competency assessment in malaria microscopy (ECAMM) course for 14 District laboratory focal persons (DLFPs) and 1 IDI staff. The training was conducted by AMREF Kenya, the aim of the course was to certify the level of competency of DLFPs by WHO standards so that they could be a 17

resource for their districts for quality assurance and control systems for malaria including training supervision and cross checking slides for results. One person out the 15 certified to the desired level Pre and post test reasults for WHO certification course 25-29 Aug 2014 indicator Pre test score% Post test score% Parasite detection( Pos/Neg) 85 88 Parasite identification( Species) 30 49 Parasite quantification( counting) 8 39 During the year, the percentage of children under five who received a diagnostic test (either microscopy or RDT) (Numerator = Tests done for children U5 and Denominator = Malaria cases of children U5) at the health facility increased from 84% in Year 5, quarter 4 to 94% in Year 6, quarter 4. 18

IR 3: NMCP CAPACITY TO MONITOR AND EVALUATE INTERVENTIONS STRENGTHENED IR 3.1: TECHNICAL RESOURCES AND SKILLS OF MONITORING AND EVALUATION (M&E) SUB- UNIT IMPROVED SMP provided financial and technical support to NMCP to conduct the Midterm Review (MTR) of the National Malaria Strategic Plan 2010/15. The MTR informed the review and revisions to the National Malaria Reduction Strategy 2014-20. The development of the GF grant proposal/concept for 2014-17 was based on the MRS. SMP participated in an HMIS stakeholders meeting that discussed the roll out plan of the new revised HMIS tools. SMP supported NMCP to hold meetings for M & E technical working groups. The meeting discussed data quality issues of mtrac data submitted by health facilities to the system; indicators for inclusion in the Malaria indicator survey and changes to make in the HMIS forms as per the revision process that started in last year. Indicators on assessing suspected malaria, IPTp 3 & 4 uptake were proposed for inclusion in the health facility and district level HMIS forms. However, IPTp 3 & 4 were not included in the final forms because Reproductive Health department advised to stay the process pending revision of the MiP guidelines by Uganda. The revision took place in November and a proposal to include IPTp 3 & 4 in the HMIS Forms was forwarded to RC-MoH for consideration. IR 3.2: COLLECTION, PROCESSING AND USE OF DATA FROM DISTRICTS AND IMPLEMENTING PARTNERS IMPROVED SMP continued to support districts to submit their HMIS reports to Resource Centre of the MoH (RC-MoH) through DHIS2. There is a tremendous improvement in the percentage of districts submitting HMIS data to the national level on time from 81% in Year 5, Quarter 4, to 94% in Year 6, Quarter 4 (90% average in year 6) compared to 80.9% at national level. Complete data submission to national level increased from 98% at the end of Year 5 to 99% at end of Year 6.compared to 85.9% at national level. Utilization of HMIS data by the facilities increased from an average of 52% at the end of Year 5 to 58% average at the end of Year 6. The indicator was calculated based on the presence of data analyzed with recent charts printed on the wall for health worker reference, especially during the planning period and quantification of drugs. 19

HMIS data accuracy increased from 71% in Year 5, Quarter 4 to 74% in Year 6, Quarter 4. The numerator is the number 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 the National level with an allowable variance of +-5) out of the 34 districts in the SMP project area. The increase in the indicator was due to SMP support to districts to conduct data quality assessments (DQA) in health facilities. During DQAs, the district teams provide mentorship on how to improve the quality of data. During year 6, SMP supported districts to conduct data quality assessments in all the 34 districts; DQA findings indicate that ACT consumption data by pack size reported through MTRAC was largely inaccurate with all pack sizes falling outside the threshold for data accuracy (-/+5%). All health facilities visited had inaccurate data in at least one pack size. Most facilities used the 24 pack size however; this was cut into the 6, 12 or 18 pack sizes. However, for mtrac reporting, these treatment doses have to be computed back to the 24 pack size. This computation presents challenges to health workers and is a key source of data error or discrepancy. This was evident in Kobwin HCIII, Omiito HCII in Ngora district, Kayum HCII, Nyero HCIII and Agurut HCII in Kumi district, Paraa HCII, Kihungya HC in Buliisa district and Ngomawene HCII in Gomba district. In addition, all health facilities had stockouts of most of the primary source documents like OPD and ANC registers making it difficult to track all health facility attendees. SMP advocated for printing of OPD and ANC registers to the donor and RC-MoH since no funds were availed to SMP to print the tools. SMP recommends that RC-MoH in collaboration with partners including WHO and UNICEF conduct a comprehensive HMIS training based on the new revised tools. The training should target all health workers involved in recording any form of data in the health facilities and consequently providing them with revised HMIS tools. This will go a long way in improving data accuracy at health facility level. Performance Indicator Data Source Target Actual Comment Percent of SMPsupported districts that provided complete data on malaria indicators to national HMIS database HMIS 98% 99% As per AHSPR 2010-14, HMIS Complete reporting is higher in SMP districts at 99% compared to 85.9% for national level. 20

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. Number of Roll Back Malaria partner meetings HMIS 70% 90% At national level, timely reporting of HMIS data stands at 80.9% compared to 90% in SMP districts. Improvement may be attributed to continuous follow up and feedback by SMP. ISS 50% 58% Numerator = number of health facilities in SMP-supported districts visited by ISS team with evidence of plotting trends on key malaria indicators and using the data for planning in the quarter. Denominator = the number of health facilities visited by the ISS Project and Partners records team during the same quarter. 3 3. The meetings were held on 10 th January 2014 at Hotel African, 5 th March 2014 at MoH Boardroom and 13 th August, WHO Boardroom CROSS CUTTING ACTIVITIES SUPPORT SUPERVISION During Year 6, SMP provided funding and technical support to districts to conduct integrated support supervision - ISS focused on IPTp, ANC, LLIN distribution, diagnosis and treatment, health education, community mobilization, malaria commodities management and HMIS. In districts where SMP overlaps with Strengthening Decentralized Systems (SDS), funding for district teams was provided by SDS. Implementation of ISS was combined with Data Quality Assessments (DQAs) and Data Demand & Use (DDU) meetings. The aim of ISS was to improve performance of health facilities in the delivery of malaria prevention and treatment services. The activity was conducted in Q1, 2 &4; No ISS was conducted in Q3 because focus of districts and NMCP was on completion of the universal LLIN distribution campaign. Health facilities mainly targeted for ISS were: all hospitals and HC IV, about 80% of HCIII and a few HC II. District ISS teams made on-site observations using the standard ISS tool, and provided on-job mentorship to the health facility staff to strengthen their skills in malaria control. The ISS district teams then worked together with facility staff to develop facility own actions to address the gaps identified in the ISS tool. Facility action plans form the basis for tracking of progress on previously agreed actions within the health facility. 21

CREATING DEMAND FOR MALARIA SERVICES AND PRACTICES During year 6 of the project, SMP implemented communication activities to support NMCP to address malaria prevention and treatment aspects. The key activities implemented included Test and Treat Campaign to promote malaria diagnostics services, universal distribution of Long Lasting Insecticidal Nets, bed net care and repair which was piloted in Serere district. Multi media and IPC approaches including radio spots and talk shows, T.V talk shows, bill boards, posters and health provider job aids were used to create demand and utilization of the malaria control services. During quarter four of the year, efforts to improve IPTp uptake among pregnant women started with a focus on Village Health Teams (VHTs) as the entry point. An orientation meeting was held with the District Health Team members to inform them on the approach to be used to monitor pregnant women through the VHT structure. a) Demand for LLINs. SMP, together with key partners steered the roll out of the communication support activities for the Universal Net Distribution Program for Uganda. Electronic media (mostly radio) was utilized to increase awareness about the program, registration and distribution schedules as well as promoting usage, care and repair of nets among the communities. A total of 174,143 radio spots were aired, 337 radio talk shows on 64 radio stations were conducted and a total of 12 TV talk shows were aired to support the activity. b) Test and Treat. The Test and Treat media campaign, implemented in 18 Central region districts is expected to contribute to increased public awareness on the benefits of testing before treating malaria among caregivers of children as well as enhancing health provider IPC competences in managing fever among children aged five years and below. SMP supported NMCP to implement the IPC and media components of the Test and Treat communication campaign. More health workers at HC II and HC III were trained to increase the impact of IPC on client - provider relationship as part of the efforts to increase demand and utilization of malaria diagnostic services at the participating health facilities which stands at 94% in Year 6, quarter 4 from 71% in Year 5, quarter 3. SMP conducted an evaluation of the Test and Treat Campaign, data entry is going on, we expect results in January 2015, 611 health providers benefited from the training. It has 22

been observed that the Continuing Medical Education (CME) approach works best for the lower level health centers (HC III and HC II) due to the service delivery flow, which enables the health provider take a caregiver through the key stages (Patient history, assessment, diagnosis and management). However this is not possible with higher level facilities since the patient/caregiver sees different service providers in the different section of the health units e.g. Lab, prescription room etc. A total of 14,236 radio spots and 258 radio talk shows were conducted on 7 FM radio stations during the reporting year. c) Net care and repair The Net care and Repair campaign was successfully completed, an evaluation was done and results are expected at the end of December, SMP will share findings with PMI. In April with 16 radio talk shows, 1,136 radio spots and 559 DJ mentions aired. The campaign continued to support interpersonal communication approaches to motivate the communities for sustained practices of net usage, care and repair. Technical support was also given to 30 schools through teacher orientations for pupils to emulate good net care and repair practices among the communities using drama competitions. Testimonials, Forum Theater shows and Music competitions were the different approaches used to pass on the messages to communities. The district leadership team included, District Education Officers (DEO), DHO, Local Council Chairperson, malaria focal person and the Chief Administrative Officer (CAO). The District leadership expressed appreciation for the Net Care & Repair campaign and also noted the spillover effect that it has to the neighboring districts within the Teso Region. SMP conducted briefing meetings with the district health team in Serere to discuss the project close out and review possible sustainability mechanisms for the implemented initiatives. The school communal sewing activity is expected to continue with support from the district education office. The District Inspectors of school will integrate this initiative for the 30 schools in their routine monitoring activities. d) Village Health Team district orientation. In order to strengthen the demand and motivation for Intermittent Preventive Treatment in Pregnancy (IPTp) uptake, SMP will be supporting VHTs to conduct home visits to educate the pregnant women and monitor their ANC visits. 23

During the 4 th quarter, district orientation meetings were held in Masaka, Mukono, Hoima and Bulisa districts to prepare the DHT for the planned activity. The meeting was an opportunity to brief the DHT on the VHT orientation scheduled next quarter. During the meeting the District Health Educator provided a list of VHTs attached to the health center IIIs and IIs who will be the center of focus. A training manual has been developed in preparation for the training. The table below shows the status of the indicator-tracking table Performance Indicator Data Source Target Actual Comments Demand for LLINS Number of radio spots aired on LLIN distribution, use, care and repair Number of radio talk shows conducted Number of TV shows conducted Number of radio Spots Number of radio talk shows conducted Number of health providers trained Number of Radio Talk Shows conducted Project and partner records 200,000 174,143 Activity was stalled during the month of April and May due to unavailability of LLINS in the country. Project and partner records 230 337 Project and 19 12 partner records T 3- Test and Treat Campaign Project and Partners records Project and Partners records Project and Partners records Project and Partners records 6,000 14,236 Bonuses were given by the FM stations thereby surpassing the targets 48 258 Radio Talk shows are conducted on 8 FM stations twice a month. There were bonuses given by FM stations hired by the media agency. 230 331 Net Care and Repair 3 4 These are conducted monthly 24

Performance Indicator Data Source Target Actual Comments Number of radio spots aired Project and Partners records 990 1136 Bonuses were given by the FM stations thereby surpassing the targets PROJECT MONITORING AND EVALUATION During the year, data entry into the HMIS database was done by the SMP M & E Team 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 in the District Health Information System (DHIS2), which contributed to improved reporting at the national level. There s notable improvement in the quality of HMIS data being reported as a result of regular feedback, data accuracy increased from 71% in Year 5, Quarter 4 to 74% in Year 6, Quarter 4. SMP held regional review and planning meetings with districts in all its regions of operation (Central, Mid Western and Teso). District participants included the political (Secretaries for Health of different districts), administrative (Chief Administrative Officers) and technical leaders (District Health Team members). The objective of the meetings were to review the status of SMP supported malaria services in regard to achievements, lessons learnt and challenges, and together with the district partners discuss implementation plans for following quarter. Performance of districts on the key malaria HMIS indicators and proposals for improvement of the indicators were also discussed. During these meetings district leaders are able to question and learn from each other. The good performing districts usually shares their experiences and what they do to improve performance on key health facility indicators for instance Masaka district shared of how they were able to conduct clinical audits without SMP support, Mukono shared on how to request for artesunate drugs from NMS, other districts weren t aware that the drug was available. At the end of the quarter, SMP ended activity implementation in Teso region and the subregion office was closed. A close-out event with district leadership and stakeholders was held on June 30 th, 2014. The Ag. Program Manager for NMCP was the chief guest. In his speech he applauded SMP for contributing to improvements in malaria policy development and reduction in morbidity and mortality. He called upon all partners to support the new Malaria Reduction Strategy developed with support from SMP and other stakeholders. SMP conducted an evaluation of the Test and Treat campaign, data has been collected, and the report is expected at the in January 2015. SMP will share with PMI the study findings once the report is ready in January 2015. 25

COORDINATION AMONG KEY PARTNERS IMPROVED SMP held quarterly meetings with NMCP to share project implementation progress and strategies to address gaps identified during the course of implementation. A meeting with SMP partners i.e. CDFU and IDI was organized to discuss partner close out on the SMP project. SMP actively participated in the LLIN National Coordination Committee and subcommittee meetings during the LLIN campaign. SMP held a meeting with Communities for Health Communication project (CHC) to discuss areas of synergy. SMP shared IEC materials with CHC for use and future updating. SMP continued to coordinate with SDS management team to support the integrated support supervision to the 6 districts of Sembabule, Mpigi, Luwero, Kayunga, Kumi and Mityana on time. Prior to the ISS visits, the districts shared with SMP the schedule for the ISS visits. SMP supported NMCP to hold quarterly Rollback Malaria meetings for malaria partners. These meetings ensured coordination of the implementation of the NMCP Strategic and M&E Plans. During the meetings update on country performance on specific indicators was given, plans for following quarter were shared and sometimes research findings, updates and announcements from individual malaria programs were shared. LESSONS LEARNED Providing data collection tools e.g. ANC registers, in-patient observation forms and ANC cards improve the culture of data collection in health facilities and is vital to health facility records management. Observation during supervision in the health facilities indicated that health workers documented patient records when in-patient observation forms and registers were available in the health facilities compared to when these were not supplied. There is a general improvement in records in the health facilities, which may be attributed to regular ISS, clinical audits, DQAs and DDU meetings during which emphasis is put on use of data at point of collection. Most health facilities have plotted data graphs for different HMIS indicators, the graphs are updated every month. The data graphs easily show performance trends in the health facilities. Training of health workers is needed to ensure compliance with the new national policy for treatment of malaria. Observation during IMM trainings showed that health workers had limited knowledge on the new malaria treatment policy. For example in 7 districts in Teso region, the lowest pretest score was 12% and highest was 51%; yet lowest post test score 26