THE UGANDA STOP MALARIA PROJECT YEAR 5 WORK PLAN

THE UGANDA STOP MALARIA PROJECT YEAR 5 WORK PLAN October 1, 2012 September 30, 2013 USAID/JHU Cooperative Agreement No. CA 617-A-00-08-00018-00 Re-Submitted 27 September 2012 Johns Hopkins Bloomberg School of Public Health Stop Malaria Project Center for Communication Programs Plot 30B Impala Avenue Plot 15 Binayomba Avenue Kampala, Uganda P.O. Box 3495 Tel: +256 0312-600-600 Kampala, Uganda Tel: 256 0414-250-192/183 i

Table of Contents I. Introduction... 3 II. IR 1 Malaria prevention programs in support of the national malaria strategy improved and implemented... 4 IR 1.1: Malaria related policies and guidelines operationalized... 4 IR 1.2: Access to IPTp increased... 5 IR 1.3: Access to LLINs increased... 8 III. IR 2 Malaria diagnosis and treatment activities in support of the national malaria strategy improved and implemented... 12 IR 2.1: Service providers capacity to manage severe malaria improved... 12 IR 2.2: Malaria diagnostic capacity and services improved... 15 IV. IR 3 NMCP capacity to monitor and evaluate interventions strengthened... 18 IR 3.1: Technical resources and skills of M&E unit improved... 18 IR 3.2: Collection, processing and use of data from and implementing partners improved 19 V. Cross cutting activities... 22 A. Support supervision/quality improvement (QI) activities... 22 B. Creating demand for malaria services and practices... 24 C. Project monitoring and evaluation... 30 D. Documentation... 33 E. Management Information System (MIS)... 35 F. Coordination among key partners improved... 35 G. Project management and coordination... 36 VI. Annex A: List of Year 5 project... 1 VII. Annex B: Year 5 Activity Implementation Plan... 4 i

List of Acronyms ACT Artemisinin-based Combination Therapy ANC Antenatal Care BCC Behavior Change Communication BP Blood pressure CCP Center for Communication Programs CDFU Communication for Development Foundation Uganda CPHL Central Public Health Laboratory DDU Data Demand and Use DHI District Health Inspector DHO District Health Officer / Office DHIS2 District Health Information System 2 DHT District Health Team DLFPs District Laboratory Focal Persons DO3 Development Objective 3 DOTs Directly Observed Treatment EPI Expanded Program on Immunization EQA External Quality Assurance GF Global Fund GFATM Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria GPRS General Packet Radio Service HCP Health Care Provider HIPS Uganda Health Initiatives for the Private Sector Project HMIS Health Management Information Systems HPAC Health Policy Advisory Committee HSD Health Sub District IDI Infectious Diseases Institute IEC Information, Education and Communication IMM Integrated Management of Malaria IP Implementing Partner IPTp Intermittent Preventive Treatment in pregnancy IR Intermediate Result ISS Integrated Support Supervision IVM Integrated Vector Management JHU/CCP Johns Hopkins University Bloomberg School of Public Health/Center for Communication Programs LLIN Long Lasting Insecticide Treated Net LQAS Lot Quality Assurance Survey MC Malaria Consortium MCH Maternal and Child Health MDD Music, Dance and Drama MDGs Millennium Development Goals MEMS Monitoring and Evaluation Management Services MESST Monitoring and Evaluation Support System Tool MFPs Malaria Focal Persons MIP Malaria in Pregnancy MIS Malaria Indicator Survey MoES Ministry of Education and Sports MoH Ministry of Health MOP Malaria Operational Plan ii

MPR Metric NMCP NMS NUMAT PMI PMP PNFP QI RBM RC MoH RDA RDT RHD SDS SMP SP STAR STRIDES SURE TA ToT UBOS UCSF UHMG UMEMS UMIS UMSP USAID VHT IT S Malaria Program Review Mobile Tracking National Malaria Control Program National Medical Stores Northern Uganda Malaria AIDS and Tuberculosis Programme President s Malaria Initiative Performance Monitoring Plan Private Not-for-Profit Quality Improvement Roll Back Malaria Resource Centre of the MoH Rapid District Assessment Rapid Diagnostic Testing Reproductive Health Department Strengthening Decentralization for Sustainability Stop Malaria Project Sulfadoxine-pyrimethamine Strengthening TB and AIDS Response STRIDES for Family Health Securing Ugandan s Right for Essential Medicines Technical Assistance Training of Trainers Uganda Bureau of Statistics University of California San Francisco Uganda Health Marketing Group Uganda Monitoring and Evaluation Management Services Uganda Malaria Indicator Survey Uganda Malaria Surveillance Project United States Agency for International Development Village Health Team World Health Organization iii

Executive Summary The Stop Malaria Project (SMP), funded by the U.S. President s Malaria Initiative (PMI), is managed by Johns Hopkins University Bloomberg School of Public Health Centre for Communication Programs (JHU/CCP), Malaria Consortium (MC), the Infectious Diseases Institute (IDI), and Communication for Development Foundation Uganda (CDFU). SMP is designed to assist the Government of Uganda in reaching the PMI and Roll Back Malaria (RBM) goal of reducing malaria-related morbidity and mortality by 70% by 2015 (MOP FY 2012), and subsequently contribute to the attainment of the Millennium Development Goals (MDGs). During Year 4, SMP made progress in providing the following key interventions to its implementation ; SMP supported NMCP to develop the Strategic Plan and M&E Plan (2010/15) and the Three- Year Rolling Implementation Plan (2010/13). The documents were finalized and are pending endorsement by the Director General, MoH; 1,025 out of 1,115 health facilities providing antenatal services (ANC) were provided with LLINs for distribution to pregnant women (1 st, 2 nd & 3 rd QTR SMP Report, July 2012); and 209,697 LLINs were distributed to pregnant women (data collected through integrated support supervision); SMP trained 5,651 district health workers in the integrated management of malaria (IMM) (as of July 2012). This was 115% of the targeted 4,907.Initially SMP targeted 14 staff per hospital but most had more staff and therefore trained on average 20 staff per hospital. Parasite-based diagnosis and treatment of malaria in outpatient cases reached 59% in SMP compared to the year target of 50% (District HMIS data, 2012); IPT2 uptake by pregnant women attending ANC was sustained at 53% in Q3 of Year 4 compared to 54% in Year 3 (HMIS May 2012); Timely HMIS reporting from to national level increased from 45% in Q2 of Year 3 to 85% in Q2 of Year 4 (HMIS Data 2010-12 tracked by SMP), which may be attributable to SMP s training of district HMIS personnel, provision of internet modems to the as well as regular support supervision and follow up; Complete HMIS reporting on key malaria indicators (new attendance, IPTp 1, IPTp 2, lab diagnosis, malaria admissions, and malaria mortality) increased from 65% in 2010 to 95% in Year 4; target: 95% (HMIS Data 2010-12 tracked by SMP). SMP supported the RC-MOH to develop DQA implementation guidelines and Data Demand and Use (DDU) Training materials. 10 national and 164 district ToTs were trained. As of August 15 th, 2012 SMP trained a total of 570 against a target of 2148 health workers in how to conduct data quality in their facilities, data demand and use. The training is ongoing and will end by September 26 th 2012. In this final year of implementation, SMP will build on the achievements and lessons of the last four years, to strengthen implementation and ownership of SMP-supported activities in the. SMP will work with the district authorities and the National Malaria Control Program (NMCP) to integrate 1

the project activities into the district work plans to foster sustainability and transitioning of the activities to the Government of Uganda. SMP will document and disseminate its work over the years (achievements, best practices, success stories and lessons learned) to NMCP and key stakeholders, to inform future programming for malaria services in the country. 2

I. Introduction The Stop Malaria Project (SMP) is designed to assist the Government of Uganda, in particular the National Malaria Control Program (NMCP) and the District Health Teams (DHTs), to scale up proven interventions for malaria prevention, diagnosis, and treatment over a period of five years. SMP interventions are targeted to reach 85% coverage of children under five years of age, pregnant women and other vulnerable groups by improving diagnosis and treatment of malaria with Artemesinin-based Combination Therapy (ACTs), and by expanding prevention efforts through Intermittent Preventive Treatment of malaria in Pregnancy (IPTp) and Long-lasting Insecticide Treated Nets (LLINs). The project activities are designed to meet three intermediate results (IRs): IR 1 Malaria prevention programs in support of the national malaria strategy improved and implemented. IR 2 Malaria diagnosis and treatment activities in support of the national malaria strategy improved and implemented. IR 3 NMCP capacity to monitor and evaluate interventions strengthened. The development of the Year 5 work plan involved a consultative process. SMP engaged district partners at regional review meetings in all three SMP regions (Teso, Central and Hoima regions). In the review meetings SMP and its partners reviewed project performance during Year 4 and identified district priority activities for SMP support during Year 5, and discussed the need for the to plan for the sustainability of the SMP-supported activities. SMP organized a planning meeting with participation from all SMP partners (JHU/CCP, Malaria Consortium/UHMG, IDI and CDFU), PMI/USAID and NMCP. District representatives from six also participated in the planning meeting. 1 In Year 5, SMP will focus on documenting and disseminating project best practices over the years, success stories and lessons learned to inform future program activities in the country. SMP will work with the district authorities and the NMCP to integrate the project activities into the district work plans in order to foster sustainability of services beyond the project lifetime. Year 5 activities are organized into three sections by intermediate results (IRs) and by cross-cutting activities. In each section there is a brief review of the progress to date based on last year s achievements, lessons learned and remaining key issues which have informed the design of planned activities selected for Year 5. During Year 5, SMP will continue to support services in the current 34, with a total of 1,115 Public and Private Not For Profit (PNFP) health facilities. SMP will work with each of the 34 SMP to incorporate Year 5 activities into the district s work plans. The MoH will endorse the updated SMP work plan for each of the 34, which seals their commitment to implementation of the work plan. 1 This work plan is a requirement under section A5, sub-section 2(iii) on reporting and evaluation of the Cooperative Agreement No. 617-A-00-08-00018-00. 3

Project supported district activity implementation & timelines Planned Activities Incorporate updated SMP implementation plans into the district plans for each of the 34 Sign letters of agreement to SMP supported activities with 34 Indicator Number of district plans that have incorporated SMP implementation plans Number of that have signed letters of agreement Activity Targets/Outputs Q1 target Q2 target Q3 target Annual target 34 incorporated SMP implementation plans into their work plans 34 signed letters of agreement 34 incorporated SMP implementation plans into their work plans 34 signed letters of agreement II. IR 1 Malaria prevention programs in support of the national malaria strategy improved and implemented IR 1.1: Malaria related policies and guidelines operationalized Progress to date Policy and guidelines developed: During Year 4, SMP provided technical and financial assistance to NMCP to develop the Strategic Plan and M&E Plan (2010/15) and the Three-Year Rolling Implementation Plan (2010/13). SMP also provided technical and financial assistance to NMCP to finalize the National Communication Strategy 2010/15. NMCP plans to disseminate the documents including the newly approved National Malaria Control Policy during quarter 1 of SMP Year 5. Key issues The integrated National Malaria Control Policy was approved; the National Malaria Communication Strategy, the NMCP Strategic Plan and M&E plan 2010/15 were finalized. The planned printing and launch of these documents in Year 4 was not done as Ministry of Health authorities (Commissioner National Disease Control, Director General Health Services and Permanent Secretary) are to study the documents. However, NMCP plans to print and launch these documents in quarter 1 of SMP Year 5. SMP will support NMCP to print and launch these documents. Planned activities 1. Provide TA and financial support to NMCP to develop the annual work plan 2013/2014. SMP supported the development of the consolidated (incorporated priorities of NMCP and partners) 2011/12 NMCP work plan as this was among the key recommendations of the 4

Malaria Programme Review of 2011. SMP support to development of the 2012/13 NMCP consolidated work plan will focus on institutionalizing the annual planning process within the NMCP. IR 1.1 Activity Implementation & Timelines Planned Activities 1. Provide financial support to quarterly national level RBM coordination meetings Indicators Number of RBM meetings conducted Activity Targets/Outputs Q1 target Q2 target Q3 target Annual target 1 RBM meetings supported by SMP 1 RBM meetings supported by SMP 1 RBM meetings supported by SMP 3 RBM meetings supported by SMP 2. Provide TA and financial support to NMCP to develop the annual work plan 2013/2014 Annual Work Plan 2013/14 developed NMCP Annual Work Plan 2013/2014 developed NMCP Annual Work Plan 2013/2014 developed IR 1.2: Access to IPTp increased Progress to date IPTp stock: During Year 4, in collaboration with the SURE project, SMP tracked SP stock levels in the health facilities to help health facilities maintain adequate SP stocks for IPTp; 91% of health facilities did not have any SP stock outs in the 1 st & 2 nd quarters; and 83% in the 3 rd quarter (HMIS data 2011/12). SURE provided monthly updates of SP stock status at the national level, and SMP through integrated support supervision obtained SP stock levels within the health facilities which SMP relayed to the and NMCP to promote replenishment from NMS or redistribution of SP within the from health facilities with higher stocks of SP to those without or minimal stocks. IPTp uptake: Out of 352,594 pregnant women who attended ANC1 during Q1-Q3, 53% (186,875/352,594) received at least 2 doses of SP (IPTp2). While this reflects an improvement from 39% in Year 1, IPTp2 uptake remains below the SMP target 0f 60%. In order to capture data on pregnant women who attend ANC and administration of IPTp, SMP printed 550,000 ANC cards and distributed to the health facilities during malaria specific integrated support supervision (focused on IPTp, LLIN, diagnosis and treatment, health education on malaria, malaria commodities management, community mobilization and records management). Chart 1, below, shows the improvement registered in IPTp2 uptake since inception of the project to Q3 of Year 4. 5

IPTp and commodity distribution: In Year 4, SMP also procured and distributed IPTp delivery commodities to health facilities (3,760 packets of aqua safe tablets: each packet contains 80 tablets, 1,700 cups and 170 jerry cans). Most of the health facilities were provided IPTp delivery commodities during year 2 and 3 of the project; year 4 supply was to replace those which were damaged, and to add to busy health facilities like hospitals and HC IV. Increasing the availability of drinking water commodities in the health facilities was to ensure that pregnant women who attended ANC received IPTp under directly observed treatment (DOTs) as per the MoH policy. Key issues Although there was progress made in IPTp2 uptake by pregnant women in SMP from 39% in Q4 of Year 1 to 53% in Q3 of Year 4; during Q1-Q3 of Year 4 IPTp2 (HMIS data) uptake stagnated at about 50%, below the SMP target of 60%. Inadequate staff numbers and skills, stock out of SP, none recording of SP administration in the ANC registers as well as myths about safety of SP were among the challenges to improving IPTp uptake. However, although not within the scope of the Stop Malaria Project, these issues suggest a need for research into the actual reasons that uptake of IPTp2 has stagnated as well as identifying what could be done to improve the proven prevention method. Planned activities 1. While SMP will continue to track stocks of SP and the availability of IPTp commodities in health facilities to prevent or identify stock outs and share this information with the, this activity will be increasingly focused on working with the to support them to do this on their own. In particular, SMP will work with the to review existing stock tracking mechanisms (ISS, mtrac, DHIS 2, Logistics Management System from the National Medical Stores) to identify and use the most effective means through which the can sustainably track SP stocks and IPTp commodities in their health facilities. 2. Continue to conduct on-the-job mentoring during support supervision to strengthen interpersonal communication of health workers and reinforce the knowledge around IPTp DOTs and preventing malaria in pregnancy conveyed in the recent trainings on the Integrated Management of Malaria (IMM) (this activity is covered in the section on integrated support supervision). 3. Print and distribute ANC cards (Other HMIS tools e.g. registers are available in 5 SMP (SMP has printed and distributed in 5. Number of to print registers for were allocated to IPs by USAID. Other IPs is to print for the remaining 29 SMP to document pregnancy events including administration of SP for IPTp in all 34. 4. Procure water purification tablets and distribute to health facilities for IPTp DOTs. In Year 5, SMP will procure only water purification tablets as these are consumables, and not other IPTp delivery commodities (i.e. cups and jerry cans) which were supplied to health facilities in the previous years. Distribution of these supplies will be done during quarterly support supervision. SMP will work with the to ensure continuous procurement and distribution of water purification tablets after Year 5. 6

5. Implement behavior change communication (BCC) activities that target pregnant women to improve IPTp knowledge and IPTp uptake as part of the overall project BCC activities (see BCC details under demand creation for malaria services). 6. During Year 5, the NMCP will play a leading role in the 34 project to support the to consolidate the achievements in IPTp services gained over the previous 4 years of the project. Strengthening uptake of IPTp is among the interventions in the recently completed NMCP strategic plan 2010/2015 (yet to be launched). Performance tracking Percentage of pregnant women attending ANC that receive 2 doses of SP Proportion of health facilities with no stock outs of SP Percentage of health facilities fully equipped with all the three IPTp commodities (cups, jerry cans, and water purification tablets) IR 1.2 Activity Implementation & Timelines Planned Activities Work with using existing mechanisms (ISS, mtrac, DHIS2, LMIS) to sustainably track their SP stock in health facilities Procure and distribute water purification tablets. Indicators Proportion of tracking their SP stock using a standardized mechanism (ISS, mtrac,dhis 2, LMIS) Proportion of health facilities with no stock out of SP Number of packets of water purification tablets distributed to health facilities. Proportion of health Activity Targets/Outputs Q1 target Q2 target Q3 target Annual target 60 % of tracking their SP stock 95% of health facilities reporting no stock out of SP 1,538 packets of water purification tablets (each packet of 80 tablets) procured and distributed to health facilities 100% of all health facilities providing ANC services (i.e. 1,025 health 60 % of tracking their SP stock 95% of health facilities reporting no stock out of SP 1,537 packets of water purification tablets (each packet of 80 tablets) procured and distributed to health facilities 100% of all health facilities providing ANC services (i.e. 1,025 health 60 % of tracking their SP stock 95% of health facilities reporting no stock out of SP 1,537 packets of water purification tablets (each packet of 80 tablets) procured and distributed to health facilities 100% of all health facilities providing ANC services (i.e. 1,025 health 60 % of tracking their SP stock 95% of health facilities reporting no stock out of SP 4,612 packets of water purification tablets (each packet of 80 tablets) procured and distributed to health facilities 100% of all health facilities providing ANC services (i.e. 1,025 health 7

facilities that received water purification tablets facilities)provided with water purification tablets facilities)provided with water purification tablets facilities)provided with water purification tablets facilities)provided with water purification tablets Re-print ANC cards and distribute to 34 Number of ANC cards re-printed and distributed 246,815 ANC cards re-printed and distributed to health facilities conducting ANC 246,816 ANC cards re-printed and distributed to health facilities conducting ANC 493,631 ANC cards re-printed and distributed to health facilities conducting ANC IR 1.3: Access to LLINs increased Progress to date ANC LLIN distribution: In Year 4, SMP distributed 244,800 LLINs (48 % of Year 4 target: 513,408) to all 34 for distribution to pregnant women through 1,025 ANC clinics out of the total 1,115 health facilities (data obtained from the way bills signed by the confirming receipt of nets delivered). In order to foster ownership and integration of the ANC LLIN distribution system into the routine district health services, District Malaria Focal Persons (MFPs) took the lead in the distribution of LLINs to the health facilities. Distribution of LLINs to pregnant women is on-going in the 1,025 ANC clinics in public and private not for profit health facilities in the 34. In total, 209,697 pregnant women were provided with LLIN through ANC in the October 2011 June 2012 period; which is 60% of the 352,594 pregnant women recorded attending ANC 1 in the same period i.e. 209,697/352,594 (support supervision data). As detailed below under the section on key issues, there have been some challenges with LLIN distribution as well as in collecting accurate data on LLIN distribution at health facility levels, which likely explains why we are below the target of 95% for LLIN distribution to pregnant women. These issues are addressed more fully below. LLIN record book and reporting forms: In collaboration with the NMCP, SMP developed and printed an ANC LLIN distribution record book and LLIN monthly reporting forms for the health facility and district levels: 1,200 record books, 816 district monthly reporting forms and 12,960 health facility ANC LLIN monthly reporting forms were printed. The record books and reporting forms are being distributed to the health facilities during integrated support supervision (ISS). The health workers in the health facilities (ANC providers and records assistants) will be responsible for filling of the registers and reporting forms. The health workers were oriented on-job (at the time of distributing the forms) on the process of filling the forms/registers and reporting to the next levels. The SMP zonal staff and the district supervision teams will continue to mentor the staff on the use of the tools during ISS. This is anticipated to improve reporting on ANC LLIN distribution as well as tracking of LLINs to ensure that the LLINs are given to the intended beneficiary. In addition, the protocol for conducting an ANC LLIN distribution quality audit/distribution process evaluation was finalized (process evaluation focusing on LLIN procurement, storage and distribution at each level central,, health facilities and the pregnant women at ANC). Data collection and report writing will be completed by Q1 of Year 5. 8

Universal LLIN distribution in four of eastern Uganda: In collaboration with NMCP, SMP developed the concept, work plan and budget for universal LLIN distribution under PMI support in four eastern Uganda (Serere, Kaliro, Bugiri and Mayuge Districts). The universal distribution of 649,948, received LLINs in the four was successfully completed in the third week of September 2012. Lessons learned from the distribution in the four will inform universal distribution of LLINs across the country under Uganda s Global Fund (GF) Round 7 Phase 2 Grant. Key issues T The number of LLINs distributed to the for distribution through ANC in Year 4 is currently less than the target (513,408), because these were the nets available in the SMP Kampala stores. The previous consignment of 708,905 LLINs received in the SMP Kampala stores in March/April 2011 has all been distributed to the (during Year 3 and Year 4) and other Implementing Partners (IPs). 407,037 LLINs were distributed in Year 3, in addition SMP supplied 120,000 LLIN to NUMAT, 20,000 to HIPS, 20,000 to STRIDDES, 320 to the sickle cell clinic in Soroti Regional Hospital and 180 to orphaned children attending a Peace Corps supported Bududa vocational institute in Bududa District During the month of August 2012, Malaria Consortium reported 6,047 LLINs missing out of the 708,905 LLIN received. In August 2012, SMP received a consignment of 549,900 LLINs, and plans are underway to supply all the 34 with additional LLIN in September/October 2012. SMP s focus in August/September 2012 was on providing support to NMCP to carry out universal LLIN distribution of 650,000 LLIN under PMI support in the four of Bugiri, Kaliro, Mayuge and Serere. A critical issue in most is not reporting timely data or a complete lack of reporting (in some ) of LLIN distribution. This is attributed to a lack of the revised MoH HMIS forms in the. SMP supplied the revised HMIS forms to 5 (out of the 34) in August/September 2012, and will monitor any changes in ANC LLIN distribution reporting during quarter 1 of Year 5 in these with the new tools. SMP will also continue to encourage to report on LLIN distribution using the tools provided by SMP/NMCP (ANC LLIN distribution register, health facility and district monthly reporting forms) to strengthen the ANC LLIN distribution tracking system and ensure that the nets reach the intended beneficiaries. Given the challenges the project has faced in collecting data on LLINs through the HMIS, SMP has been using data collected through support supervision to ascertain the number of pregnant women receiving nets through ANC. However, support supervision is conducted at approximately 65 percent of the 1,025 health facilities distributing LLINs. As such, this is an under-representation of the total number of LLIN provided to pregnant women (209,697). If we were to project the number of LLINs distributed through all 1,025 health facilities, we are likely to be closer to our Year 4 target of 513,408 (which is for all 1,025 health facilities). It is expected that the ANC LLIN data collection tools mentioned above will help to streamline data collection on LLIN distribution and help to provide a more accurate picture of the total number of nets reaching pregnant women through ANC.The data collection tools were supplied to the in quarter 4 of Year 4 and the /health facilities are yet to fully utilize them. SMP will work with NMCP (NMCP will take lead) to encourage and health facilities to use the tools for reporting on ANC LLIN distribution. There was also a gap in the distribution of nets to eight in the Central Region for several months at the beginning of 2012 due to challenges in amending the Year 4 sub-contract 9

with the Uganda Health Marketing Group (UHMG). This is likely to have contributed to not meeting the target for pregnant women receiving LLINs at their first ANC visit. The GF round 7 Phase 2 LLIN distribution by NMCP under the universal distribution mode is planned to be done during SMP Year 5. SMP will provide technical support to the GF Phase 2 LLIN distribution exercise by drawing on lessons learned from the pilot distribution in the 4 eastern Uganda. In addition, NMCP plans to conduct an assessment on different channels of routine LLIN distribution (i.e. ANC, EPI, schools) in the four following the universal distribution to keep up net coverage in these. Planned activities 1. Store LLINs at the national level. Malaria Consortium and UHMG will lead the ANC LLINs distribution. Malaria Consortium will distribute LLINs directly to 26 while UHMG will be responsible for distribution in Public and Private Not For Profit health facilities in eight (the list of is indicated in the annex). 2. Transport LLINs from national stores to and provide technical and financial support to to distribute to health facilities. The district Malaria Focal Persons, with technical and financial support from SMP, will deliver LLINs to health facilities that provide ANC services. SMP will continue to work with the district teams to integrate delivery of LLINs to health facilities along with other activities, such as integrated support supervision and delivery of vaccines, in order to integrate LLIN distribution into routine health services and thereby develop a sustainable system for routine distribution. Data collection and reporting on LLIN distribution at the health facilities will be done through the data collection forms recently distributed in Year 4, until the revised HMIS forms are in place, and quarterly support supervision visits to the and health facilities. 3. Provide BCC through the Stop Malaria in Community Campaign (see details under BCC section) as well as interpersonal communication between providers and pregnant women to encourage women to sleep under LLINs (to be promoted as part of the support supervision visit). 4. Support universal LLIN distribution plans of the NMCP. SMP will provide technical assistance to the GF Round 7 Phase 2 LLIN distribution. 5. Provide TA to the NMCP for the assessment and design of a continuous distribution system in four eastern (Serere, Kaliro, Bugiri and Mayuge) drawing on lessons learned from the ANC distribution in the 34 project. 6. Under the Global Fund Round 10 anticipated to start in Q1 of SMP Year 5, the NMCP will distribute LLINs through the ANC and immunization clinics. SMP will work with the NMCP to ensure that the appropriate quantities of LLINs are allocated to the 34 SMP-supported in order to ensure continuous distribution of LLINs through ANC. Performance tracking Proportion of SMP-supported ANC clinics distributing LLINs. 10

Number of pregnant women provided with LLINs through ANC. Percentage of pregnant women who slept under an ITN the previous night preceding the survey (source of data will be MIS 2013).However, this data will not be available by project close out. Number of LLINs distributed to with SMP support. IR 1.3 Activity Implementation & Timelines Planned Activities Distribute LLINs in 34 through 1,025 ANC clinics Provide TA and financial support to NMCP for PMI Universal LLINs Pilot Distribution in 4 in eastern Uganda (Serere, Kaliro, Bugiri & Mayuge) Provide TA to the NMCP for the assessment and design of a continuous distribution system in four eastern Provide TA to NMCP for GF Phase 2 LLINs universal distribution Indicators Number of LLINs distributed in 34 Number of LLINs distributed with SMP support Report on system for distribution of keep-up LLINs through the various channels TA provided to NMCP for GF Phase 2 universal distribution Activity Targets/Outputs Q1 taget Q2 target Q3 target Annual target 123,408 LLINs distributed in 34 Report on SMP TA support to the NMCP distribution of 650,000 LLIN in the 4 System for distribution of LLINs in various channels designed TA provided to NMCP (1 at central and 1 at district level) for GF Phase 2 universal distribution 123,408 LLINs distributed in 34 System for distribution of LLINs in various channels designed TA provided to NMCP (1 at central and 1 at district level) for GF Phase 2 universal distribution 246,815 LLINs distributed in 34 (will include quantity for Q4) TA provided to NMCP (1 at central and 1 at district level) for GF Phase 2 universal distribution 493,631 LLINs distributed in 34 Report on SMP TA support to the NMCP distribution of 650,000 LLIN in the 4 System for distribution of LLINs in various channels designed TA provided to NMCP (1 at central and 1 at district level) for GF Phase 2 universal distribution 11

III. IR 2 Malaria diagnosis and treatment activities in support of the national malaria strategy improved and implemented IR 2.1: Service providers capacity to manage severe malaria improved Progress to date Service provider training: During Year 4, SMP trained 5,651 district health workers in the integrated management of malaria (IMM). This was 115% of the targeted 4,907 (target includes 4,567 health workers at health facilities and 340 district trainers). Of those trained, 3,909 were female and 1,742 were male and were from hospitals, HC IV, HC III and HC II. The training was done using the NMCP/MoH IMM training curriculum. SMP printed 5,660 IMM manuals for the trainings. These included 3600 IMM Facilitator s Guides, and 5,310 IMM practical guides for health workers. The trainings provided an opportunity to update the health workers on current approaches in the treatment of malaria as per the new national malaria control policy, as well as use of RDTs. Clinical audits: SMP provided technical and financial support to district clinical audit teams to carry out clinical audits in 89 health facilities (35 hospitals and 54 HC IVs). District teams also conducted clinical audits at selected HC IIIs that manage severe malaria. All hospitals and HC IVs (SMP clinical audit reports Year 4 Q2) have established a functional triage system for timely recognition of severely ill patients followed by appropriate treatment; all hospitals and HC IV that conducted clinical audits had designated high dependence areas for providing emergency care to patients with severe malaria (SMP clinical audit reports). Further, the project printed 55,000 in-patient observation forms and distributed these to hospitals and HC IV. The forms are used by the health facilities to document in-patient clinical records. Clinical equipment: 89 blood pressure (BP) machines were procured and distributed to hospitals and HC IVs. SMP will monitor the availability of the BP machines in the health facilities and encourage health workers to use the equipment to improve patient care. As highlighted below in the section on key issues, there is a need to provide health facilities with other commodities essential to the management of malaria e.g. IV fluids, HB machines. ACT supply: Observed trends in anti-malaria medicines and supplies indicate improved availability of ACTs in the health facilities: 80 91 % of health facilities supervised in Year 4 (Q1-Q3) did not experience ACTs stock outs (SMP support supervision reports). SMP regularly tracked and relayed information about the stock levels to the to ensure timely requests to National Medical Stores (NMS). Although parenteral quinine is the treatment for severe malaria, ACTs is used by the Ministry of Health as a tracer medicine to track availability of antimalarials in the /health facilities. Key issues Due to the delayed start of the IMM training in late March 2012 following the MoH approval of the new national malaria control policy, the training will be completed at the end of Year 4 rather than earlier on in the lifetime of the project. SMP does not plan to conduct new trainings in Year 5. 12

There is a need to follow up health workers trained in IMM during support supervision visits to strengthen malaria case management skills on-site. The new treatment policy for severe malaria recommends a switch from use of parenteral Quinine to parenteral or rectal Artesunate (for prereferral treatment at the lower level health facilities). However, Artesunate is not currently available in parenteral or rectal form in Uganda. The National Medical Stores is expected to begin the procurement process, but the commodities are not expected in country for some time. As such, there will be little time for SMP to support the switch. SMP still intends to revise and print job aids for severe malaria case management so that they are ready for distribution when the new drugs are available. Districts have not fully integrated the clinical audits into their routine services as expected. They continue to wait for SMP funding to conduct clinical audits. In addition, the clinical audit tool currently being used is bulky; it was initially designed to capture baseline data. The tool requires revision and development of critical variables identified to track performance improvement resulting from the clinical audit approach. There will be need for SMP to support the NMCP to ensure tool is promptly revised and used by the. Essential commodities for management of severe malaria e.g. HB machines, IV fluids (clinical audits and SMP integrated support supervision reports) are not adequately available in the health facilities. SMP will support NMCP advocacy to the clinical services department of the Ministry of Health for these commodities to be supplied to the /health facilities. Planned activities 1. Provide financial and technical support to district clinical audit teams to carry out clinical audits at all hospitals and HC IVs in the 34 at-least once every quarter. SMP will put emphasis on reviving the health facility audit committees so that clinical audits become centered at the HF and are less reliant on the district teams (and therefore, there is less need for funds to get the district teams to the HF) to do the clinical audits. The health facility clinical audit teams are required to send reports of their clinical audits to the district clinical audit team. This way, the district clinical audit teams can monitor the performance of the health facility audit teams. 2. Continue to work with the district malaria teams during the SMP malaria specific integrated support supervision to provide onsite mentoring of facility health workers in management of malaria (un-complicated and severe malaria). JHU will take lead on integrated support supervision, but all SMP partners will participate in the activity (JHU, Malaria Consortium, CDFU, and IDI). 3. Hold consultative meetings with NMCP and other partners to revise the clinical audit tool and identify key indicators for tracking performance improvement resulting from the clinical audit approach. 4. Update the job aids on severe malaria to reflect the new malaria treatment policy, and then reprint and distribute the revised job aids to health facilities. 13

5. Reprint and distribute in-patient observation forms to all hospitals and HC IVs in order to improve documentation and collection of in-patient data. 6. Continue to track stock levels of anti-malaria medicines in the health facilities to generate information on stock status for the to place orders to NMS. As mentioned above under IR 1.2: Access to IPTp increased, SMP will work with the using existing mechanisms (ISS, mtrac, DHIS 2) to sustainably track their stocks of antimalarial medicines and RDTs stocks in the health facilities. In the past, SMP has relied on ISS to obtain data on availability of antimalaria medicines in the health facilities, and relaying this information to the and NMCP so that stock gaps could be addressed. Currently, some are implementing mtrac, and others DHIS 2; SMP will thus use the mechanism that is existing in a particular district to improve commodity data management. 7. SMP will work with the (through district planning meetings and quarterly regional meetings) to encourage them to include targeted supervision of malaria activities into the routine district support supervision. By budgeting for and implementing ISS under the Government of Uganda funding to the, the goal is for health workers to be provided with mentorship and support after SMP closure. The district malaria support supervision teams, which have been gaining skills over the four years of the project, will lead the mentorship process. Performance tracking Proportion of health facilities carrying out clinical audits for the management of severe malaria. Proportion of health facilities which have established clinical audit teams carrying out clinical audit in their health facilities at-least once per quarter. Proportion of health facilities with revised and updated job aids on severe malaria case management. Proportion of health facilities reporting no stock out of ACTs (ACTs and SP are the Ministry of Health tracer medicines for antimalarials). IR 2.1 Activity Implementation & Timelines Planned Activities Support NMCP to revise, print and distribute job aids on severe malaria case management Indicators Revised job aids on severe malaria case management Proportion of hospitals and HC IVs provided Activity Targets/Outputs Q1 target Q2 target Q3 target Annual target Revised job aids on severe malaria case management Revised job aids on severe malaria case management 85% of hospitals and HC IVs Revised job aids on severe malaria case management 85% of hospitals and HC IVs provided with job 14

Planned Activities Indicators Activity Targets/Outputs to 34 Support NMCP to hold joint stakeholder piloting meetings to revise the clinical audit tool to improve tracking of clinical performance Provide financial and technical support to district and health facility teams to carry out clinical audits at hospitals and HC IV Re-print and distribute inpatient observation forms to hospitals and HC IVs with job aid on severe malaria Clinical audit tool revised and updated Proportion of hospitals and HC IVs that have had atleast 1 round of clinical audit conducted Proportion of hospitals and HC IVs provided in-patient observation forms Clinical audit tool revised and updated 80% of hospitals and HC IVs in SMP that conduct atleast 1 round of clinical audit 85% of hospitals and HC IVs in SMP provided inpatient observation forms provided with job aid on severe malaria 80% of hospitals and HC IVs in SMP that conduct atleast 1 round of clinical audit 85% of hospitals and HC IVs in SMP provided inpatient observation forms 80% of hospitals and HC IVs in SMP that conduct atleast 1 round of clinical audit 85% of hospitals and HC IVs in SMP provided inpatient observation forms aid on severe malaria Clinical audit tool revised and updated 80% of hospitals and HC IVs in SMP that conduct at-least 3 rounds of clinical audits 85% of hospitals and HC IVs in SMP provided in-patient observation forms IR 2.2: Malaria diagnostic capacity and services improved Progress to date Malaria diagnostic training: Using the cascade training model, SMP trained 96 district laboratory focal persons (DLFPs) on malaria diagnosis using microscopy and RDT and skills to offer in-service training to district laboratory personnel. All 34 were covered and 80% (1,186/1,483) of targeted laboratory staff across the 34 received in-service training on malaria diagnosis by Microscopy and RDT. The staff trained included DLFPs and laboratorians. DLFPs were trained as trainers, who then cascaded the training to other laboratorians. The training focused on malaria 15

diagnosis using both microscopy and RDT. The laboratory staff were given knowledge on RDT use so as to be able to supervise and offer quality assurance/control for clinicians who use it RDT out of the laboratory. The trainees were from public, PNFP and selected private for-profit health facilities. SMP conducted on-site post training support supervision to all trained staff. Technical and financial support: SMP provided technical and financial support to the district laboratory teams to carry out External Quality Assurance (EQA) in 136 laboratories mainly in HC IVs and hospitals in each of the 34. As a result of these interventions, the average diagnostic accuracy by microscopy improved from a baseline of 75% (EQA Report, Quarter 1, Year 3) to 91% in Year 4. Accuracy is defined as sensitivity and specificity, the percentage given here is an average of specificity and sensitivity. Sensitivity and specificity are determined by comparison of results from a test to results from a gold standard, in case of EQA our gold standard is concordance between 2 trainers in the district, in case of dis-concordance the results are forwarded for a tiebreak reading at Central Public Health Laboratories (CPHL). SMP s focus in Year 5 will be sustaining of these achievements, and working with the on a long-term plan for EQA system operations. Planned activities 1. Strengthening district capacity to conduct EQA by: - Conducting periodic competency assessments, reagent quality control, equipment maintenance, cross checking of routinely collected EQA slides and assess performance benchmarks. - Strengthening the hierarchical reporting system and feedback for results of EQA at all levels. This is in line with NMCP reporting guidelines systems. During our implementation of EQA, we have noted a weak feedback system of results which requires to be strengthened. SMP will provide logistical support (transport for collection of slides from the health facilities, and on-site feedback of EQA results to staff at the health facilities) to ensure comprehensive hierarchical feedback at each of the EQA levels. - Rechecking slides at district. Malaria microscopy is done on slides stained with Fields or Leishmanns stains. The NMS supplies with these stains but quantitities are sometimes not sufficient. SMP will provide with a buffer stock of the stains so that the EQA process is not affected by stock outs. - Procuring buffer EQA supplies. - Conducting onsite mentorship and on job-training to ensure continuous quality improvement at facility level. - Assisting Laboratory staff to develop action plans to address gaps and strengthen the EQA system. Development of action plans is part of a continuous quality improvement process, and the primary audience of these plans is the laboratory staff. The action plans will be shared with the rest of their facility teams and these will be secondary audiences. 16

- Ensuring timely data collection in the health facilities and at the district level for data cleaning entry and analysis at SMP. Data collection is done by the laboratory staff and DLFPs in each of the while data entry, cleaning and analysis is done by SMP data staff, laboratory technologists and statisticians. - Holding quarterly EQA review meetings to discuss achievements and ways to improve performance. (This will be done during the quarterly regional review meetings of SMP partners and ) 2. Build a sustainable EQA structure at district-level, in collaboration with Central Public Health Laboratories (CPHL), by conducting regional meetings for re-orientation on the EQA process. This will help to strengthen coordination and to ensure sustainability when activities are handed over to the at the end of SMP. 3. Improving malaria laboratory diagnosis using microscopy. 23 microscopes will be procured and distributed to priority health facilities that have laboratory staff. SMP will check with other USG IPs operating in the same to ensure that equipment supplied is well coordinated and given to the most appropriate facility. Performance tracking Number of regional meetings held Number of receiving EQA reports per quarter Number of health facilities receiving EQA reports IR 2.2 Activity Implementation & Timelines Planned Activities Conduct regional meetings to transfer EQA coordination to the. Indicators Proportion of that are coordinating EQA activities Activity Targets/Outputs Q1 target Q2 target Q3 target Annual target 30% of coordinating EQA activities 60% of coordinating EQA activities 80% of coordinating EQA activities 80% of coordinating EQA activities Strengthen the reporting system and feedback for results of EQA at all levels Proportion of receiving EQA reports from SMP per quarter (reports covering EQA participating health facilities 40% of receiving EQA reports every quarter 60% of receiving EQA reports every quarter 80% of receiving EQA reports every quarter 80% of receiving EQA reports every quarter 17

Planned Activities Indicators in each district) Activity Targets/Outputs Proportion of health facilities receiving EQA reports 40% of 238 health facilities receiving EQA reports every quarter (7 per each SMP ) 60% of 238 health facilities receiving EQA reports every quarter (7 per each SMP ) 80% of 238 health facilities receiving EQA reports every quarter (7 per each SMP ) 80% of 238 health facilities receiving EQA reports every quarter (7 per each SMP ) IV. IR 3 NMCP capacity to monitor and evaluate interventions strengthened IR 3.1: Technical resources and skills of M&E unit improved Progress to date Improved support supervision: In Year 4, SMP strengthened NMCP s capacity to supervise through support to NMCP for joint integrated support supervision to. NMCP conducted support supervision to all the 34 project (100%) and to two conveniently selected health facilities in each district that received support supervision. NMCP collaborated with other MoH departments: MCH, HIV/AIDS, TB, to conduct supervision to the ; this is vital for integration purposes. NMCP coordination role: In order to support NMCP s coordination role, SMP provided financial support to quarterly RBM meetings. The RBM meetings provided a forum to advocate for the approval of the Integrated National Malaria Control Policy. In addition, the meetings provided a platform to share policy updates to partners and to review progress made in the implementation of key malaria control interventions. Key issues The revision of NMCP M&E curriculum was not done as planned in Year 4; instead, this activity changed to training of NMCP M&E staff in data analysis. However, this also did not happen due to competing activities and staff transfers at the NMCP. NMCP lacks a national malaria database for easy storage and retrieval of data to guide programmatic reporting and decision making. NMCP is expected to operate the WHO malaria database; however, the database needs to be modified to suit the Ugandan context. In Year 5, SMP will provide financial assistance to hire a consultant to modify the database. In addition, SMP will hire two data entrants to capture available malaria data into the modified database. The NMCP will take lead on this activity and the NMCP data manager will actively be engaged to ensure the database is maintained when SMP comes to an end. 18