Universal Coverage of LLINs in Uganda - Insights into the Campaign Implementation. Cover Photo Source: Kim Burns Case, JHU-CCP/Stop Malaria Project

Transcription

1 Universal Coverage of LLINs in Uganda - Insights into the Campaign Implementation Cover Photo Source: Kim Burns Case, JHU-CCP/Stop Malaria Project October 2014

2 CONTENTS ACRONYMS 4 EXECUTIVE SUMMARY 5 CONTEXT 8 A HEAVY BURDEN AND A READINESS TO TAKE ACTION 8 THE MAP (ABOVE) CLASSIFIES PLASMODIUM FALCIPARUM ENDEMICITY IN UGANDA INTO SUCCESSIVE LEVELS OF RISK, WITHIN THE LIMITS OF STABLE MALARIA TRANSMISSION. 8 TIME FOR UGANDA TO TAKE UP THE CHALLENGE OF UNIVERSAL COVERAGE 9 CAMPAIGN INITIATION 10 THE EARLY DAYS OF THE CAMPAIGN PLANNING PROCESS 10 THE NUMBERS START ADDING UP 10 CAMPAIGN ROLL-OUT - AT A GLANCE 13 ROLLING WAVE PLANNING 13 LEADERSHIP WITH INTEGRITY 15 THE MANAGEMENT OF COMPLEXITY 15 FOLLOW MY LEADER CLEAR GUIDANCE AT ALL LEVELS 18 TALKING OF LEADERSHIP 18 INEVITABLY, SOME MISTAKES WERE MADE 19 PLANNING FOR IMPLEMENTATION 20 THE THREE SUBCOMMITTEES 20 GETTING TO THE FINER DETAILS 20 MONITORING &EVALUATION/OPERATIONS 20 INFORMATION IS POWER 21 LOGISTICS MANAGEMENT 23 KEEPING NETS MOVING THROUGH DIFFICULT TERRAINS 25 ADVOCACY AND SOCIAL MOBILISATION 26 DECENTRALISIED IMPLEMENTATION 28 THE GOVERNMENT STRUCTURES IN UGANDA, WHICH MADE IT POSSIBLE 28 DISTRICT TASK FORCES 28 2

3 SUB-COUNTY TASK FORCES 29 THE VILLAGE LEVEL 29 THE VILLAGE HEALTH TEAMS 30 VHT PROFILE: 31 THE MOBILISATION EFFORT 34 VITAL HELP FROM EXTERNAL PARTNERS 35 THE ROLE OF UNIFORMED SERVICES 35 EXTERNAL MONITORING 37 QUIET DIPLOMACY AND ASSISTANCE FROM A PARTICULARLY INTERESTED PARTY 38 KEY ACHIEVEMENTS 40 KEY LESSONS 43 CHALLENGES 45 THE LEGACY 47 UNIVERSAL COVERAGE AT SPEED AND SCALE 47 POTENTIAL FOR REVOLUTIONARY INFORMATICS 48 STAKEHOLDERS INTERVIEWED 51 ACKNOWLEDGEMENTS 53 BIBLIOGRAPHY 54 3

4 ACRONYMS ACHS Assistant Commissioner Health Services ANC BCC CAO CBO CSO Antenatal Care Behaviour Change Communication Chief Administrative Officer Community Based Organisation Civil Society Organisation DFID Department for International Development DISO DHIS DHO DPP District Internal Security Officer DistrictHealth Information System District Health Officer Directorate of Public Prosecutions FCO Focal Coordinating Office (For GFATM) GFATM Global Fund for TB, AIDS, Malaria GISO HE HF Gombolola Internal Security Officer (village level) His Excellency (President Museveni) Health Facility HMIS Health Management Information System ICCM Integrated Community Case Management IGP ITN IPC Inspector General of Police Insecticide Treated Net Interpersonal Communication JHU-CCP Johns Hopkins University Center for Communications Programs LC1 LG LLIN Local Council Chairperson 1 (Village Level) Local Government Long Lasting Insecticidal Net M&E Monitoring and Evaluation MC Malaria Consortium MHSDU Medicines & Health Service Delivery Monitoring Unit MOH Ministry of Health MoU Memorandum of Understanding NDA National Drug Authority NCC National Coordinating Committee NMCP National Malaria Control Program NRM National Resistance Movement (Ruling Party in Uganda) PMI U.S. President s Malaria Initiative PSM Procurement and Supplies Management RBM RC RDC SMP SMS Roll Back Malaria Resource Centre Regional District Commissioner Stop Malaria Project Short Message Service UBOS Uganda Bureau of Statistics UC Universal Coverage UgSh Ugandan Shillings UPF Uganda Police Force UPDF Uganda People s Defence Force USD US Dollar USAID United States Agency for International Development VHT VPP Village Health Team Voluntary Pooled Procurement WHO World Health Organisati 4

5 EXECUTIVE SUMMARY This is the story of the world s largest continuous universal coverage campaign for LLINs. With an initial estimated population of 37.2 million people 1, Uganda s distribution of 22.3 million LLINs in one continuous campaign is the largest to date. This report sits alongside many other reports of the Ugandan campaign (including process and impact evaluations and reports from partners). It serves as a brief informal narrative record of the elements that made the Uganda Universal Coverage Campaign a success. It aims to capture issues that may not be covered in the other reports and to highlight the extraordinary efforts of the many people involved in this campaign a campaign of unprecedented scope and scale. The report highlights the context in Uganda at the start of the universal distribution campaign. Uganda was falling behind its neighbours in tackling malaria control and with the country s child mortality the highest in Africa, it was time to act. Uganda was ready to execute a universal LLIN campaign providing one net for every two people in the population. The confluence of events, partners and resources coming together to enable the campaign to get off the ground is detailed in this report. The National Coordinating Committee (NCC) led the vision for universal coverage with passion and conviction. The campaign was launched in Soroti in May 2013, by the highest political office in the country: His Excellency the President of the republic of Uganda Yoweri Kaguta Museveni. The dedication and commitment towards the success of this campaign was shown in the collective action and resources made available to support the campaign: 21 million LLINs and $21million for distribution contributed by the U.S. President s Malaria Initiative (PMI), the UK s Department for International Development (DFID), World Vision and the Global Fund for TB, AIDS, Malaria (GFATM). This was supported by the technical expertise of the implementing agencies: Johns Hopkins University s Stop Malaria Project and Malaria Consortium; and the invaluable contributions of the Ministry of Health and technical teams within the National Malaria Control Programme (NMCP) and other government officials at all levels. At the beginning of the Campaign: His Excellency President Museveni, Soroti May 10, 2013 Source: New Vision The timeline of the campaign across the 112 districts from the pilot distribution September 2012 to the official start May 2013 through the finish in August 2014 is illustrated. 1 UBOS 2012 population estimate, with additional 15% for rural populations and 20% for urban populations added after pilot study 5

6 This report focusses on the 108 districts covered in the campaign from May2013 August The various stakeholders involved in planning and executing the campaign are described. These include the whole structure of national and local government actors, from central government, down to district, sub-county and village-level health teams. State-of-the-art implementation guidelines provided to all officials in the embedded decentralised government structure made this distribution process possible. A profile of the pivotal Village Health Teams is given. These are volunteers who provide basic primary health care services to their fellow-villagers and who were an invaluable resource to the campaign in registering the population for receiving nets and then in distributing nets to those same community members. The crucial roles external stakeholders played in the campaign s success are highlighted. The unique inclusion of the uniformed personnel gave a powerful sence of national importance to this exercise. Indeed His Excellency the President himself emphasized the need for security during the distribution of the 22.3 million nets procured for the campaign. A second high level of accountability and security was given to the campaign by the appointment of the Medicines and Health Services Delivery Monitoring Unit, who provided a team of monitors who also had powers to assist in implementation, including legal powers to follow up on any wrong-doing immediately. There were negligible losses in this campaign 2. There was also high level support and advocacy from the U.S. Ambassador right from the start-up to the close-out events of LLIN distribution. And at campaign closure: His Excellency President Museveni, Kampala, Aug 18, Source: New Vision The report highlights Uganda s signficant achievements. Current estimates suggest population coverage of around eighty-nine percent (89%) of the 41,034,354 Ugandans was 2 This still has to be determined following the final programme evaluation 6

7 achieved, at an estimated distribution cost of $0.89 per net delivered. Despite a four months interruption,the LLIN distribution covering the entire country was completed in 15 months 3 of continuous effort. Key lessons have been learnt which will be of value internally and to share across Africa. Clear guidance, multi sectoral support from all levels of government and the particpation of partners ensures that a country can get behind a truly government-led national campaign. The momentum created by a campaign of this scale signaled an unprecedented application and effort from people at all levels of planning and implementation people were prepared to go above and beyond their normal call of duty to ensure that this enormous juggarnaut kept moving and the campaign achieved its aims. Finally an incredible legacy has been left behind by the campaign: Uganda has shown that its decentralised government structures can work together in new efficient ways to implement programmes at scale. Uganda has shown that it can employ security and accountability through its uniformed personnel and its uniquely-equipped Medicines and Health Services Delivery Monitoring Unit. Uganda also now posesses an invaluable source of health and LLIN data at household level with the potential to further develop and utilise this data to provide a robust and revolutionary system of health informatics to take the country into the twentyfirst century with a state of the art digitised health management information system. We now have the evidence to show what can be achieved with collective action Dr. Jane Ruth Aceng, Director General of Health From the African proverb: If you want to go fast, go alone, but if you want to go far, go together Dr. Bernard Nahlen, PMI Global Deputy Coordinator, at Campaign closing ceremony, 18 Aug This includes a 4 month delay in LLIN supply from the manufacturer 7

8 CONTEXT A heavy burden and a readiness to take action Of the 44 countries in the WHO Africa region with malaria, 32 countries have adopted a policy of mass campaigns aiming at universal coverage, 4 with free provision of one net for every two people in the country. There had been tremendous progress in worldwide malaria control, particularly in Africa, with estimates of malaria mortality rates reduced by 49% in the WHO Africa region between Yet, Uganda records one of the highest prevalence rates of malaria in the world in % of children aged 0 59 months had malaria parasites in their blood 6. Malaria is still the leading cause of death and illness in the country, with approximately 16 million cases in 2013 and over 10,500 deaths annually. 95% of the population is at risk of contracting malaria (see malaria prevalence map below). A single episode of malaria costs a family on average 9 US dollars, or 3% of their annual income. Moreover, a poor family in a malaria endemic area may spend up to 25% of the household income on malaria prevention and treatment. Industries and agriculture also suffer due to loss of person-hours and decreased worker productivity 7. Unfortunately, Uganda had fallen behind its neighbours in its effort to control malaria. This dire situation called for unprecedented action to improve the lot of the Ugandan population. 4 Dr S Hoyer, WHO GMP Presentation 17 Feb 2014 AMP 5 World Malaria Report 6 MIS, Uganda Malaria Reduction Strategic Plan The map (above) classifies Plasmodium falciparum endemicity in Uganda into successive levels of risk, within the limits of stable malaria transmission. The majority of the country areas, shown in dark red, are those at the highest levels of risk, where annually averaged infection prevalence in 2-10 year olds (PfPR 2-10) is likely to exceed 40%. Source: MAP Malaria Atlas Project 2010 R

9 Recognising this threat, malaria received priority status at the highest levels. The Presidential Manifesto 2010 stressed malaria eradication as the goal. The National Constitution, the National Development Plan 8, and the National Health Policy (II)- all position malaria as a program of national importance. Long-lasting insecticide-treated nets (LLINs) have proven to be a critical and highly effective component of malaria prevention and control programmes. Net use has been shown to reduce all-cause mortality in children under five years of age by about 20 per cent and malarial illnesses among children under five and pregnant women by up to 50 per cent. LLINs not only protect individuals sleeping under them from being bitten, but the insecticide also both repels and kills mosquitoes that land on nets, reducing overall malaria transmission in the community. Picture: Stop Malaria Project UNIVERSAL COVERAGE = 1 LLIN FOR EVERY 2 PEOPLE TARGET: 85% Time for Uganda to take up the challenge of Universal Coverage Following the United Nations Secretary General s call for 100% coverage of malaria control interventions and the elimination of malaria as a threat to public health (2007),the government of Uganda moved from targeted malaria control interventions (aiming primarily to cover children under five and pregnant women) to universal coverage (aiming to protect everyone in a community), joining the 32 African countries in seeking to ensure that all Ugandans could access and use long-lasting insecticide treated nets (LLINs). Together, with the active support of international donors, technical partners, Ugandan citizens and government at all levels, in 2013 the country embarked on the largest universal LLIN distribution campaign in the world to date. 8 NDP 2010/ /15 9

10 CAMPAIGN INITIATION The early days of the campaign planning process Following the 2007 WHO recommendation Uganda began planning for universal coverage in early Seven million LLINs had already been distributed to pregnant women and children under five years in targeted campaigns. An additional 10 million LLINs were ordered in the Global Fund Round 7 Phase 2 funds. There were difficulties with Global Fund accountability and there was a delay in procurement of these nets. It was decided that it would be wise to wait for the original 7 million LLINs to become obsolete before embarking on the UC campaign. 9 Picture: Volunteer during targeted campaign, Malaria Consortium The numbers start adding up In 2013, Uganda found itself in a position, following delays and difficulties in Global Fund allocations and net procurements, whereby they were in receipt of 15.5 million nets, rather than the original 10 million budgeted for. The cost of nets had fallen significantly since 2010 (see graph). This presented an opportunity and this was the first of many opportunities that were capitalised upon. LOWER PRICES Source: UNICEF May As stated in an interview with Head of FCO, (GFATM), August

11 The initial number of nets required to achieve UC was calculated at 21 million. Global Fund monies procured the new higher volume of 15.5 million; PMI and DFID combined funding to procure 5 million; and World Vision International offered the additional 0.5 million to take the total to 21 million LLINs. Uganda was now in a position to attempt the biggest universal distribution of LLINs in the world to date. Financial resources for the distribution of the nets again came from multiple sources. The Global Fund contributed US dollars 5.8 million, PMI and DFID proposed funding of US dollars 15.2 million operational costs of the campaign thus 21 million LLINs was matched with a $21m budget for distribution costs. This confluence of donors who came together to work with excellent coordination 10 and gave the campaign this resource incentive, which was the impetus to begin something never before attempted at such scale, timeline and magnitude. As one of the managers noted: Many things had to be done in unchartered waters Dr. Godfrey Magumba, Director, Malaria Consortium, Uganda This coordination was challenged however, by the difficult and laborious process of drawing up a Memorandum of Understanding between the Government of Uganda and partners. This, in fact, took the most time to agree on. Meetings to agree clauses went on long after normal working hours. Discussions continued as late as 2am. It was not only the donor representatives but their families also who gave of their time to get behind the largest continuous distribution campaign in the world to date. There was a sense early on that this was an initiative that could have real impact and it was a programme that ultimately the whole country could get behind. Fortunately, Uganda had good tools on which to build the campaign. Targeted campaign and routine distribution through antenatal care (ANC) had been implemented in Uganda for some time; Implementation and training guides from previous campaigns and routine ANC distribution models were adapted for universal coverage. 10 As stated by K Belay, PMI in an interview, 12 Aug

12 Picture: Stop Malaria Project The Quantification Issue Universal coverage is required, based on the 2007 WHO position paper on ITNs. This is operationally defined as one ITN for every two individuals, based on evidence from across sub-saharan Africa that, on average, two individuals occupy each sleeping space. (PMI Technical Guidance April 2014) Quantification for universal coverage, which relies on some form of delivery based on households, has evolved in recent years. To take into account rounding up of net numbers in households with an odd number of inhabitants (e.g., a household with five inhabitants receives three not two ITNs), WHO now recommends using one ITN for every 1.8 individuals for macro-quantification purposes. (PMI Technical Guidance April 2014). This was used for macro-quantification in Uganda. [See Lessons Learned where it is suggested that purchasing one ITN for every 1.64 individuals may be a more accurate way to reach universal access (Kilian 2013)] Ugandan census data was used to calculate the 21m nets requirement. Population census data was last collected in [Uganda is conducting the official census in September 2014.] However, there was a revised estimate made of Uganda s population in 2012 by the Uganda Bureau of Statistics (UBOS). Planning was conducted using these statistics, which were shown to be inaccurate by 15% in rural areas and 20% in urban areas, following a pilot study. This quantification error was to impact the later stages of campaign, which meant nets had to be diverted from planned ANC distribution, and forced a change in the distribution strategy for Kampala and urban Wakiso district. Population 2002 (Official Census) 24.2m 2012 (UBoS Revised Estimate) 34.1m 2013 (UC Campaign estimate) 37.2m 12

13 Campaign Roll-Out - at a glance The campaign was conducted in waves rather than by regions. Clusters of districts were grouped and scheduled for ease of access. Rolling Wave Planning The Universal Campaign was conducted using rolling wave planning. This permitted work activities to move forward, while planning for future work requirements continued. For example, after completing registration in wave 1, the registration teams proceeded to register the districts in wave 2 while waiting for wave 1 allocation lists to arrive from central level. When the allocation lists arrived, the teams returned to the wave 1 districts to distribute the nets. In some districts pre-visits were made ahead of registration to assess any potential distribution problems, which could result from hard to reach areas. Each wave s total activity ran over a period of days, non-concurrently, to allow the whole country to be covered in this rolling wave pattern. This type of campaign management approach and technique helped to shorten the time to UC coverage completion in 2 ways: By making it possible for productive activities to begin without waiting for every detail of the project work to be determined in advance By eliminating downtime for additional planning in the middle of the campaign since planning is done continuously The table below shows coverage calculated using Administrative data following distribution of nets across the entire country WAVES REGION DISTRICTS (# of TIMING COVERAGE* Pilot Easter n districts) (4) Bugiri, Mayuge, Kaliro and Serere Pre-Visit: Aug 2012 Distributi on: Sep % 1 Easter n 2 Easter n 3 Eastern& Central (2) Soroti, Busia Apr May 2013 (Campaig n Launch) (16) Amuria, Kumi, Sironko, Kween, Manafwa, Bukwo, Ngora, Kaberamaido, Katakwi, Bukedea, Nakapiririt, Kapchorwa, Bulambuli, Bududa, Pallisa and Amudat (16) Mbale, Budaka, Kibuku, Namutumba, Tororo, Namayingo, Luuka, Iganga, Buyende, Jinja, Kamuli, Buikwe, Buvuma, Mukono, Butaleja and Kayunga. 13 Aug 2013 Sep % Oct % Nov %

14 4 Centr al 5 Centr al&w estern 6 Weste rn& North ern 7 North ern 8 West Nile (N) (18) Bukomansimbi, Butambala, Mpigi, Gomba, Kalangala, Kalungu, Kiboga, Kyankwanzi, Luwero, Lwengo, Lyantonde, Masaka, Mityana, Mubende, Nakaseke, Nakasongola, Rakai and Sembabule. (15) Mbarara, Isingiro, Ibanda, Kiruhura, Bushenyi, Mitooma, Buhweju, Sheema, Rubirizi, Kabarole, Kyenjojo, Kyegegwa, Ntoroko, Bundibugyo, and Kamwenge (17) Ntungamo, Kisoro, Kabale, Kanungu, Rukungiri, Kiryandongo, Kasese, Masindi, Buliisa, Hoima, Apac, Kibaale, Lira, Kole, Oyam, AmolatorandDokolo (17) Abim, Kaabong, Kotido, Moroto, Napak, Alebtong, Otuke, Gulu, Amuru, Nwoya, Lamwo, Kitgum, Pader, Agago, Adjumani, Nebbi and Zombo (5) Arua, Koboko, Maracha, Moyo and Yumbe Oct-Nov 2013 Nov 2013 Jan 2014 Feb-Mar 2014 Nov % Jan % 5 month delaybottleneck in delivery/ NDA May 89% 2014 Jun % Apr 2014 Jun % Urban City (2) Kampala, Wakiso Jun 2014 Aug 2014 TOTAL Nationwide 112 Districts ( pilot districts) Jul 2013 Aug % Insufficient nets Universal coverage meant registered households received 1 2 nets 89% 14

15 LEADERSHIP WITH INTEGRITY It is imperative that a campaign of this scale requires inspirational leadership and this, as many have stated categorically, came from the National Coordination Committee (NCC). This committee was formed in March of External Stakeholders NCC Sub Committees District Task Forces Sub-County Task Forces Village Health Team s & Community Members The NCC s role was to mobilise resources; oversee and communicate on all aspects of the campaign; to resolve problems as they arose; and to advocate at all levels to ensure engagement and support for the campaign. Chaired by the Director General of Health Services, together with the NMCP Program Manager as Secretary, this committee was made up of donor partners and representatives of the implementing agencies. (See illustration of Coordination structure, above right). The management of complexity Picture: Stop Malaria Project One of the early bottlenecks and what has subsequently been seen as one of the leading achievements of the campaign process, was the creation of the Memorandum of Understanding (MoU) established between the Ugandan Ministry of Health; the partnership of donors; and the lead implementing partners. This process took four months to complete (April-July 2013). The resulting MoU was a landmark document, of some complexity, which facilitated the campaign via the pooled financing reserves of the key donors (PMI, DFID and GFATM); the appointment of a lead management agency, JHU CCP, who in turn appointed the lead implementing agency, Malaria Consortium. Malaria Consortium was also appointed a Principal Recipient to receive the Global Fund Malaria Round 7 Phase 2 grant. We are managers; we will manage difficult situations Dr. Kassahun Belay, PMI 15

16 Illustration of the contribution of funds and nets to the UC campaign (Source: Stop MalariaProject): A problem shared is a problem halved the power of partnership Pictures: Implementing Partners Logos The funding for the distribution was allocated amongst the implementing partners as follows: All USAID/PMI/DFID funding ($14.7m) was routed through JHU CCP, for management, BCC in selected districts, support to the Ministry of Health Resource Center for data entry activities, and to Malaria Consortium for implementation activities. The majority of GFATM funding ($4.8m) was given directly to Malaria Consortium for implementing activities. The additional $1m was given directly to the Ministry of Health for implementation facilitation. All World Vision International funding ($0.5m) was spent on distribution of LLINs in Busia and Soroti districts in Wave 1. 16

17 As stated clearly in the MoU: The objective of this Agreement is to streamline the funding mechanisms of the LLINs mass campaign and: The scope of the Programme will be defined in the joint work plan, joint budget and the national implementation guidelines for the LLINs mass campaign. And most importantly, the ownership for the campaign resided within the MoH: All 20.5 million LLINs in the campaign supported by the various donors will be distributed according to the Ministry of Health of the Republic of Uganda LLIN Campaign Implementation Plan and Detailed Implementation Guidelines, under the guidance and technical oversight of the National Coordination Committee for distribution in all districts of Uganda. (MoU - 2 July 2013) 17

18 Follow my leader clear guidance at all levels These implementation guidelines are state of the art and must be shared widely throughout Africa Dr. Kassahun Belay, PMI Picture: Stop Malaria Project The Implementation Guidelines and Training manual (pictured above) formed the other essential cornerstone of the campaign. These Guidelines, produced in July 2013, clearly articulated all aspects of the campaign, for all stakeholders, detailing their respective roles and responsibilities, from the role of the Cabinet down to the role of the Village Health Worker volunteering to distribute nets to their community members. It is a 45 page document, which was referred to throughout the campaign process. It became the main tool, along with the Training Guidelines for implementation activities at District level down to the grassroots. These were developed through a consultative process that aimed at ensuring stakeholder buy-in at all levels. We had never done anything like this before but through it I learnt about the power of teamwork. The partners are here to support us and not here to drive strategy and create parallel systems. Dr. Jane Ruth Aceng, Director General of Health Services Talking of Leadership Some have referred to her as the Iron lady, and too tough but she had to be. They are talking of the chairperson of the NCC, Dr. Jane Ruth Aceng, Director General of Health Services at the Ministry of Health. This was an extraordinary event, which required an extraordinary response from the stakeholders in Uganda. She is a woman of steely reserve, but humble demeanour: We had never done anything like this before but through it I learnt about the power of teamwork. Dr. Aceng went on to elaborate, I enjoyed every minute of it, when I have an activity, I take it personally. The clear goal to bring down the prevalence of malaria and the very clear strategy to make the goal a reality, and at speed and scale was a motivating factor for all. The steely resolve certainly helped in keeping the campaign focussed, I believe the partners are here to support us and not here to drive 18

19 strategy and create parallel systems. said Dr. Aceng referring to some projects that are regionally focussed duplicating efforts resulting in inappropriate use of resources. Dr. Aceng - and all partners - saw the coordination and partnership as hugely important to have a greater impact for the whole of the Ugandan population. And of equal importance, the partners were motivated by the vision too. This campaign has set the Ugandan sights on being Malaria Free by Inevitably, some mistakes were made Despite a strong leadership, there were issues which did not get addressed satisfactorily and sometimes decisions were delayed. The delay to act on information provided in 2013 about the shortage of LLINs for Kampala is a major lesson learned. Kampala had a shortage of LLINs as the population estimates were 39% lower than the actual population. This was known in as early as November 2013, but very little was done to address the situation leading to a shortfall of nets for Kampala and Wakiso in August The high coverage levels could have been achieved in Kampala and urban Wakiso if there had not been a variance between actual and estimated need. However, PMI was able to rechannel 1.2 million LLINs from ANC distribution and so reduced this gap drastically to 600,000 nets. In a bid to salvage the situation, the distribution strategy was changed for Kampala and urban Wakiso the parts of the country with the lowest burden of malaria and a high ability to pay for nets. Based on the LLINs available and emphasizing the target population, NCC decided to distribute two nets for registered households with pregnant women or children under five years, and one net for all other registered households in Kampala and urban Wakiso. 19 Picture: Stop Malaria Project

20 PLANNING FOR IMPLEMENTATION External Stakeholders The Three Subcommittees The UC Campaign Implementation Guidelines articulated the necessity to form three sub committees at the central planning level. These included: M&E/Operations; Logistics management; and Advocacy and Social mobilisation. NCC Sub-Committees District Task Forces Sub County Task Forces Village Health Team s & Community Members Getting to the finer details The three sub committees form the essential load-bearers of a three-cornered stool - without one, the others fall. All three provide essential components required for the success of a national campaign. Members of the National Malaria Control Program chaired all these sub-committees. The expertise brought to their respective tasks was integral to campaign success. Monitoring &Evaluation/Operations Monitoring & Evaluation/Operations Sub-Committee Core Members: NMCP M&E Specialist (Chair) NMCP Data Manager MoH Resource Centre PMI NMCP Programme Manager Stop-Malaria Project Uganda Police Force (UPF) This committee was responsible for all activities related to implementation: development of training materials for all actors; training and evaluation of training; tools for household registration and data management; monitoring and evaluation support and development of evaluation questionnaires. Pictures: Training Manual, containing e.g. Household Registration/Distribution Form; Waybill/Delivery Note, Stop Malaria Project 20

21 The coordination from the centre down to the lowest village distribution point worked it shows that the systems are in place and can be fine- tuned in the event of another campaign or similar exercise Badru Gidudu, Supervisor, Malaria Consortium Picture: Sensitization in Napak, Malaria Consortium There were lessons applied to UC from the targeted campaigns, materials were borrowed, adapted and improved upon. Information is POWER Picture: Data Allocation, Busheyni, Malaria Consortium A vital element, perhaps underutilised in the main campaign, which falls under this committee is the Resource Centre. This is an unassuming name, for a resource of considerable potential and power 21

22 Resource Centre An Opportunity Missed but certainly not Lost The potential for the Resource Centre was never fully realised in this campaign. Indeed an ehealth moratorium had already been called in 2012, due to the Pilotitis (see graphic representation) many pilot health programmes, which had plagued Uganda: too many pilots and no progression nor scale-up. The UC campaign was an opportunity to produce an ehealth information system at scale, but the budget could not be stretched to accommodate it fully. The result: data was collected, but not fully used during the campaign. The vision, under Dr. Eddy Mukooyo, ACHS, Ministry of Health is to create a fully interactive Community Health Management System. He passionately believes this is an opportunity to revolutionise health care delivery. A fully computerised data capture and data input Resource Centre was tested in Busia and Soroti, but was found to be too costly to establish and manage for the UC campaign with such short notice. So an off-line version was used. Although some funding was provided by CDC, improvisation was required to get the centre running no server- so a laptop was used; no furniture - so boxes were used and some chairs borrowed from numerous offices. Data entrants bought their own personal laptops to use. Some people joined as volunteers, knowing that they would get vital training which would be very important for the country and for the future. These were young people in their 20s adventure was part of their motivation. There were two work shifts created - 8am-6pm and 8pm to 6am. Between people were employed per shift. They were given targets of 1000 records to enter per day. The system created could detect errors and these were kept below 2%. The staff designed the LLIN Electronic Data Management System software (LEDMSS). Staff and volunteers were learning core competencies in management of data and data entry. Management of data in this way is unique in Uganda. Now this data has been collected, it can be maintained and updated via VHTs and a mobile smartphone system of data collection at far less cost. 59% of Ugandans now own a mobile phone and, alongside Kenya (68%), Uganda has the highest rate of usage for mobile banking (50%). (Source: Pew Research Centre Global Attitudes Survey Spring (2013). As Dr Jim Arintaitwe said: Thanks to the efforts of the UC we have an opportunity to expand the national health database to build a robust health informatics department. The LLIN UC campaign has provided a platform for many other things Picture: Pilotitis - showing Uganda s many e-health/m-health pilot projects 22

23 Logistics Management Logistics Sub-Committee Core Members: NMCP Technical Officer (Chair) Transportation Agent (SPEDAG) PMI VPP Agent (Khune& Nagel) NMCP Procurement & Supply Management (PSU) MoH/FCO Stop Malaria Project Procurement Agent Representative (PACE/PSI) We ve done great work and developed the capacity of government structures Rukaari Medard, Technical Officer NMCP Uganda procured LLINs through 3 different mechanisms, including the GFATM s Voluntary Pooled Procurement (VPP) process. This should have been a straightforward process, but as Uganda found, there were key elements required to ensure that logistics and pipelines supplies were secured. Picture: Stop Malaria Project They learnt from using the Public Procurement System for the targeted campaigns, where there were problems with transparency and bureaucracy. The VPP system was therefore used, whereby an additional 4 million nets were bought with cost savings due to bulk purchasing but mainly reduction of net prices. There were unforeseen challenges, such as the delays in international LLIN shipment arrivals. Nationally, challenges of long holding times by National Drug Authority (NDA) as the nets waited quality testing were frequent; the National Drug Authority (NDA) had problems of capacity: they did not have the necessary equipment for inspecting and testing LLINs at a 23

24 pace commensurate with the speed of the campaign. The GF were to buy testing equipment but procurement issues meant this did not arrive in time for the campaign. Nets were brought into the country and stored at central level, which produced centralisation efficiencies. They were then transported to the Districts. The Global fund was responsible for transportation of the nets from manufacturers to sub-county stores, which was an advantage in terms of resources. Pictures: Stop Malaria Project and Malaria Consortium At District level, nets were then transported directly to the sub-county level. Government structures were used for storage in 99% of cases e.g. Town Council Hall, Health Facility, thereby reducing on storage and holding costs at this level. It was found that pre-positioning for hard-to-reach areas was beneficial. Nets were taken 1 day prior to distribution from sub-county stores to the distribution point. On average 30% were pre-positioned. This was particularly beneficial in places like Bududa where landslides are common. It is clear that transport plans need to be developed in pre-visits, since not all districts have trucks. In some districts, such as Kalangala, Buvuma, Namayingo (islands on the N shore of Lake Victoria) government boats had to be used. 24

25 Picture: Malaria Consortium Logistical arrangements for hard to reach areas such as islands were made at central level but coordinators said this mechanism of planning was lacking since rigid accounting practices did not allow for flexibility in allowing payments for such difficulties in transportation costs in such areas. In future, a degree of decentralization when making plans would allow teams to address such challenges. Keeping Nets moving through difficult Terrains It was important to ensure that nets reached all areas of the country, regardless of the difficulties of access. Teams of District Supervisors (recruited by NMCP) and District Coordinators (recruited by Malaria Consortium) worked together to ensure that pre-visits were made to assess potential bottlenecks and further preposition nets, if it was obvious that there could be delays in distribution. These teams worked tirelessly at district level and below to assure training, coordination and monitoring of all implementation activities. Pictures: The difficult terrains included transporting nets over water and where roads were impassable by vehicles, Malaria Consortium 25

26 Advocacy and Social Mobilisation Advocacy and Social Mobilisation Sub-Committee Core Members: [MoH Health Education Division (Chair)] Stop Malaria Project (Lead agent) NMCP Programme Manager Malaria Consortium Advocacy from the President s Office was good the messages developed were excellent there was just not enough communications activity on the ground The Advocacy and Social Mobilization committee was responsible for the development of advocacy and communications, plans, tools and messages. Effective communication at all levels is vital for the success of any campaign and more so a campaign of this scale. It was generally felt that the communication campaign could have been further strengthened. Most stakeholders were of the opinion that this committee needed strong leadership at the central level. There was no single chairperson for this subcommittee who stayed in post long and there were frequent staff member changes. The BCC strategy was three pronged: use mass media for creating awareness of the campaign, ensure VHT s pass on campaign messages during pre distribution activities and continue with net use messages during post distribution phase of the campaign. This plan was premised on the assumption that a campaign of this scale generated word-ofmouth buzz and interest. True to this effect, the sight of trucks bringing LLINs to local dropoff sites created a visible presence on the ground and the VHTs activity at village level encouraged people to collect their nets. More effort is needed to ensure the message of net use is reaching families. This can certainly be a focus for future BCC prevention campaigns. Picture: Local radio station in Uganda Picture: Radio use in Soroti, Salem News Due to the lack of leadership and the decision to centralise all communications, the communications output resulted in heavy reliance of the campaign on radio messages aired on local stations, bought and planned centrally by a Kampala advertising agency. This approach addressed the component of sensitization as evidenced by the relatively high population coverage. 26

27 It was acknowledged that of all the three legs of the stool, this one may have had a greater impact if the process of implementation had been decentralized and districts had been able to mobilise their own health educators to take the campaign and develop it at district level. Despite these challenges, the communication campaign messages (radio spots and radio talk shows) prior to distribution, during distribution and post distribution were disseminated through radio stations that could be easily monitored by the media monitoring agency - IPSOS and who could provide timely reports on the messages that were aired. These radio stations provided adequate support on the ground activities especially to VHTs who were able to mobilize communities to come and collect their nets. One of the lessons learned is that the communication campaign could also have been further strengthened through IPC activities. Engaging district based radio stations that could also help increase the reach if they can be monitored independently by a media monitoring agency. The utility of the data collected by the Resource Centre is of potential value to the behaviour change communications efforts, for example, mobile phone numbers can be used to send follow-up messages to promote correct and consistent net use to both village health teams and also to those receiving nets. 27

28 DECENTRALISIED IMPLEMENTATION The Government Structures in Uganda, which made it possible The decentralisation policy in Uganda has been recognised as a External Stakeholders success story internationally. Yet, many stakeholders believed that NCC this was the first time that the Ugandan government structures had been Sub Committees used to their full potential. A few local government officials stated that District Task Forces they believed all government campaigns should be conducted in this Sub-County Task Forces way in future, by utilising cross-sectoral district and local government support, and not just for health programming. Indeed, one of the legacies, which local government officials spoke of is the new partnerships forged and power of the combined approach to implementation. Village Health Team s & Community Members It is befitting to state that the success of the Universal Coverage of LLIN distribution can be attributed to the capacities of the decentralised government structures. District Task Forces Picture: Busheyni District Task Force Meeting, Malaria Consortium District Task Forces were the planners and coordinators of the campaign at the district level. A laudable outcome for the UC campaign, although of no surprise to the local officials, is that Uganda s decentralised government structures work. This was perhaps not fully anticipated at the time. However, much of the success of these structures was due to the clarity of roles and responsibilities well articulated in the Implementation Guidelines and reiterated in the thousands of training sessions held throughout the country. The creation of a District Task Force to build leadership at District level had never been done before this was a huge experiment but clear guidelines made this possible Dr. A. P. Okui, NMCP Acting Programme Manager 28

29 At present Uganda has 112 districts. Twenty-eight years ago, when His Excellency President Y.K. Museveni captured power, Uganda had only 30 districts. The District is made up of several counties, which is in turn made up of sub-counties; for example, Soroti district has 3 counties and Soroti country has 7 sub-counties. The district has a government-appointed head, the Regional District Commissioner (RDC) and an administrative head, (CAO), with an elected council and LC5 chairperson. The district has heads of various departments, including health, education and internal security, all of which were represented in the District Task Force. Sub-County Task Forces External Stakeholders NCC Sub Committees District Task Forces Sub-County Task Forces Village Health Team s & Community Members Picture: Training of trainers session in Busheyni, Malaria Consortium The sub-county is run by the sub-county chief on the technical side and by an elected local council 3 (LC3) chairman and his/her executive committee. The council consists of elected councillors representing the parishes, other government officials involved in health, development and education, and NGO officials in the sub-county. A sub-county is made up of a number of parishes. Each parish has a local council 2 (LC2) committee, made up of all the chairmen from the village LC1s in the parish. For the UC campaign this LC1 cadre took on an essential operational role and participated heavily in ensuring nets were distributed and guarded at village distribution points. The Village Level A village is the lowest political administrative unit. A village usually consists of between 50 and 200 households and may be home to anywhere between 250 and 1,000 people 11. The average household size is 5 people 12. Each village will be run by a local council local council 1 (LC1) - and is governed by a chairman (LC1 chairman) and nine other executive committee members. It is at village level that External Stakeholders NCC Sub Committees District Task Forces Sub County Task Forces Village Health Team s & Community Members UBOS estimate 2009/10 29

30 volunteers have been sought to make up village health teams to bring essential primary health care close to the people of Uganda. Picture: Training of VHTs and LC1s Sheema, Malaria Consortium The Village Health Teams Picture: Stop Malaria Project In each sub-county, healthcentre nurses treat 10,000-50,000 people. Health workers feel futile in rural clinics. They are often underpaid and lack resources and essential drugs to treat their patients. In 2000, Uganda first reported the impact of their Village Health Teams (VHTs) consisting of 9-10 volunteers per village. Initially their duties were to maintain birth and death registration, utilizing community based management of common childhood illnesses including malaria, diarrhea and pneumonia and monitoring of ARV adherence. In 2010, Uganda adopted the integrated community case management (iccm) strategy where two of the five VHTs members are responsible for diagnosis and treatment of common childhood illnesses including malaria, pneumonia, and diarrhoea in addition to the 30

31 preventive platform. [Source: Malaria Reduction Strategy ]. The rollout of the VHT programme took time and currently, the VHT s tend to be getting training updates on a project-by-project basis, rather than national through a national training programme. VHTs need regular training since they only receive a 5 day initial government training on volunteering. The UC Campaign was the first time the VHT s had been utilised on a nationwide programme, other than in mass immunization programmes. VHTs cost considerably less than health centres and their worth has been proven. Health centres report fewer cases of communicable diseases when VHTs are present (AkshaySanghi, JHU ). VHTs give personalized and local care and are trusted by their community. They were certainly a pivotal element of the UC campaign which could not have been conducted without them. Pictures: Malaria Consortium VHT Profile: Meet Grace Katumba Village Health Team (VHT) Volunteer I learnt and saw the tremendous work of the VHT I applaud the village health workers as the backbone of this campaign Linden Morrison, Head High Impact Africa II Department, GFATM at closing ceremony (18 Aug 2014) Picture: Grace Katumba VHT, Stop Malaria Project Uganda 13 A. Sanghi. Village Health Teams Incorporation in Uganda s Healthcare (JHU) The Triple Helix Spring

32 Grace, a farmer from Mityana district, is typical of the committed, community-spirited volunteers, who formed the backbone of the campaign. Grace has been serving her community for five years. She first trained as a Community Based Distributor and then in 2012 was last trained as a VHT. She spends three hours a day as VHT, visiting on average of four homes a day. Grace pays regular visits to a total of fifty homes in her village. She calls on her neighbours and talks to them about the importance of cleaning their homes and taking their children for immunisation; she also gives out de-worming tablets and vitamins. Grace was called to participate in the Universal Coverage campaign, identified by the Local Council 1 (LC1) chairperson. During registration she worked long hours for three days. She visited village homes, knocking on doors to ask the number of people in the household and explain the registration and distribution process. Often villagers were not at home and so Grace had to go back to homes after 8pm. When asked how she was received by the village people, Grace said that she had been well received, - they trust me, she stressed. It is the trust established between VHTs and their communities that makes VHTs influential advocates for the use of LLINs and other essential health initiatives. Grace recounted that at the time of distribution of nets, close to people came for distribution at the parish. A buzz had been created since villagers had spotted the huge trucks delivering the nets at the parish headquarters. Grace described the chaos at the parish since villagers gathered there, rather than at the chosen distribution points in the villages, once they had heard the news. There had been a miscommunication. However, the villagers rallied, once it was clear that distribution could not progress. The Local Chairpersons and Health Assistants called for people to go back to their villages. Bales of nets were carried back to the village by VHTs using their bicycles. Grace explained that many VHTs in Mityana had received bicycles to carry out their work and so they were able to carry one bale per bicycle back to the village, assisted by many others who had arrived to help. Grace received UgSh15,000/- facilitation for the three day registration but had not yet received anything for her distribution duties. Grace pointed out the she had notice that the maize is ripening and it is mango season when malaria is present, but not so many people are in hospital falling sick with malaria fever now. She said that she is also aware that people going to hospital for suspected malaria do not seem to be having malaria now they are being sent back from the hospital with pain killers for simple fever, rather than malaria. Grace wants people to understand that her role is important in the community. She is helping prevent disease. She said, You know you are doing something good when you move in the sub-county you won t see a distended stomach. 32

33 Grace said that she would be happy to use SMS to send and receive messages for health informatics especially as it helps people to understand the vital role she plays. Picture Picture: Grace Katumba, VHT,Stop Malaria Project Uganda This is a commitment for my people As a VHT, I want to work for my people. Grace Katumba, VHT 33

34 THE MOBILISATION EFFORT 112 District Task Force Teams Up to 14 people on each team 1,568 people 1328 Sub-County Task Force Teams Up to 5 people on each team 6,640 people 60,501 Village Health Teams Up to 2 people on each team + 1 LC1 Chairperson 181,503 people Distributed 22,289,644 LLINs 41,034,354Ugandans 34

35 VITAL HELP FROM EXTERNAL PARTNERS The Role of Uniformed Services External Stakeholders The President of the Republic of Uganda directed the Uniformed Forces to support the distribution of the nets warning that no theft or misappropriation of the nets whatsoever will be tolerated. The Ministry of Health made provisions in the Implementation Guidelines for the uniformed forces to provide security and to distribute the nets together with the VHTs. NCC Sub Committees District Task Forces Sub County Task Forces Village Health Team s & Community Members Picture: Army leadership with the Soroti Municipality MP during the launch of the campaign in Soroti, Malaria Consortium The smoothness and success of the campaign was aided by the planning of the management teams, including District Internal Security Officers (DISOs) and Gombolola Internal Security Officer (village level) (GISOs) and by the security provided by the uniformed forces. The uniformed forces provided security - the Uganda People s Defence Force(UPDF) and the Uganda Police Force (UPF) supported security of the LLINs at various levels, depending on their capacity on the ground in the various sites at sub-county stores, during transportation of the LLINs to and from the SC stores to the distribution points and at the village level distribution points, where they maintained crowd control. 35

36 Pictures: Security of UPDF and UPF, Malaria Consortium To ensure their total involvement, the District Police commander, the District Internal Security Officer and the Resident District Commissioner were part of the district task force team that planned and oversaw the distribution in the district. During the distribution in, Mukono district, 39 bales were reported as missing or stolen. Using joint operations by the Uganda Police and UPDF, the missing nets were recovered and brought back to MOH stores. Other attempts to steal or grab nets during the distribution exercise in various parts of the country were diffused or contained by the security personnel deployed during the distribution exercise. Picture: Uganda Police Force (UPF), Malaria Consortium As part of its contribution to the universal coverage campaign, the Government of the Republic of Uganda committed to fund the participation of the security/uniformed forces in the exercise by allocating 5 billion Uganda shillings to the Health Sector Budget to facilitate the uniformed forces during the LLIN mass distribution campaign. 36

37 This was an unusual event we have not had anything like this kind of work before. We had worked on some national exercises, security for the registration ID, but this was different.have been in touch with the DPC in Mukono very important to share lessons with colleagues from other districts Police UPF Peter Nkulega District Police Commissioner (DPC) for Kira Town Council, at Kampala Distribution External Monitoring This Medicines and Health Service Delivery Monitoring Unit (MHSDMU) was set up in 2009, under the office of the President, to monitor the health sector in a bid to strengthen systems and the overall capacity of the health sector in Uganda and improve health services delivery in the country. The unit monitors the management of essential medicines and health service delivery accountabilities nationwide and takes appropriate action with the other government stakeholders i.e. Ministry Of Health, DPP, Uganda Police (IGP), Auditor General, and development partners. It is a multi-disciplinary unit made up of doctors, pharmacists, lawyers, auditors, M&E specialists, and criminal investigators. Picture: Monitors in Campaign T-shirts, Malaria Consortium For the LLIN campaign, the unit functioned as the external programme monitoring unit. They acted as a link between the LLIN campaign and the administrative function at local government level. However, the MHSDMU acted beyond simply external monitoring. How MHSDMU benefitted the Campaign Ensured that the campaign was embraced as a government programme Ensured maximum cooperation at district level Ensured that the programme was taken down to grassroots Acted as advocates for the campaign and its activities Investigated criminal cases immediately for theft of LLINs 37

38 The unit handled problems at the time of implementation. For example, there was initial resentment in Arua when they questioned the use of centrally appointed Campaign District Supervisors. It was believed that the local university graduates could have been employed for this work. MHSDMU personnel were able to intervene and talk with the RDC and LC5 Chair to explain the rolling wave campaign process and that this was a government programme, so no short cuts could be taken. The authority of the department helped ensure that there was recognition of the importance placed on this campaign. We helped in diffusing the red-tape at the district level. Many expected a financial reward, as they were aware of the high level of donor support for this campaign, but the presence of MHSDMU ensured that district personnel understood the campaign policies. The unit worked with the DISO, who were instrumental in the campaign for coordination and intelligence. This function was further enhanced by the ability of the MHSDMU to act on criminal investigations. For example, in Luwero District, 20 bales were stolen in-transit. All 20 bales were recovered. The process of investigations were started by the unit and then passed on to local level to deal with. This meant that thefts were acted on quickly and so recovery of stolen nets was made possible. There were negligible losses in this campaign. This unit was very close to the ground, in terms of monitoring implementation and so was very aware of the difficulties of operating at sub-county and village level. They witnessed the confusion over facilitation of UPDF and VHTs; the difficulties with local transportation within the districts and the scrabbling for resources that was required when plans went awry. It was extremely beneficial to have members of the unit from different arms of government, the professions and with direct access to the President to ensure matters were dealt with efficiently and effectively. They will produce their own comprehensive report in October Quiet diplomacy and assistance from a particularly interested party The US Ambassador, Scott Delisi, had a personal interest in malaria. Much of the US donor funds were spent in health and so this was an important area of US government support to Uganda. On occasions, particularly early on, when the MoU was still being negotiated, the Ambassador offered to speak directly with the President to help to explain difficulties, which had arisen. For example, the facilitation of the UPDF and UPF required funding but foreign aid funding could not be provided directly to support military expenditures, so the Ambassador took up this delicate issue. The President himself was then able to sanction government payment to the UPDF, because he saw the importance of Uganda supporting this essential security function. A different sphere of influence was beneficial to the campaign process in keeping things moving forward. Dr. BK Kapella, Senior Malaria Technical Advisor CDC 38

39 Picture: HE President Museveni (left), British High commissioner Alison Blackburn (center) and US Ambassador Scott Delisi(right) at Kampala Close-out event, New Vision 39

40 KEY ACHIEVEMENTS Pictures: Stop Malaria Project and Malaria Consortium Uganda completed the LLINs universal coverage campaign in all 112 districts Number of people registered in all districts: 41,034,354 LLINs distributed: 22,289,644 Kampala and urban Wakiso distributed 1,866,845 LLINs, after reallocation, achieving an administrative coverage of 74% Administrative coverage, excluding Kampala and Wakiso was 91% Total national administrative coverage (including Kampala and Wakiso) was 89% Estimated cost per net delivered of $0.89 Estimated over 53, malaria related deaths prevented among children underfive years 14 WHO estimate for Uganda 40

41 At the time of writing this report, Uganda is still waiting for complete impact research data, however anecdotally the impact has certainly been felt at community level, as heard from community members. See selected quotations from various community members (next page). Anecdotally, the impact was immediately felt by community members The net has reduced the mosquito bites. I no longer worry about getting malaria Female Villager in KayubgaVilage, Mafubira sub-county, Jinja The community are happy that mosquitos are greatly reduced Kiganira Mohammed LC1 Chairperson, KayubgaVilage, Mafubira sub-county, Jinja At least 4 times a month someone in the family would have fever I know the value [of the LLIN] and would buy Female Villager in KayubgaVilage, Mafubira sub-county, Jinja I have noticed now whenever the kids are at home, they rarely fall sick Male Villager in KayubgaVilage, Mafubira sub-county, Jinja Picture: Stop Malaria Project New partnerships have been formed [i.e. DHO and DISO] we re happy to meet and work together in future. Mityana District Health Officer (DHO) and District Internal Security Officer (DISO) 41

42 It s planting season now and I see people planting we used to see many were sick and fields untended VHT Busimbi, Mityana I know that nets have had impact there are fewer quantities of malaria drugs required from health facilities. Mityana, Busimbi sub-county chief and GISO Normally they ensure drugs from District Medical Stores get to the Health Centres in the past anti-malarial drugs would not last 2 weeks now the number available can push on for a month.. Jinja DISO The health staff tells us that the number of [malaria] cases registered at health centres has gone down Jinja DISO This has been one of the best programmes I have seen it has been most successful in reaching the community Busimbi sub-county chief, Mityana Pictures: Stop Malaria Project People are attributing wellness to the net VHT, Jinja We didn t really expect any facilitation, we knew it was for the country and it was going to help all Ugandans 42 Iganga DISO

43 KEY LESSONS Pictures: Malaria Consortium Key Lessons Learned It is essential to take the time to secure a Memorandum of Understanding acceptable to all partners Full and explicit implementation guidelines must be developed which can create clarity for planning and implementation at all levels Political commitment must be sought from the highest level to ensure success and high level advocacy All partners in key decision making positions must be prepared to take informed risks and respond rapidly Country ownership of the process and implementation is a prerequisite for a successful campaign which can then be bought into from all levels of government structures Passion, commitment and strong leadership are essential to create positive synergy in partnerships Donor coordination and flexibility is critical in ensuring all speak with one voice and provide necessary resources when required An effective partnership of stakeholders instilled with trust and confidence contributes greatly to the success of the campaign Flexibility and the desire to go beyond the usual scope of work can be found at all levels when executing a campaign of this scale and national importance 43

44 Ugandan government structures at all levels are functional and can be called on to execute a campaign of this nature and scale A monitoring team with a presence at all levels and the powers to act quickly to investigate crimes can help prevent problems and ensure issues are resolved in a timely way New multi-disciplinary partnerships have been formed at district and sub-county level and these are likely to be sustained after campaign closure The power and potential for the VHT cadre is pivotal and can be further utilised with increased support through training and/or facilitation The immediate impact seen in a campaign of this nature is highly motivational to those involved and this helps to encourage people to work above and beyond their normal call of duty It is safer to estimate LLIN need based on a divisor of population of 1.64, rather than 1.8 used (The Chair of the Logistics sub Committee) [See also: Kilian, ] It is important to maintain the momentum and the gains from campaign activity and dovetail as seamlessly as possible into the new Malaria Reduction Strategy ( ) Strengthening the ANC LLIN distribution system and piloting new continuous distribution channels will be essential to ensuring there are limited interruptions to universal coverage. Pictures: Malaria Consortium 15 Kilian, A et al How many mosquito nets are needed to achieve universal coverage? Recommendations for the quantification and allocation of longlasting insecticidal nets for mass campaigns Malaria Journal 2010, 9:330 44

45 Challenges Maintaining momentum and campaign activities while operating in a political climate of fragile international diplomatic relations Lack of stability in leadership at the central level to coordinate the Advocacy, Communication and Social Mobilization committee and the limited IPC reduced on the impact of the BCC campaign District level ownership was not guaranteed in all districts. Many recommended that implementation could be further decentralised or district partners could be included earlier in the planning process and allowed greater input into the planning There is no guarantee that a Universal Coverage campaign can be funded again, therefore it is important to ensure continuous distribution following campaign activity. It is important to ensure that there is sufficient capacity to quality-assure nets and clear them quickly from the National Drug Authority. The NDA did not have the capacity for testing of LLINs for quality when brought into the country, causing delays in distribution Restricted access to real-time data caused frustrations for planning. However, it is necessary to budget for significant investment in data capture and feedback systems to ensure they are fully functional. A barcode system of tracking LLIN bales could also link logistics and implementation. There were insufficient supplies of nets for the urban areas of Kampala and Wakiso. This was an unfortunate outcome due to the lack of action on reports of possible shortfalls. The reallocation of ANC nets by PMI to support UC reduced on the shortfall for nets 45

46 Pictures: Malaria Consortium and Stop Malaria Project It was a true partnership - the NMCP, VHTs, UPF, UPDF, JHUCCP - Stop Malaria Project, Malaria Consortium can be very proud of what you have achieved together Alison Blackburn, British High Commissioner to Uganda, at closing ceremony, 18 Aug

47 THE LEGACY Uganda s Campaign Innovations Leave a Powerful Legacy Picture: Malaria Consortium Universal Coverage at Speed and Scale Uganda has been successful in implementing the largest continuous universal coverage campaign in the world. The country is now primed to make a significant impact on malaria reduction. Malaria-ravaged countries throughout Africa can learn valuable lessons for implementing continuous Universal Coverage campaigns. Uganda is at a tipping point - the LLIN UC campaign has provided a platform for many other things Dr Jim Arintaitwe, FCO GFATM MOH Security for a Campaign of National Importance Picture: Malaria Consortium 47

48 Utilisation of the uniformed personnel ensured enhanced security and a sense of national importance behind the distribution and use of LLINs in Uganda. In addition, H.E. President Museveni invoked the Public Health Act to punish individuals found misusing their newly acquired LLINs (see Monitor article below) Misusers of mosquito nets face arrest President Museveni says homes will be inspected to ensure that the mosquito nets are used effectively. You could get yourself jailed for an unspecified period of time if you are caught misusing the recently distributed mosquito nets. And if you are thinking of making a make-shift bathroom using that net or turning it into a fishing net, think twice because the Public Health Act which the President has invoked could be used against you..warned..should be accused of sabotaging government programmes.in this case eliminating malaria. The Monitor, Monday August 18, 2014 Picture: The Monitor We will reach a point where the mosquito bites will no longer transmit malaria the obuwoka (Plasmodium falciparum) will be eradicated. Influential Support of Monitoring Unit HE The President of the Republic of Uganda, during closing speech, 16 Aug 2014 The creation of an influential unit of external monitors who have the ability to act immediately to support campaign implementation requirements and remove potential barriers was hugely beneficial in ensuring that eyes and ears were kept on the ground. The MHSMDU supported the monitoring functions of district supervisors and coordinators, but in addition they were able to sway district level politicians who were not prepared and also bring in an additional layer of security and follow-up on any misdemeanours committed. Potential for Revolutionary Informatics The LLIN campaign enabled the development of the potential for powerful use of big data. A great deal of data has been gathered and entered on a dedicated database, which holds population data for LLINs, but which can be applied to other areas of health at household level. The inclusion of mobile phone numbers of LLIN recipients and VHTs makes it possible for follow up campaigns to be conducted using SMS for informatics and LLIN behaviour change communication. The ground is now set for the establishment of institutional informatics for the of benefit malaria, heath and beyond 48

49 Picture: Household Registration Form used in both registration and distribution, Malaria Consortium It is clear from the many interviewed for this report that Uganda has undergone something unprecedented in its history. The impact will be felt in malaria and health circles, but also wider than this. The decentralisation of government powers has put local government structures in place, which can be called on to rally behind issues of national importance. Though the campaign may have not been conducted perfectly, but it proved successful in attaining high administrative coverage levels of 89% and huge lessons have been learnt for future projects at scale within and beyond Uganda s borders. This is the way government should work across all areas, not just for malaria DISO, Jinja It is now critical that malaria control partners advocate for funding of multi-pronged approaches to continuous distribution, if we are to sustain the hard-won gains of Uganda s Universal Coverage Campaign. 49

50 Picture: Stop Malaria Project Uganda We now have the evidence to show what can be achieved with collective action Dr Jane Ruth Aceng, Director General of Health 50

51 STAKEHOLDERS INTERVIEWED Dr. Jane Ruth Aceng Director General Health Services Ministry of Health (MOH) Dr. Mukooyo Eddie Assistant Commissioner MOH Dr. Albert Peter Okui Program Manager NMCP MOH Dr Kassahun Belay Senior Technical Advisor PMI/USAID Dr BK Kapella Senior Technical Advisor PMI/CDC Romano Fernandez Technical Advisor JHU CCP Catherine Chime Mukwakwa Chief of Party Stop Malaria Project Dr Godfrey Magumba Country Director Malaria Consoritium Lawrence Mumbe Programme Manager Stop Malaria Project Simon Peter Waigumba District Coordinator (1) Malaria Consortium Dr Jim Arinaitwe NMCP FCO Global Fund Godfrey Kkanu District Coordinator (2) Malaria Consortium Mariam Nabukenya District Coordinator (3) Malaria Consortium Herbert Magumba District Coordinator (4) Malaria Consortium Oleja Charles Logistics and Admin Manager Malaria Consortium Dr Charles Ayume Assistant Director Medicines Monitoring Unit Dr Henry Katamba M&E Advisor NMCP Patience Karungi District Supervisor (1) NMCP MedaadRukaari Technical Officer NMCP Mathias KasuleMulyazaawo M& E Officer NMCP BadruGidudu Project Manager Malaria Consortium Peter Nkulega District Police Commander Mary, Peter MMU Monitor (x2) Allan Muzzanganda Volunteer VHT, Kampala Mohammed Balinimwe VHT, Kampala Dr Sam SidudaGudoi Senior Technical Advisor Malaria Consortium Esther LunkuseLutaaya RDC, Mityana Asst District Health Officer Joseph Muwanga (DHO) Tugume Wenceslas DISO, Miyana and Iganga Dr Faith Makiyima Malaria Focal Person Tom Miro Sub County Chief Gombolola Internal Security Hussein Kato Officer Grace Katumba Village Health Team Robinah Mwangale District Health Educator William Buzigi Dep DISO, Jinja Gombolola Internal Security TardeoTibulija Officer Mohammed Kiganira LC1 Village Health Team + Joy Nabiryo Community 51

52 Kenneth Mulondo BCC Coordinator (ex) Stop Malaria Project (ex) 52

53 Acknowledgements The compilation of this report would not have been possible without the substantial time and support given to the author from the staff at Stop Malaria Project, most notably Catherine Chime Mukwakwa (Chief of Party) and Lawrence Mumbe (Universal Campaign Coordinator); and indeed the generous time and candid responses offered by all stakeholders interviewed. These interviews took place during the final push of the campaign distribution in Kampala and Wakiso, from 11 th -22 nd August Many of these stakeholders were exhausted and yet elated at the end of this long campaign. Tears were shed at the final distribution event, held in Mulago, Kampala and it was clear that Uganda had undergone a transformational exercise, both for the continued effort to prevent malaria; and for the implementation of efficient and effective government-led programmes into the future. Picture: Stop Malaria Project This report is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of USAID/JHU Cooperative Agreement No. 617-A The contents do not necessarily reflect the views of USAID or the United States Government. 53