STATEMENT OF OBJECTIVES FOR RHITES-N, LANGO
C.1 PURPOSE
The purpose of the Regional Health Integration to Enhance Services – North, Lango (RHITES-N, Lango) contract is to increase the access and utilization of quality health services in the Lango Region of Northern Uganda, developing health systems to sustain these goals. Working through a life-cycle lens, over five years this contract is expected to contribute to measurable improvements in key population-based national health indicators.
C.2 SCOPE
USAID requires services to strengthen the capacity of Ugandan institutions and communities to increase access to and utilization of quality, integrated health services in the Lango Sub-Region of Northern Uganda in eight districts in Northern Uganda. These include Amolatar, Alebtong, Apac, Dokolo, Kole, Lira, Oyam, and Otuke (Attachment J.10). The Uganda Bureau of Statistics (UBOS) 2014 population estimate for the target districts is approximately 2.2 million Ugandans, of which as many as 49% are below the age of 15 (~1.1 million) and 20% are below the age of five (~450,000).
Figure I: Lango Sub-Region by PEPFAR Category and SMGL Classification, 2015District / PEPFAR Category / SMGL District
Amolatar / Sustained / No
Alebtong / Sustained / No
Apac / Scale Up / Yes
Dokolo / Scale Up / Yes
Kole / Scale Up / No
Lira / Scale Up / Yes
Oyam / Scale Up / No
Otuke / Sustained / No
RHITES-N, Lango is one of five upcoming USAID/Uganda activities for comprehensive regional health and HIV/AIDS programs to build on USAID health programs ending in 2015 and 2016. These current and past programs are Strengthening TB and HIV/AIDS Responses East Central (STAR-EC), STAR-South West, STAR-East, and STRIDES for Family Health; which are implemented by JSI Research and Training Institute, Elizabeth Glaser Pediatric AIDS Foundation, and Management Sciences for Health, respectively. By responding to disease-specific burdens in respective regions and concentrating increased resources on specific interventions in focus districts, RHITES-N, Lango is expected to provide a significant, measurable, and lasting impact on key indicators such as HIV and malaria prevalence; maternal, neonatal and child mortality; met need for modern contraception; and child development outcomes, as the activity builds health systems to sustain the local capacity to improve the availability of quality health care.
Support will target public, private and private-not-for-profit facility level and community level health care platforms, to improve high impact, evidence based, preventative and curative family planning and reproductive health (FP/RH), maternal, newborn, and child health (MCH), malaria, HIV/AIDS, tuberculosis (TB), water, sanitation and hygiene (WASH), and nutrition services. Priority will be given to strategic integration of services as a means of achieving greater efficiencies and effectiveness across all program areas. Integration of services is supported by existing policies and plans, including the revised National Health Policy (NHP II) and the Health Sector Strategic and Investment Plan (HSSIP). How the support is provided matters, this effort requires high levels of innovation and a creative approach to partnership to not just deliver services directly, but to build capabilities for these services to be provided locally.
Changes in the Government of Uganda (GOU) Ministry of Health (MOH) policies and programs, uncertainty of emergent health care priorities, and fine-tuning of USAID development interests make it difficult to anticipate how USAID requirements will evolve over the life of the contract. The contractor must be able to demonstrate capacities for adapting to changes, as well as the ability to learn through collaborative partnerships to rapidly incorporate changes in health programming priorities and policies, and advances in technology to ensure the GOU will continue to build a national health system that is more cost effective and efficient. For example, the contractor will be required to implement priority activities in line with PEPFAR 3.0 guidance (see Attachments J.11-J.13), DREAMS and SMGL Phase II scale-up (See Figure I). Innovative and evidence-based approaches that systematically improve the GOU’s health care system will be continuously incorporated into program implementation throughout the life of the program. Linking shifting policies, service delivery programs, effective capacity building and building local networks to improve health will demand a problem-solving mentality and a holistic understanding of the health organizational dynamics in the region and their interface with national entities.
C.3 BACKGROUND
USAID/Uganda’s health and HIV/AIDS portfolio has evolved over time from a parallel, disease-focused approach to an integrated health systems strengthening approach for primary health care, in line with Uganda’s Health Sector Strategic and Investment Plan (HSSIP). Under USAID/Uganda’s 2011-2015 CDCS, the Mission defined a set of strategic shifts to address the health needs of largely rural Ugandans to realize equitable access to quality services, improved individual and community outcomes, and strengthened health systems. The key strategies are to:
· Improve integration of service delivery and systems strengthening in USAID’s health portfolio;
· Conduct service delivery in ways that positively affect systems strengthening and reduce dependency-producing partnerships across the portfolio;
· Support the strengthening of decentralized health services with greater community citizen control and accountability;
· Facilitate improved engagement of Uganda’s private health sector, especially not-for-profits;
· Promote civil society, civic engagement, and advocacy so that Ugandan policy makers increasingly make the necessary investments for basic health service delivery.
While this activity currently falls under USAID/Uganda’s 2011-2015 Country Development Cooperation Strategy (CDCS), the mission is currently developing its CDCS 2.0, which will run from 2016-2021. While still in draft, it will likely feature the need to improve key systems accountability and responsiveness, as well as positively shifting demographic drivers. In the two years prior to the launch of the CDCS 2.0 development process in March 2015, USAID conducted a series of learning exercises from the implementation of CDCS 1.0. These exercises ultimately generated several top-line, strategic-level lessons learned which impact RHITES-N Lango including:
· The systematic application of a thoughtful and deliberate Collaboration, Learning and Adapting (CLA) approach to programs achieved better results;
· When integration is built into project and activity design, and deliberately managed through implementation, results are transformational;
· Neither Ugandan systems nor USAID assistance has to date given appropriate weight to the youth bulge and its attendant effects, raising questions about long-term sustainability.
Under the new CDCS, this activity will mainly contribute to the following draft IRs:
IR 1.1: Citizens actively participate in development,
IR 1.2: Key elements of systems strengthened,
IR 1.3: Enabling environment that supports functional systems improved,
IR 1.4: Transformative Leadership Developed,
IR 2.1: Adoption of reproductive health behaviors and practices increased,
IR 2.2: Child well-being improved, and
IR 3.1: Enhanced prevention and treatment of HIV, malaria, and other epidemics among the most vulnerable.
This activity will therefore be implemented in accordance with the revisions and assumptions that will guide the new CDCS.
Geographically, services will be targeted on the basis of:
1. Regions and facilities prioritized by epidemiology, population, and potential to leverage other USG investments;
2. Districts as organizing units for service delivery investments within the priority regions; and
3. The GOU’s and other donors’ complementary efforts within the regions and districts to ensure well-coordinated, non-duplicative efforts.
Integrated services will include a priority package of high impact, evidence-based HIV/AIDS and TB prevention, care, and treatment interventions; malaria prevention and control; family planning services; newborn and child survival interventions that include child development approaches; management of obstetrical complications through treatment, referral, and prevention; focused antenatal care (ANC); and nutrition outreach. Measurement of success will go beyond disease specific achievements, also being measured from a systems perspective. Experience has shown that without structural integration, technical integration is less likely to succeed.
USAID/Uganda has been working on health in the North for many years, including technical assistance and capacity building interventions under the Northern Uganda Malaria, AIDS and Tuberculosis (NUMAT) and USAID/Uganda’s Northern Uganda – Health Integration to Enhance Services (NU-HITES) Project. NU-HITES was designed to build upon primary healthcare provisions and was set up to provide “…additional support in Maternal, Neonatal and Child Health (MNCH), HIV, Family Planning (FP) and nutrition, while prioritizing the strengthening of district level health systems.
The next Demographic and Health Study (DHS) is expected in early 2016, with preliminary results anticipated in late 2016. Analysis of the 2011 DHS suggested that the health conditions of Ugandans were stagnating or improving only modestly, with some indicators worsening over the past five years. Significant issues contributing to these trends are:
a) Rapid population growth: Rapid population growth compounded with high disease burden and mortality contribute to Uganda’s slow progress in improving key health indicators. With an estimated population of more than 35 million, a total fertility rate of 6.2 births per woman nationally (6.3 births per woman in the Northern Region) and a population growth rate of 3.2%, Uganda’s population is expected to double within 20 years and reach an estimated 100 million by 2050. While family planning use has slowly increased over the past decade, the unmet need nationally stands at 34% (and nearly 42.5% in Northern), with only 26% of currently married Ugandan women using a modern method of contraception. Adolescent fertility rates in Uganda also remain among the world’s highest and 24% of women between the ages of 15‐19 are either already mothers or pregnant. Sustained high fertility rates over the past decades have stretched national capacities to provide necessary services and created an enormous youth bulge, with half of the current population under 15 years of age.
b) High disease burden and mortality: Despite recent improvements in some maternal and child health indicators, these positive trends are tempered by significant infectious disease burden and under nutrition:
· HIV, malaria, and TB continue to account for a major portion of Uganda’s disease burden. Although National HIV prevalence declined steadily to 6.4% in 2006, it rose to 7.3% in 2011. The 2011 AIS HIV prevalence for the Mid Northern region was 8.5% (6.3% for men and 10.1% for women). Uganda’s malaria prevalence is among the highest in Africa, and malaria is the most frequently reported disease contributing to maternal mortality. Malaria continues to be a major cause of morbidity and mortality for pregnant women and contributes to as much as 20% of deaths among children under five years of age. The Lango sub-region of Northern Uganda has the highest prevalence of malaria in Uganda. Northern Uganda, in particular, experienced an outbreak of malaria in 2015, after years of downward trends. TB is also a major cause of morbidity with HIV/AIDS co-infection (at 64%) and emergence of multi-drug resistant TB (MDR-TB) has been identified as an issue in the Lango region.
· Maternal mortality remains high and showed no decline from 2006 to 2011 despite increases in skilled birth attendance (from 42% to 59%) and increases in the number of women delivering in health facilities (from 41% to 57%) during the same time period. In the Northern Region, 53.4% were delivered by a skilled birth attendant and 52% delivered in a health facility.
· Newborn mortality has also remained unchanged from 2006 to 2011, although infant mortality and under-five mortality have declined. Under nutrition continues to be a significant underlying cause of death among children under five. In 2010, Uganda tied for the seventh highest number of under-five deaths globally with 2% of global child mortality and 13% of Uganda’s post-neonatal mortality attributed to diarrhea.
c) Weak health systems: Between the 1980s and 2000s, Northern Uganda experienced more than twenty years of armed conflict between the Government of Uganda (GoU) and Lord’s Resistance Army (LRA). The resulting humanitarian crisis led to the displacement of over 90% of the population of the Acholi sub-region and a lesser percentage of the population of Lango sub-region into IDP camps. Living conditions in the camps were extremely poor with very high prevalence rate of HIV and tuberculosis, violence and gender based violence.
While it has been almost 10 years since the Cessation of Hostilities Agreement was signed and relative peace ensued, the local health system is still marred by this history. In general, most primary care facilities in the rural Uganda are owned publicly or by private-not-for-profit providers. Throughout the conflict and transition periods, health services in Northern Uganda were mostly provided by local and international NGOs, particularly faith-based organizations. The brutal nature of the LRA and its fondness for abduction of women (who comprise a significant percentage of the health workers population in the area) resulted in most public health workers abandoning their posts for safer parts of the country. While human resource challenges related to recruitment, distribution, retention, and performance (e.g. pay, motivation, management) cut across the country, the conflict in northern Uganda exacerbated them.
As is often the case, the transition from humanitarian to development assistance has not been easy. Even after a number of years of significant donor assistance, key constraints to delivering and improving the quality, access and availability of health services remain. A largely rural sub-region, poor road access, weak administration centers, and distinct social/cultural barriers to healthy behaviors – exacerbated by high illiteracy and poverty levels – play important contributing contextual roles.
Governance and fostering stronger Ugandan political commitment to health in Northern Uganda also remains a key concern. For example, while more health facilities were constructed, rehabilitated, and equipped during the Peace Recovery Development Plan, according to the 2011 DHS, women in the southwestern and the northern parts of the country (the areas with highest infant and under-five mortality rates) still reported the greatest access challenges. Numerous site implementation and monitoring visits (SIMS) completed by USAID to the Lango sub-region in 2014 and 2015 consistently pointed out weak referral systems, late care-seeking practices, and the need to improve community health seeking and support systems.
C.4 PERFORMANCE OBJECTIVES AND ILLUSTRATIVE RESULTS
The goal of USAID/Uganda’s Health programming is to improve health and nutrition status in the project areas in which we work. The purpose of the Regional Health Integration to Enhance Services in Northern Uganda, Lango (RHITES-N, Lango) activity is to increase the effective use of integrated health services in the Lango Region of Northern Uganda and develop health systems to sustain these gains. This will be accomplished through three sub-purposes: