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1 CCM Request for Renewal 26 September 2013.

CCM Request for Renewal · 1.2 CCM Approval of Request for Renewal ... SOP Standard Operating Procedures ... UGD-T-MOFPED 1. st. July 2014

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CCM Request for Renewal

26 September 2013.

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Table of Contents

LIST OF ABBREVIATIONS AND ACRONYMS ............................................................................................ 5

SECTION 1: SUMMARY OF REQUEST ......................................................................................................... 7

1.1 General Program Information .................................................................................................................................... 7

1.2 CCM Approval of Request for Renewal ....................................................................................................................... 7

1.3 Summary of CCM Request for Renewal ...................................................................................................................... 9

1.3.1 Summary of Request ................................................................................................................................................ 9

1.3.3 CCM Request for Renewal .................................................................................................................................... 11

SECTION 2: CCM GOVERNANCE ................................................................................................................. 12

2.1 CCM Governance Overview ...................................................................................................................................... 12

SECTION 3: COUNTRY CONTEXT .............................................................................................................. 19

3.1 Epidemiological situation ......................................................................................................................................... 19

3.2 Country Context ....................................................................................................................................................... 20

3.3 Health Systems Analysis ........................................................................................................................................... 21

SECTION 4: PROGRAM OVERVIEW .......................................................................................................... 32

4.1 Financial Gap Analysis, Counterpart Financing and Additionality ............................................................................. 32

4.1.1 Overview of Government Financing of the National Program ......................................................................... 32

4.1.2 Estimation of Current and Anticipated Domestic and External Funding ...................................................... 34

4.1.4 Compliance with Counterpart Financing Requirements .................................................................................. 36

4.2 Progress towards Proposal Goals and Impact/Outcome ........................................................................................... 39

4.3 Program Effectiveness .............................................................................................................................................. 57

4.3.1 Aid Effectiveness .................................................................................................................................................... 57

4.3.2 Equity ...................................................................................................................................................................... 58

4.3.3 Value for Money ..................................................................................................................................................... 58

4.4 Quality of Services Assessment ................................................................................................................................ 60

4.5 Partnerships ............................................................................................................................................................. 62

SECTION 5: CURRENT PHASE/IMPLEMENTATION PERIOD PERFORMANCE (PR 1) .............. 63

5.1 Programmatic Achievements and Management Performance .................................................................................. 63

5.1.1 Programmatic Achievements ................................................................................................................................ 63

5.1.2 Grant/SSF Risk Management ............................................................................................................................... 68

5.1.3 Grant Performance Rating .................................................................................................................................... 71

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5.2 Financial Performance .............................................................................................................................................. 72

5.2.1 Financial situation at cut-off date ........................................................................................................................ 72

5.2.2 Analysis of expenditures versus budget .............................................................................................................. 73

SECTION 6: CCM REQUEST FOR RENEWAL (PR 1) .............................................................................. 75

6.1 Programmatic Proposal ............................................................................................................................................ 75

6.1.1 Program Objectives, SDAs, Indicators and Targets ........................................................................................... 75

6.1.2 Pharmaceutical and Health Product Management (if applicable) .................................................................. 77

6.2 Financial Proposal .................................................................................................................................................... 79

6.2.1 Resources available to finance the grant/SSF after cut-off date ...................................................................... 79

6.2.2 Summary funding request from cut-off date to end of next Phase/Implementation Period ...................... 80

6.2.3 CCM Budget Request for the next Phase/Implementation Period ................................................................. 80

6.3 Compliance with Focus of Proposal Requirement ..................................................................................................... 82

SUPPORTING INFORMATION (TO BE SUBMITTED WITH THE CCM REQUEST) ....................... 83

ANNEXES ........................................................................................................................................................... 83

Annex 1 CCM Oversight Plan ................................................................................................................................... 83

Annex 2 Conflict of Interest (COI) Policy .................................................................................................................. 83

Annex 3 A summary of the preparation process for TB SSF Renewal Request ......................................................... 83

Annex 4 The Minutes of the CCM Resource Mobilization Committee Meeting ....................................................... 83

Annex 5 The Minutes of the CCM Board Meeting ................................................................................................... 83

Annex 6 Fund flow mechanism for GF TB SSF Grant ................................................................................................ 83

Annex 7 Joint External Review of the National TB Programme in the Republic of Uganda ...................................... 83

Annex 8 A concept paper on internal controls to manage food and transport refund for MDR patients. .............. 83

Annex 9 Progress on Conditions Precedents and GF concerns ................................................................................. 83

Annex 10 Comparative Analysis of Activities in Round 10 and TB SSF phase 2 .......................................................... 83

Annex 11 Performance Framework for Phase II, TB SSF ............................................................................................ 83

Annex 12 NTLP Strategic Plan 2012/13-2014/15 ....................................................................................................... 83

Annex 13 M&E Plan for the NTLP Strategic Plan ........................................................................................................ 83

Annex 14 National Drug Resistance Survey-Uganda .................................................................................................. 83

Annex 15 Assessment of HIV/STI/TB and Drug Abuse among Prisoners in Uganda,2009 .......................................... 83

Annex 16 Procurement and Supply Management (PSM) Plan ................................................................................... 83

Annex 17 Renewals Financial template (Financial Gap Analysis and Counterpart Financing ..................................... 83

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CCM Summary Budget Request, Financial Request, CCM analysis of the request versus original budget ....................... 83

Annex 18 Detailed budget ......................................................................................................................................... 83

Annex 19 Workplan .................................................................................................................................................. 83

List of Figures

Figure 1: Performance Achievement on Case Notification and Treatment Success 39

Figure 2: Performance achievement on Case notification of TB cases 44

Figure 3: Performance achievement on TB Treatment Success and stock outs 44

Figure 4: Performance achievement on TB/HIV collaboration 47

Figure 5: Performance achievement on DST and MDR indicators 49

Figure 6: Performance on timely reporting 56

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List of Abbreviations and Acronyms

ACSM Advocacy, Communication and Social Mobilization

ADPs AIDS Development Partners

AIDS Acquired Immune Deficiency Syndrome

ART Antiretroviral Treatment

ARV Antiretroviral

CBO Community Based Organization

CCM Country Coordinating Mechanism

CDC Centers for Disease Control

CIDA Canadian International Development Agency

CN Case Notification

CNR Case Notification Rate

COI Conflict of interest

CPHL Central Public Health Laboratories

CPT Cotrimoxazole Preventive Therapy

CSG Commodity Security Group

CSO Civil Society Organization

DHIS District Health Information System

DOT Directly Observed Treatment

DOTS Directly Observed Therapy Short course

DTLS District Tuberculosis Leprosy Supervisor

DTU Diagnostic and Treatment Unit

EMHS Essential Medicines and Health Supplies

FCO Focal Coordination Office

FY Financial Year

GDP Gross Domestic Product

GF Global Fund

GoU Government of Uganda

HC Health Centre

HDP Health Development Partners

HIV Human Immunodeficiency Virus

HMIS Health Management Information System

HSSIP Health Sector Strategic and Investment Plan

ICT Information and communication technology

IDA Internatinal Development Association

IEC Information, education and communication

IMR Infant Mortality Rate

JMS Joint Medical Stores

KAPs Key Affected Populations

KCCA Kampala City Council Authority

LAF Local Fund Agent

LED Light Emitting Diode

LMIS Logistics Management Information System

LTIA Long Term Institutional Arrangement

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MARP Most at risk population

MDG Millennium Development Goals

MDR Multi-Drug Resistant

MDR-TB Multi-Drug Resistant Tuberculosis

M&E Monitoring and Evaluation

MMR Maternal Mortality Ratio

MoFPED Ministry of Finance, Planning and Economic Development

MoH Ministry of Health

MTB Mycobacterium Tuberculosis

MTEF Medium Term Expenditure Framework

NA Not applicable

NAP National AIDS Programme

NGO Non Governmental Organization

NHS National Health System

NMS National Medical Stores

NSP National Strategic Plan

NTLP National Tuberculosis and Leprosy Control Program

NTP National Tuberculosis Program

NTRL National Tuberculosis Reference Laboratory

ODA Overseas Development Assistance

OC Oversight Committee

PEPFAR Presidential Emergency Plan for AIDS Response

PHP Private Health Practitioners

PLHIV People living with HIV

PLWHA People living with HIV/AIDS

PMDT Programmatic Management of Drug Resistant Tuberculosis

PNFP Private not For Profit

PPM Public Private Mix

PPP Public Private Partnership

PPPH Public Private Partnerships for Health

PR Principle Recipient

PSM Procurement Supply Management

QPPU Quantification Procurement and Planning Unit

SDA Service Delivery Area

SO Strategic Objective

SOP Standard Operating Procedures

SP Strategic Plan

SR Sub-Recipient

STP Stop TB Partnership

TB Tuberculosis

TB SSF Tuberculosis Single Stream Funding

TRS Treatment Success Rate

UNMHCP Uganda National Minimum Health Care Package

UPS Uganda Prisons Services

USAID United States Agency for International Development

USTP Uganda Stop TB Partnership

VHT Village Health Team

WHO World Health Organization

ZTLS Zonal Tuberculosis Leprosy Supervisor

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SECTION 1: SUMMARY OF REQUEST

1.1 General Program Information

Applicant UGANDA CCM.

Country UGANDA.

Component TUBERCULOSIS.

Implementation Period 01 JULY 2014 – 31 DECEMBER 2016.

Cut- off date 30 JUNE 2014.

Renewal date 01 JULY 2014.

Current Phase/ Implementation Period Currency: USD

Next Phase/Implementation Period Currency: USD

Principal Recipient (PR) Name Grant/SSF Number Grant/SSF start date PR 1 MINISTRY OF FINANCE, PLANNING AND ECONOMIC DEVELOPMENT (MOFPED)

UGD-T-MOFPED 1st July 2014

1.2 CCM Approval of Request for Renewal Role Name Title / Organization

1.CCM Chairperson Prof.Vinand Nantulya Chairman, Uganda AIDS Commission- Public Sector

2.CCM Vice Chair Person&(s) MS. Rosemary Ssenabulya Federation of Uganda Employers (FUE) – Private Sector

3.CCM Chair of Program Oversight committee (POC)

Dr. Edward Katongole Mbidde Uganda Virus Research Institute (UVRI)–AIDS Partnership Committee.

4.CCM Chair of Resource Mobilization and Proposal Development Committee(RM&PD)

Prof. Edward Kirumira Makerere University - Research Academia and Sciences (RAS) - Academia

5.CCM Member at Large Mr.Bharam Namanya Uganda Network of AIDS Organizations (UNASO) - CSO

6.Member Ms.Karen Klimowski United States Agency for International Development(USAID)-Health Development Partners (HDPs)

7.Member Ms.Mary Ochan Oduka Irish Aid - AIDS Development Partners (ADPs)

8.Member Dr. David Kihumuro Apuuli Uganda AIDS Commission (UAC) – Public Sector

9.Member Dr.Asuman Lukwago Ministry of Health (MOH) – Public Sector

10.Member Dr. Jane Ruth Aceng Ministry of Health (MOH) – Public Sector

11.Member Mr. Stephen Kasangaki Ministry of Finance, Planning and Economic Development (MOFPED) -

12.Member Mr. Edward Mugimba Ministry of Labour, Gender, and Social Development (MOLGSD) – Public Sector

13.Member Dr.Patrobas Mufubenga Malaria and Childhood Illnesses Secretariat (MACIS) – CSO/People affected with Malaria.

14.Member Mr. Sam Ocen Uganda Youth Program (UYP) – CSO/People living with HIV& affected by TB

15.Member Mr.Abenet Berhanu African Medical and Research Foundation (AMREF) - International NGOs

16.Member Dr.Richard Oketch UNICEF – Multilateral partners

17.Member Mr.Vasco Kura Uganda Protestant Medical Bureau -Faith

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Based Organizations (FBOs)

18.Member Dr.Geoffery Mujisha Most at Risk Populations Network (MARPs)

19.CCM Focal Point Ms.Syson Namaganda Laing Secretariat Coordinator-UCCM

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1.3 Summary of CCM Request for Renewal 1.3.1 Summary of Request

Please provide a brief overview of the current progress toward goals and objectives of the proposal as well as

main observations, the recommendations and the rationale for the Request for Renewal.

The National TB and Leprosy Control Program (NTLP) has been implementing the Tuberculosis

Single Stream Fund (TB SSF) which is a consolidation of the Round 6 TB Phase 2 and the Round

10 TB Phase 1 since 01 January 2012. The grant is aimed at reducing the morbidity and mortality

attributable to tuberculosis in Uganda, towards the global case notification and treatment targets,

namely TB case detection and treatment success rates at 70% and 85% respectively. The TB SSF

grant is managed by Ministry of Health (MoH) as a delegated Principal Recipient (PR) on behalf

of Ministry of Finance, Planning and Economic Development (MoFPED). The country has

prepared the renewal proposal to request Global Fund (GF) to support second implementation

period of the TB SSF which is expected to run from 01 July 2014 to 31 December 2016.

The Phase 1 TB SSF grant performance has been B1 since the start of the grant. B1 is defined as

adequate performance between 60-89%.

In the period 1 January to 30 June 2013, the notification rate for all forms of TB cases was 130 per

100,000 population, translating into 93% achievement. The treatment success rate of new smear

positive pulmonary TB cases was 77% against a target of 85%, translating into 90% achievement

on this indicator. The average performance for all indicators rose from 78% in December 2012 to

99% in June 2013. The average performance for Top 10 indicators rose from 73% in December

2012 to 92% in June 2013. Poorly performing indicators e.g. the enrollment of Multi Drug

Resistant Tuberculosis (MDR-TB) patients on treatment, and the failure to obtain data on stock

status from health facilities remained a challenge and had a negative impact on the overall rating

of grant performance.

Although all the six objectives of Phase 1 TB SSF have been maintained for this Phase 2 TB SSF

application, the Phase 2 TB SSF will mainly focus on 1) ensuring availability of anti-TB medicines

for both susceptible and drug resistant TB patients, 2) strengthening Programmatic Management

of Drug Resistant TB (PMDT) to ensure that all diagnosed MDR TB patients are enrolled on

treatment and 3) strengthening NTLP’s capacity to plan, implement, monitor and evaluate TB

control interventions.

Other interventions that will be strengthened with the Phase 2 TB SSF include activities to:

increase the uptake of Anti-Retroviral Treatment (ART) among TB-HIV co-infected patients;

improve reporting and analysis of health facility stock status of anti-TB medicines to the national

authorities; improve community partnerships and the Public Private Partnership (PPP) for TB

control especially with the Private Health Practitioners (PHP). The Uganda Stop TB Partnership

(USTP) will play a significant role in coordinating all partner activities including interventions for

strengthening community and public-private partnerships.

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1. Are you proposing any changes in the Implementation Arrangements of the grant/program? Yes

Reallocation of funds between PRs Changes in institutional arrangements Budgetary changes

No A non-public sector sub-recipient is

proposed for financial management of

training and M&E related activities.

Yes

Please describe and provide rationale and justification for each proposed change.

In order to mitigate the risks related to financing of training and M &E activities and ensure

value for money, in phase 2, the Country Coordinating Mechanism (CCM) proposes that the

PR will engage a non public sector sub recipient with adequate internal controls to safeguard

the financial resources from GF and ensure that training and M&E activities are carried out as

planned for optimal program performance.

In phase 2 TB SSF, efforts will be directed towards better management, coordination and

implementation of activities with relevant stakeholders. Further, in order to optimize the

performance towards achievement of the goal and the six objectives of the TB SSF, new

activities have been proposed in the renewal document that are aligned with the updated TB

strategic plan (2012/13-2014/15). Activities proposed in phase II TB SSF are addressing the

weaknesses and challenges identified in the external program review (September 2013) and

those identified by the NTLP and Global Fund during phase I TB SSF implementation. With

the guidelines for implementation of MDR-TB, TB strategic plan and the monitoring and

evaluation plan for the strategic plan, the NTLP will undertake as well as monitor activities

effectively with the necessary support.

Although the GoU made a decision to buy commodities with GF grants and find additional

resources from GoU and partners for activities like training, supervision, review meetings etc,

the government was not able to find adequate financial resources to fund these activities. This

affected performance of the program especially in the area of monitoring performance and

ensuring quality.

In order to safeguard the financial resources from GF and ensure adequate accountability of

funds for training and M&E related activities, the PR will engage a non public sector sub

recipient with adequate internal controls to follow up implementation of these interventions

and ensure adequate accountability for the funds disbursed. This will help to mitigate the risks

that were identified by GF and ensure value for money. The NTLP will provide programmatic

technical support for these activities. A memorandum of understanding that articulates the

responsibilities of MoH/NTLP and the sub recipient will be signed by the PR and the sub

recipient. The PR will retain the responsibility of accountability and the CCM will have an

oversight role.

A new SDA on PPM has been introduced under objective 5 to improve the public-private

partnership for TB control, which is expected to contribute to TB case finding as well as

improve the treatment success rate.

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2. Are you proposing any changes to the scope and/or scale of the performance framework of the

grant/program? Yes

Do the proposed changes entail material reprogramming compared to the original proposal(s)? No

1.3.3 CCM Request for Renewal

CCM Requested Budget for Renewal

PR 11 PR 2 Total Program

A Adjusted TRP clarified amount for the next Phase/ Implementation Period (please insert numbers from section 6.2)

11,585,908 - 11,585,908

B Total budget requested (after cut-off date to the end of the next Phase/Implementation Period)

22,695,487.03 22,695,487.03

C Undisbursed amount at cut-off date 11,202,841.4 11,202,841.4

D Cash at cut-off date (please insert numbers from section 5.2)

1,220,841.48 1,220,841.48

E = Incremental amount requested 10,271,804.15 10,271,804.15

F % of adjusted TRP clarified amount (cannot exceed 100% of adjusted TRP clarified amount)

89% 89%

Has the CCM taken into account any Board-approved funding limitations? Yes

(Please refer to the CCM Invitation Letter for further details).

Although the CCM appreciates that it is only eligible to access 89% of the ceiling, the remaining funds

less procurements were inadequate to address the critical gaps identified by the Program review and

those identified by MOH/NTLP and GF during Phase I implementation. For this reason, the CCM has

applied for 100% of the Adjusted TRP approved budget for Phase II TB SSF and 100% of the balance

of the Phase 1 undisbursed sum amounting to US $ 2.647M.

1 Total amounts for each PR.

The indicator on "number and percentage of districts/reporting units reporting no stock-out of first-line anti-TB drugs during the reporting period" has been modified to “number and percentage of Hospitals and HC IVs with no reported stock outs of anti-TB medicines anytime during the reporting period”.

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SECTION 2: CCM GOVERNANCE 2.1 CCM Governance Overview

Please refer to the CCM Requirements listed in the CCM Request Guidelines.

2.1.1 When was the last Round that the CCM/RCM/sub-CCM applied for funding?

August 2010, Round 10.

Was the CCM/RCM/sub-CCM determined compliant with the CCM requirements at this time? No

(delete as applicable)

If the CCM/RCM/sub-CCM was not compliant when they last applied, please describe what remedial actions were

taken by the CCM/RCM/sub-CCM?

2.1.2 CCM Membership

a) When was the last time that changes were made in the CCM/RCM/sub-CCM membership of people

living with HIV and people affected by tuberculosis and malaria? Please provide details for those

changes, including the current membership of people living with and/or affected by the diseases.

By the time the CCM applied for Round 10 it was not compliant on Requirement 3 (oversight)

and 5 (conflict of interest policy). Since then the following are the remedial actions taken by the

CCM.

Requirement 3: The CCM developed an oversight plan and submitted it to the Global Fund

Secretariat in July 2012. The oversight plan details the activities the CCM carry out in order to

ensure effective oversight of Global Fund grants and Principal Recipients (PRs). Three

Committees (for further details, see Section 2.1.3) are holding quarterly and extraordinary

meetings in which oversight over the Global Fund grants and PRs is carried out and make

recommendations to the CCM Executive committee for decision making and necessary action

on oversight issues. Programme stakeholders represented on the CCM are actively engaged in

oversight activities, while non-CCM stakeholders are co-opted on the Committees or invited to

participate in meetings on an ad hoc basis. The Vice-Chair position in all the Committees is

allotted to Non-government constituencies and there is at least one CCM member representing

people living with and/ or affected by the diseases in each Committees.

Requirement 6: The CCM developed and published a Conflict of Interest Policy in May 2012

and is implementing it in meetings and other CCM activities. All CCM members are required to

sign a Conflict of Interest Declaration once a year. The CCM Secretariat maintains

documentation of Conflict of Interest declarations as well as minutes and reports.

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The last time changes were made to the CCM was in October 2011 when the Uganda CCM went

through structural adjustments of its governance and made various changes in the entire CCM

membership and operations. The size of the CCM membership was reduced from 25 to a

manageable size of 17. All constituencies were requested to renew their membership according to

Global fund guidelines. The changes in the CCM restructuring affected the size of representation

of every constituency including people living with HIV and people affected by tuberculosis and

Malaria. People living with HIV were allotted one member and an alternate member, and people

affected by tuberculosis and Malaria were also allotted one member and an alternate to be

selected. CCM renewal of membership from both people living with HIV and people affected by

tuberculosis and Malaria was done through a process that was developed and agreed by members

of each constituency. The processes involved open consultative meetings organised by their two

constituency umbrella organizations to foster participation and fairness in selection of their

representatives to Uganda CCM. Delegates convened for a workshop that was facilitated by

independent CCM consultants. Delegates discussed and agreed on a secret ballot box voting

method to select their members. Candidates vying for a CCM membership were nominated,

seconded and given an opportunity to campaign and talk about themselves. Finally, the CCM

member and his/her alternate were both selected through a method of secret ballot box voting.

The voted candidate signed an acceptance form to serve as a representative of people living with

HIV and/or people affected by tuberculosis and Malaria to Uganda CCM. The Documentation of

the process followed the following steps;

1. Umbrella organisations updating their comprehensive contact list of constituency member

organization and used the list to channel continuous consultation and feedback

information to constituencies during the time of preparation and electing of

representatives to the CCM. This list ensures coverage of constituency stakeholders.

2. Open invitations to ensure transparency.

3. Minutes of meetings for election of CCM representatives were put together and submitted

to the CCM secretariat describing evidence of the democratic and transparent process

used.

4. Election of CCM member and alternate member through secret ballot.

5. The elected CCM representatives signed an acceptance/commitment form which was

submitted to the CCM secretariat for archiving.

6. The convening representatives and/or umbrella organization writes a formal letter to the

CCM Chairperson introducing the elected CCM members of the constituency and this was

submitted to the CCM secretariat together with the minutes of the meeting and the

acceptance/commitment form.

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Therefore the following members were elected to represent their constituencies

Constituency

Substantive

Member E-mail

Telepho

ne

Alternate

Member E-mail Telephone

1

Civil Society

(People Living

with HIV &

Affected by TB)

Mr. Sam

Ocen

ocensam@yah

oo.com &

ocensam@gma

il.com

+256772

638763

+256392

963 287

Dr.Lydia

Mungherera

lmungherera7

@gmail.com

+256772

448102

2

Civil Society

(People Affected

by Malaria)

Dr. Patrobas

Mufubenga

pmufubenga@

gmail.com

00256

772 455

122

Mr. Zacch

Akinyemi

zakinyemi@pa

ce.org.ug

+256312

351100

+256753

387363

b) When was the last time that changes were made in the representation of non-government constituencies (e.g.

community based organizations, faith based organizations, private sector, private academic institutions, people

living with and/or affected by the diseases, key affected populations) on the CCM/RCM/sub-CCM? Please

describe how new members were selected by their own constituencies based on a documented, transparent

process developed within each constituency.

The last time that changes were made in representation of non-government constituencies on the

Uganda CCM was in October 2011 and this process was one of the vital components of the overall

CCM reform process since its inception in 2002. The old CCM acquired consultants to support a

process in which all the 6 Non-public (Civil Society/private sector) representatives were elected in

a transparent and documented process. The same situation happened in June 2012 when Civil

Society (International NGOs) made a replacement after the substantive member resigned from the

CCM.

The process started with each constituency holding a pre-renewal consultative meeting and

mapping out their own process. The meetings were held to consult among constituency members

on what process needed to be followed by each constituency, which people/organisations should be

involved, defining constituency boundaries and the timeframe for the renewal process. Debates

took place during the consultation meetings. For example; some private sector organisations had

challenges of defining their constituency boundaries with other cross-cutting civil society

organisations. However this issue was resolved by consensus among different groups. Even among

the defined constituencies, there was some debate before they sorted out the overlaps in

representation among CSO constituencies where some organisations potentially belonging to more

than one constituency. Finally each constituency agreed on compositions and boundaries of

stakeholders as well as a democratic process to use in selection of CCM members. The dates for

selection of members were scheduled and elections of CCM members were held accordingly.

15

Uganda CCM included a new constituency of Key Affected Populations (KAPs). There was

varied debate and interpretation between Key Affected Populations (KAPs) and Most at Risk

Populations (MARPs). However, it was noted that a MARPs network was already in place

which had created an identity among KAPs. There was appreciation of the willingness to have

representatives of this constituency on the CCM for the first time. After agreeing on the

process to be used for membership renewal, the mobilisation of constituency members was

done by key recognised CSO umbrellas to ensure that a wider section of the constituency was

reached and represented. The organisations and individuals who participated in the process

included people from upcountry districts as well as those from in and around Kampala. During

the renewal meetings, information was provided to participants to ensure that people

representing constituencies were adequately educated on the rationale and process prior to

selection of leaders. For example, presentations were made on Global Fund CCM guidelines,

the status of the existing grants, and the history of Global Fund in Uganda and the CCM

reforms and plans. The roles and expectations of the CCM representatives were articulated to

the members to ensure that the elected representatives are conversant with their expected

roles. An opportunity was given to outgoing CCM members to share real-life experiences as

representatives of the constituencies in the last CCM to orient the newly elected members.

Members of each constituency discussed and agreed on the election process they felt was

democratic and the Civil Society (Local NGOs), Civil Society (International NGOs) and Key

Affected Populations preferred secret ballot. Because of great diversity of interests in each of

the constituencies, this scenario, in some instances caused friction and tension but later on

resolved by consensus. Finally each constituency agreed on what they considered appropriate

to their constituency. The religious faith based organisation (FBOs) preferred to follow the

already existing faith based leadership structures to nominate representatives through a

process they discussed and agreed on by consensus while the Academia and Private Sector

elected their members after discussing and reaching a consensus by show of hands.

Proceedings of the meetings were documented and elected members were required to sign an

acceptance form indicating their commitment to their election as Uganda CCM members.

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2.1.3. Program Oversight

Does your CCM have an oversight plan which has been approved by the CCM? Yes

If yes, describe the oversight activities which are detailed in the plan. How has the CCM been implementing this

plan? How does the CCM engage program stakeholders in oversight, including the CCM members and non-

members, in particular non-government constituencies and people living with and/or affected by the diseases.

Uganda CCM has established a unique mechanism to ensure continuous and effective oversight

of grants and PRs by establishing four standing Committees:

- Resource Mobilization and Proposal Development Committee,

- Program Oversight Committee,

- Finance and Procurement Committee,

- Executive Committee, which reviews observations made by the three committees

mentioned above to prepare recommendations to be submitted to the full CCM for

decision and/or remedial actions.

Oversight activities

Oversight activities, described in the plan (see Annex 1), are part and parcel of the CCM

comprehensive activities and work plan. They include:

- Managing, guiding and coordinating processes for requesting grants from the Global

Fund,

- Reviewing grants reports to assist PRs to enhance grant performance,

- Cconducting oversight visits to program implementation sites,

- Reviewing information on grants to identify problems and bottlenecks affecting grants,

and carrying out investigation of specific issues,

- Taking actions to resolve problems, as well as meeting quarterly, and as called for

discussing, resolving and making policy decisions regarding grant implementation.

Implementing the oversight plan

Uganda CCM is implementing oversight activities through the CCM established standing

committees and the entire CCM membership. The CCM uses a participatory approach by

ensuring that all CCM members are involved in oversight activities. Implementation of activities

is guided by the CCM annual work plan.

The review of grant performance (achievements, bottlenecks) is done during quarterly regular

meetings, but the CCM can also call extraordinary meetings whenever an emergency occurs. The

Committees depict core issues for discussion at the CCM, but the CCM has a liberty to go over a

review of entire reports. All findings pertaining grant oversight are always discussed by the

entire CCM and policy decisions are always done through the participation of the entire CCM.

The CCM can call PRs or implementers like the Ministry of Health to Committee and/or CCM

meetings to react on issues identified in grant performance and processes of implementation of

grant activities.

17

The CCM has been involving other stakeholders/technical partners to provide ad hoc technical

support, especially for technical guidance and for review of reports as well as support for

funding requests. The CCM has been co-opting some non-CCM members and PRs during

program performance reviews and/or site visits. In spite of efforts by the CCM to address

issues of oversight, some challenges affecting program performance remain (e.g. delays in

reporting due to institutional arrangements of the government PR); but the CCM is committed

to address these challenges as described here in the section of Aid effectiveness. The CCM

secretariat provides support to the CCM members and Committees in terms of logistics

facilitation, collecting, analysing data, compiling reports and providing secretarial services.

Engagement of program stakeholders

During fiscal year 2012/13, the CCM planned to establish mechanisms to enhance

stakeholders' participation in grant oversight activities through focused Constituency

engagement. Stakeholders have generally been participating in oversight activities, especially

when developing proposals/grant renewals; conducting overall annual program performance

reviews and/or on an ad hoc basis but funding has been a limiting factor.

Despite these difficulties, CCM members have been more participative over the last year in

grant and PRs oversight by taking a leading role in decision making at all stages. The members

have been leading the process of grant applications, but also by mobilizing constituencies and

making policy decisions during grant implementation, and by participating in site visits and

assisting PRs to solving problems affecting grants implementation. In addition, some non-

CCM members/stakeholders that include civil society organisations, mainly people living with

and/or affected by the three diseases have been using their forums (e.g. the Health

Partnership Advisory Committee (HPAC) meetings) to mobilize stakeholders to participate in

various stages of grants implementation. Also, the CCM has been using the Health sector

development partners committees and HIV/AIDs development partners to engage the

government to resolve implementation bottlenecks that affect grants.

CCM Next steps/mitigation plan

Further engagement of program stakeholders in grant oversight remains a key priority. In

June 2013, the Uganda CCM applied for technical support from the US Office of the Global

AIDS Coordinator (OGAC) to establish a proper system to further engage constituency

members and their stakeholders in Global fund activities. More support is being solicited from

other development partners. The Uganda CCM aims to establish an all-inclusive system that

will enhance program oversight. It intends to put in place stakeholders communication

channels and participatory systems of grant oversight right from the beginning (proposal

development stage) and during grant implementation period. The CCM is planning to

establish this structural system through implementation of the 2014 work plan.

For further details on oversight, please see Annex 1.

Please see the CCM Oversight Plan in Annex 1.

18

2.1.4 Managing Conflicts of Interest and Constituency Engagement

How does your CCM manage conflict of interest among its members and/or grant implementers who sit on the

CCM? What measures are in place to ensure the CCM’s conflict of interest section from your CCM governance

documents is applied? How is the management of conflict of interest documented by the CCM?

2.1.5 In case of any proposed changes in Programmatic, Budgetary and Implementation

arrangements (1.3.2), please describe the documented and transparent processes followed to

ensure participation of all constituencies represented on the CCM/RCM/sub-CCM (including

members and non-members) in the development and approval of these changes. Please describe

the process that was used to ensure effective management of any potential conflict of interest

that might have affected this process.

The Uganda CCM understands that managing potential conflict of interests (COIs) among all

stakeholders involved in Global Fund activities is not only a Global Fund requirement, but most

importantly that it must be observed during the entire grants’ life cycles. Indeed, the Uganda CCM

regards management of COI not only as an issue of good governance, but also considers it as a

safeguard measure for resources mobilization and oversight. While management of COI can be a

challenge, Uganda CCM insists that CCM members affiliated to Principal Recipients, Sub-

recipients and all implementers must serve at the CCM in the spirit of promoting values of

fairness, accountability and transparency in management of Global Fund grants.

The CCM developed a Conflict of Interest (COI) Policy in May 2012 (see Annex 2 for further

details) as a rule guide to manage and mitigate potential conflicts of interest during grant

implementation. All CCM Members and alternates abide by the Uganda CCM COI policy and

therefore sign an acceptance of the policy and a Declaration of Interest Statement (DIS) on an

annual basis. Furthermore, each CCM Member or alternate must declare whether a COI exists at

the beginning or during CCM meetings and/or activities. If a COI occurs among CCM members

who sit on the CCM and that COI was not detected during CCM business, then the CCM has an

arrangement to designates a disciplinarily body to manage that conflict of interest according to

CCM bylaws and rules that govern the country. One measure in CCM rules to manage conflict of

interest is expelling a CCM member from participating in the CCM business where such a member

has or is discovered to have a potential or perceived Conflict of Interest and all these actions are

documented and made public.

The signed Declaration of Interest Statements as well as minutes and reports are filed and safely stored by the CCM Secretariat and are accessible to the public. Conflict of interest issues and actions are addressed and minute at CCM meetings.

Please see the CCM Conflict of Interest Form in Annex 2

The proposed changes in programmatic, budgetary and implementation arrangements were

discussed and agreed upon by the writing team and were presented to the CCM Resource

Mobilization and Proposal Development Committee and the entire CCM, where they were

discussed and agreed upon. All members of the writing team filled a declaration of interest form,

and none of them had a conflict of interest in regard to the Phase 2 grant renewal

request/application. At the CCM meeting, the chairman asked members whether they had conflict

of interest and none of the members that attended the meetings declared conflict of interest.

A summary of the preparation process for TB SSF Renewal Request- Annex 3

Minutes of the Resource Mobilization and Proposal Development Committee meeting _Annex 4

Minutes of the CCM Board meeting – Annex 5

19

SECTION 3: COUNTRY CONTEXT

3.1 Epidemiological situation

Please describe any changes to the disease epidemiological situation that is likely to affect program implementation or strategies. (Please indicate sources of information)

Uganda is still ranked by World Health Organization (WHO) among the 22 TB high burden countries.

According to the WHO Global TB Report 2012, the TB incidence, prevalence and mortality have

steadily declined since 1990. The incidence of TB has reduced from 623 in 1990 to 193 per 100,000

population in 2011. The prevalence from about 520 in 1990 to 183 per 100,000 population in 2011

and mortality (excluding TB mortality among HIV positive patients) from 45 in 1990 to 14 per

100,000 population in 2011.2 The direct measurement of the TB prevalence will be established when

the national TB prevalence survey is completed. The national TB prevalence survey is scheduled to

start in September 2013 and preliminary results are expected before the end of 2014.

A population based national survey on anti-TB drug resistance carried out between December 2009

and February 2011 showed that the prevalence of Multidrug Resistance TB (MDR-TB) among new

sputum smear positive cases was 1.4% and 12.1% among previously treated cases (relapses, treatment

after loss to follow up, and treatment failures). Resistance to any anti-TB drug was 10.3% among new

cases and 25.9% among previously treated cases. The survey results showed no association between

anti-TB drug resistance and HIV infection.3

The HIV/AIDS epidemic continues to be the most important risk factor for TB incidence and

mortality in Uganda. The HIV prevalence in the general population increased from 6.4% in 2004/05

to 7.3% in 2011. [4,5] The increasing trend in HIV prevalence is likely to reverse the current declining

trend in incidence and prevalence of TB as well as mortality attributed to it, if efforts to prevent new

HIV infections are not stepped up. The prevalence of HIV among TB patients notified to the national

TB program has stabilized around 50% since 2009.6 A few studies conducted in limited settings in

Uganda, showed that the prevalence of TB among people living with HIV ranged between 5.5%-

7.2%.7,8 A meta analysis conducted by Masja et al in 2011 showed that TB related deaths among

people living with HIV were three times more than those in non-HIV infected persons. 9

2 World Health Organization: Global Tuberculosis Report, 2012 3 Lukoye D, Adatu F, Musisi K, Kasule GW, Were W, et al. (2013) Anti-Tuberculosis Drug Resistance among New and Previously Treated Sputum Smear- Positive Tuberculosis Patients in Uganda: Results of the First National Survey. PLoS ONE 8(8): e70763. doi:10.1371/journal.pone.0070763 4Ministry of Health, Kampala, Uganda. HIV Sero-Behavioral Survey, 2005 5 Ministry of Health, Kampala, Uganda and ICF International Inc. AIDS Indicator Survey, 2011. 6 World Health Organization: Global Tuberculosis Reports, 2009, 2010,2011,2012 7 Moore D, Liechty C, Ekwaru P et al; Prevalence, Incidence and Mortality associated with tuberculosis in HIV infected patients initiating antiretroviral therapy in rural Uganda. 8 William Worodria, Marguerita Massinga, Harriet Mayanja et al; Antiretroviral Treatment Associated Tuberculosis in a Prospective Cohort of HIV infected patients starting ART. 9 Straetemans M, Glaziou P, Bierrenbach AL, Sismanidis C, van der Werf MJ (2011) Assessing Tuberculosis Case Fatality Ratio: A Meta-Analysis. PLoS ONE 6(6): e20755. doi:10.1371/journal.pone.0020755

20

TB case notification to the National TB and Leprosy Control Program (NTLP) has steadily increased

from 30,372 cases (all forms) in 2000 to 49016 cases in 2011.

Among the cases notified in 2011, 25614 were new pulmonary smear positive cases and 12830 were

new pulmonary smear negative cases representing a ratio of 2:1 (new pulmonary smear positive vs

new pulmonary smear negative cases). Given the high HIV prevalence in Uganda, the data above

suggest under diagnosis of smear negative TB. Extra pulmonary TB cases accounted for 11% of new TB

cases and children under the age of 15 years accounted for 3% of new smear positive pulmonary TB

cases. The number of notified TB cases in children represents the tip of the iceberg – best estimates

indicate that childhood TB cases should constitute as high as 40% of the overall case load in high

burden countries like Uganda (Marais et al).10 The male: female ratio among new smear positive

pulmonary TB cases was 1.8.11

3.2 Country Context

Please describe the relevant key changes in the national or program context (political environment, economic situation,

social situation and legal context) and the effect of these on program implementation. Elaborate on the changes adversely

influencing the program performance and any strategies put in place to mitigate the negative effect on the program. (Please

indicate sources of information).

Uganda has a fast growing population with 52% of its population comprising children below 15 years

of age. At a growth rate of 3.2% per annum, the 2013 population is estimated to be 37 million. 12 The

high proportion of children in the Uganda population coupled with a high prevalence of HIV and very

few pediatric TB cases notified to NTLP suggests under-diagnosis of TB in children below 15 years of

age. With introduction of more sensitive diagnostic tools (e.g Xpert MTB/RIF), the NTLP will

diagnose more pediatric TB cases in the coming years.

Although Uganda is slowly improving its health indicators, the current achievements in reducing the

infant, child and maternal mortality are still far from reaching the health related Millennium

Development Goals (MDGs). Infant Mortality Rate (IMR) declined from 76 to 54 and under five

mortality rate declined from 137 to 90 deaths per 1000 live births in 2006 to 2011. Maternal Mortality

Ratio (MMR) has not changed significantly from 418 in 2006 to 438 deaths per 100,000 live births in

2011.[13] However, the steady decline in the TB incidence, prevalence and mortality as shown in the

Global TB report 201214 suggests that Uganda has achieved the MDG targets of 50% reduction in

these parameters by 2015 compared with 1990 level.

The adult literacy rates have increased since 2005/06 from 69% to 71 % in 2009/10 among persons

aged 18 years and above. The male literacy rate (79%) was higher than that for females (66%). Urban

household members were more likely to be literate (88%) than their counterparts residing in the rural

areas (69%).15 It is envisaged that the increase in the literacy rate will have an impact on community

participation and mobilization initiatives for TB control.

In the financial year 2011/12, the country experienced a significant drop in economic growth with a

Gross Domestic Product (GDP) dropping from 6.7% in the financial year 2010/11 to 3.4% in the year

10 Marais BJ, Hesseling AC, Gie RP, Schaaf HS, Beyers N. The burden of childhood tuberculosis and the accuracy of

community-based surveillance data. Int J Tuberc Lung Dis. 2006; 10 (3):259-63.

11 Global TB Report, 2012 12 Uganda National Bureau of Statistics at www.Ubos.org, last update 20 February 2012 13 Uganda Bureau of Statistics (UBOS) and ICF International Inc. 2012. Uganda Demographic Health Survey, 2011 14 Global TB Report, 2012. 15 Uganda Bureau of Statitics: The Uganda National Household Survey, 2009/2010

21

2011/12. However, despite the slowdown in economic growth, the budget to the health sector

increased in absolute terms from 864.6 billion Uganda shillings in 2012/13 to 944 billion Uganda

shillings in 2013/14. The slowdown was due to high global oil and commodity prices, drought in parts

of the country, power shortages, exchange rate volatility and weak external demand.16 As a result of

strict measures including tightening of the fiscal and monetary policy, the economy rebounded with a

GDP growth rate of 5.1% in the year 2012/13. The economy is expected to accelerate its recovery to an

estimated growth rate of 6.o% per annum next financial year. The health sector remains a priority

and it is envisaged that more financial resources will be made available to the health sector when the

economy improves.

Government of Uganda (GoU) contribution towards the national budget has continued to increase

over the years reducing donor dependency. In the year 2012/13, 75% of the national budget was from

domestic sources and in the fiscal year 2013-14, the percentage will increase to 81%.17 The percent of

the national budget to the health sector is 8.7% in the fiscal year 2013/14, which is below 15% that was

agreed upon by African Governments in the 2001 Abuja declaration. Although Government funding

to the health sector has increased in absolute terms, it is still inadequate to meet all the priorities of

the health sector. The GoU is planning to formulate an appropriate legal and regulatory framework for

the establishment of the national health insurance which will lead to an increase access to health

services for the people of Uganda.

In March 2013, the Government of Uganda (GoU) launched a road map to transform Uganda from a

peasant to a modern and prosperous country within 30 years. The aim is to transform Uganda from a

predominantly peasant and low income country to a competitive upper middle income country with

per capita income of about USD 9,500 up from the current per capital income of USD 506. The

percent of the population below the poverty line is expected to reduce from 24.5% in 2013 to 5% in

2040. 18 One of the objectives of the National Development Plan (NDP) is to increase access to quality

social services which will be manifested in the social status of the population. Common measures of

this objective include: literacy levels, life expectancy at birth, infant mortality rate, maternal mortality

rate, safe water coverage, sanitation levels and incidence of communicable diseases and HIV/AIDS.19

3.3 Health Systems Analysis

Please comment on the status of the HSS (Health System Strengthening) actions undertaken with the

Global Fund and/or other domestic or partner support and how the identified health system

constraints have been addressed.

Progress has been made in strengthening the health system issues that affect delivery of health

services including TB control. Notable improvement has been made in the health work force,

infrastructure and procurement and distribution of health commodities including medicines and

equipment as explained in the sections below.

16

Ministry of Finance, Planning and Economic Development; Uganda Budget Speech , FY 2012/13, June 2012 17

Ministry of Finance, Planning and Economic Development: Uganda Budget Speech, FY 2013/14, June 2013 18

National Planning Authority, Uganda Vision 2040, April 2013. www.npa.ug. 19

Republic of Uganda, National Development Plan, 2010/11-2014/15.

22

Governance, Stewardship, including planning and performance Management

The National Development Plan 20 with a long term vision of socio-economic transformation of

Uganda prioritizes health as one of the social services that need improvement in quality of service

delivery. The National Health Policy21 provides the policy framework for implementation of health

interventions and the Health Sector Strategic and Investment Plan (HSSIP) III 2010/11-2014/15,

provides the strategic direction and the priority health interventions that need to be implemented in

order to attain a good standard of health for all people in Uganda. The HSSIP III prioritizes universal

delivery of the Uganda National Minimum Health Care Package (UNMHCP), which has TB control as

one of the sub-components.

20

Republic of Uganda, National Development Plan 2010/11-2014/15 21

Ministry of Health, The Second National Health Policy , July 2010.

The National TB and Leprosy Control Strategic Plan: The National TB and Leprosy

Control Program-Strategic Plan (NTLP-SP) 2010/11 – 2014/15 was revised to align it to new

evidence and guidance in TB control that was provided by World Health Organization (WHO),

most especially in the area of TB/HIV collaboration and the need to scale up new diagnostics. The

same opportunity was used to revise TB control targets that were not realistic given the current

performance. The revised strategic plan covers a period of three years from 2012/13 to 2014/15

and is still aligned to the; Global Stop TB Strategy and Stop TB Plan 2006 – 2015, the National

Development Plan, the National Health Policy and the HSSIP III 2010/11-2014/15.

The goal of the revised strategic plan related to TB is to reduce the prevalence of TB from

181/100,000 population in 2011 to 176/100,000 population by end of 2015. The strategic

objectives were revised as follows:

Strategic Objective 1 (SO1): Strengthen and scale up services for prevention,

diagnosis and treatment of all forms of TB including paediatric and drug resistant

TB.

Strategic Objective 2 (SO2): Improve access to HIV diagnosis and treatment

services for TB patients.

Strategic Objective 3 (SO3): Empower communities, community support

groups and social networks to prevent TB transmission and support case finding

and treatment of TB patients.

Strategic Objective 4 (SO4): Improve the quality, efficiency and effectiveness of

delivering TB services at all levels of the health system.

The targets related to treatment success rate and TB/HIV were revised as follows:

The 2015 target for

1. Treatment success was revised downwards from 85% to 80% since the country had

stagnated around 70% in the past three years.

2. HIV testing in TB patients was maintained at 95%.

3. Cotrimoxazole Preventive Therapy (CPT) was reduced from 100% to 98% because it is

inevitable that a few patients may not take CPT due to adverse reactions or high pill

burden.

4. Antiretroviral Therapy (ART) in TB-HIV co-infected patients was reduced from 100% to

60% because the performance in 2010 was only 34% yet the country still had health system

challenges that affected uptake of ART in TB-HIV co-infected patients.

23

Health Financing

Health financing in Uganda is done through government systems and off the government systems.

Government systems use both budget support and project mode to finance the health sector. Off

government support in implemented by non-government (NGO) and community based organizations

(CBOs) and funds the health sector through their own projects established outside the government

systems and these projects are mainly funded by Overseas Development Assistance (ODA) grants

Coordination of health services: The management structure of Ministry of Health guides

internal ministry coordination and ensures that all departments and programs under the

Ministry of Health implement activities in line with the HSSIP III. The management structure

of the NTLP ensures that implementation of TB control activities at the central, zonal and

district level are in line with the HSSIP III and the TB strategic plan.

The Health Sector Coordinating Committee is the Health Policy Advisory Committee (HPAC)

whose secretariat is in the Health Planning Unit of Ministry of Health. All partners providing

services at the national level engage with each other through this structure.

TB control and TB/HIV collaboration is coordinated under the Uganda Stop TB Partnership

(USTP) and National Coordination Committee for TB/HIV respectively. The USTP is

responsible for ensuring that all partner activities are aligned to the HSSIP III and the TB

Strategic Plan. With support from Global Fund TB SSF, the USTP has recently hired staff and

supported coordination activities at the USTP secretariat. The USTP secretariat will help to

strengthen coordination and advocacy for TB control and mobilize additional resources.

At the regional level, a regional performance review team and the Regional Stakeholders’ Forum

review performance and coordinate activities at that level.

At the district level, the district health office with support from the health sub districts review

performance and coordinate all health related activities.

A) Government system of health financing;

Budget Support

The government of Uganda funds the health sector through a mechanism called budget support

under the country Medium Term Expenditure Framework (MTEF) of the Ministry of Finance,

Planning and Economic Development (MOFPED) established to pool resources to support

sectors activities health inclusive. The budget support operates under MTEF guidelines and

budget ceiling systems established for all sectors as a means to ensure macroeconomic stability of

the country and to provide alternative means of allocating resources more efficiently. The

government side, pools resources for health budget support from revenues generated from taxes

and non-Taxes and debt reliefs. In addition, the government receives ODA grants to contribute

to the budget support and both the government revenue resources and ODA grants are pooled

together and form a resource envelope to finance the Health Sector Strategic and Investment

Plan (HSSIP III) and the National TB Strategic Plan. The allocations of resources are done by the

Ministry of Health based on the national priorities outlined in the HSSIP III. Implementers

include the public and private organisations.

24

Status of government funding

Although the share of Government funding allocation to the health sector spending (including TB

control) appears to remain low as indicated below compared to the expected 15% Abuja minimal

requirement for budget support towards Health, in nominal terms, the country’s health budget is

expected to grow by 47.2% in the year 2017/18 compared to the year 2011/12 health budget.

Annual Health expenditure as compared to National Expenditure

7.99%

8.6%

7.5%

7.6%

8.4%

8.7%

8.01%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

% Health Expenditure Overall National Expenditure

Average 6 years

2013/14

2012/13

2011/12

2010/11

2009/10

2008/9

8.7%

21.4%

25.7%

33.2%

40.2%

47.2%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

Out turn 2012/13

Projected 2013/14

Projection 2014/15

Projection 2015/16

Projection 2016/17

Projection 2017/18

Cumulative Nominal Growth of Health Expenditure (Base year 2011/12)

Gaps/Weakness of budget support

Because of economic dynamics in the budget support mechanism, contribution to health

financing is based on budget ceilings of MOFPED. If the economy is not performing then the

health resource envelope is affected. However, it has been projected that Uganda national

budgets have been growing for the past years and this will continue in the future and guarantee

additionality in financing of the health sector from government revenue.

Prioritization in planning is a challenge in budget support. Support for health program

activities is inadequate because of weak prioritization of investments in specific disease

spending. Funding for specific disease programs are inadequate and the country will need to

improve on reasonable allocations of resources and earmarking expenditures for key activities

in programs. Funds from budget support are disbursed en bloc to support health activities as

planned by the Ministry of Health in annual work plans and budgets. If funds are not planned

well and earmarked for core activities the implementation becomes a challenge. The MoH is

promoting prioritisation of its funding of the HSSIP III and allocates resources to programs.

Despite that, funds for purchase of pharmaceutical products are generally earmarked and the

Ministry of Health is committed to increasingly allocate funds for medicines and other key

activities and this will be reflected in the annual ministerial policy statement budget line

allocations.

Therefore earmarking of funds in budget support will promote expenditure tracking by disease

spending and sources of funding. This will help in instances of traceability of health

investments and reduce duplications. Funds from budget support recurrent and capital

expenditures support TB through holistic support of health activities.

25

It is projected that as the economy grows, the overall national budget will increase and therefore all

sector budgets will increases in nominal terms accordingly. Below is Uganda’s estimated economy

growth up to year 2017/18

7.30%

5.90%

6.60%

3.40%

5.10%

6%

7% 7% 7% 7%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

Estimate of annual GDP growth at constant prices

Annual GDP growth at constant prices

Macroeconomic Projections to FY2017/18

Project mode of health financing

The country uses a project approach mode in order to finance particular needs of the health

sector and this kind of support normally addresses funding of the health sector programs that

need special attention. The project funds are earmarked for a particular disease spending and

expenditures are traceable and not comingled with other funds.

Weakness/Gaps

The project approach needs harmonization of planning to integrate project activities in activities

of the Health Sector Strategic and investment plan to ensure efficient allocation of resources.

The coordination of planning between public and private implementers is being strengthened to

avoid duplication of efforts and minimising resource wastage. The NTLP will work with partners

in coordination and collaboration between the government and the private sector organisations

not only in areas of planning and implementation but also in financial management of resources

like Global Fund grants. This will strengthen grant implementation.

Country Status of Project mode support system

Global fund is contributing the largest proportion of direct earmarked funding to the TB

program under the project approach mode. The country has some additional indirect support

through the World Bank health systems strengthening project.

26

Service delivery including Public Private Partnership and community level

service delivery

The National Health System (NHS) is made up of the public and the private sectors. The health

services are structured into: National Referral Hospitals (NRHs) which are semiautonomous;

Regional Referral Hospitals (RRHs) which are self accounting and under Ministry of Health (MoH)

oversight; public general hospitals and Health Centre (HC) IVs, HC IIIs, HC IIs and Village health

teams (HC Is) which are under the district health system managed by the Local Governments. The

Private Not for Profit (PNFP) and Private Health Practitioners (PHP) hospitals and health centres are

autonomous. Health system challenges affect delivery of services in both the public and private health

sector.

B) Off Government system of Health Financing

On the other hand the country health financing receives additional funds off government support

contributions that come from Overseas Development Assistance (ODA) grants.

Weaknesses: The planning, implementation and expenditures on health programs is done

outside the main stream of government health financing mechanisms. As mentioned above, the

key implementers of these projects are NGO and CBOs. The Ministry of Health (MoH) assumes a

responsibility of coordinating and overseeing activities implemented by the NGO and CBOs.

However the MoH does not have adequate capacity to oversee all program activities implemented

by NGOs and does not participate in their planning and allocations of resources. It is difficult for

the Ministry to track expenditures of such resources because in a number of situations the

coordination between the Ministry and NGOs is weak and so challenging. The country has not

established proper reporting mechanisms between the government and non-government

partners. There is little Information sharing and disclosure of information on expenditures is still

a major challenge to encounter. The Ministry of Health through the NTLP is strengthening the

coordination of partners implementing the TB program and has recruited staff to achieve this

objective.

Country Status of off Government system

Funding for TB control from ODA- external sources off government systems has been consistently

flowing in the last 2-3 years with main support coming from PEPFAR through USAID and CDC

TB/HIV programs. There are other partner support from WHO and CIDA that have been

supporting various TB programs implemented by NGOs /CBOs in the past years.

Brief status of overall TB support

The external funding put together with the GoU funding is still inadequate to fund the priority

interventions proposed in the National TB strategic plan. The national TB strategic plan has been

costed and disseminated to partners. Critical interventions like training, support supervision,

mentoring, program review meetings, TB advocacy, communication and social mobilization

remain inadequately funded. These activities have little or no resources earmarked from various

sources of funding. The country will continue to mobilize financial resources from external

partners to support priority activities that are not currently funded by GoU, GF or development

partners.

Annex 6 shows the flow mechanism of funds for the GF TB SSF Grant

27

Progress in health system strengthening for service delivery and the challenges that remain are

explained in the section below:

The Health workforce: The health workforce at the NTLP has been enhanced with support

from GoU, GF and partners. The NTLP currently has a total of 09 full time and 02 part-time

health scientists.

The National TB Reference Laboratory (NTRL) is still dependant on external support for 90% of

its human resources.1 Some of the human resource support from partners will be ending in June

2014. To sustain the activities of the NTRL, the Phase 2 TB SSF will be used to provide salary for

at least two laboratory scientists. The MoH is in a process to have the NTRL access GOU support

for its operations.

In the year 2012/13, GoU targeted to recruit 10201 health workers (including laboratory

personnel) to fill vacant posts at Health Centre IIIs and IVs. In total, 8,353 health workers were

recruited for Health Centre IVs and IIIs although only 7211 had reported to the Health Centres by

end of June 2013.1 The remuneration of Medical Officers at Health Centre IVs was also

enhanced from 1 million to 2.5 million per month.1 However, the newly recruited health workers

will need training in TB control interventions in order to contribute positively to attainment of

national TB targets. The NTLP will mobilize financial resources from GoU and in country

partners to train the health workers. Although the position of the District TB and Leprosy

Supervisor (DTLS) was abolished in the district structure, it was maintained by the District

Health Officers as an assignment of duty. This enabled continued focus and support supervision

to TB diagnostic and treatment units, as well as supporting recording and reporting of TB data

which is used to monitor and evaluate program performance.

Programmatic management of Drug Resistant TB (PMDT): The PMDT program has

been established with a total of 09 health facilities currently treating a total of 120 patients. The

National PMDT guidelines and the treatment plan were finalized in 2011. In the year 2011 and

2012, partners supported the renovation of two TB wards in Mulago and Kitgum hospitals that

were converted into MDR treatment wards. The Mulago National referral hospital MDR ward

has a bed capacity of 39 patients and the Kitgum hospital of 9 patients. Infrastructure

assessments to determine suitability of five regional referral hospitals (Arua, Mbale, Mbarara,

Masaka and Fortportal) and one district hospital (Uganda-China Friendship Hospital) to treat

MDR patients were conducted. The assessments revealed a need to remodel the TB wards so as

to create safe isolation MDR wards in these hospitals. In-country partners have pledged to

support remodelling of six regional referral hospitals to create MDR treatment wards. The NTLP

will seek support from GoU and partners to have TB wards remodelled in the remaining 6

hospitals that will be treating MDR patients by end of December 2013.

The routine drug resistance surveillance system is still limited to high risk groups (all sputum

smear positive retreatment cases, failures of category 1 regimens and contacts of MDR patients)

due to limited resources.

28

Special Populations –Access to TB control services in special populations particularly Uganda

Prisons Services (UPS) has improved with support from GoU, GF and partners. GoU recruited

additional health workers for the prisons health services and GF and partners supported on-entry

and annual mass screening of inmates. On entry and annual mass screening helped to identify

inmates with TB disease and those identified were put on treatment. These strategies are helping

to reduce transmission of TB in the prisons services. These interventions have only been

implemented in 35 prison units out of a total of 233.

Access to TB diagnosis and treatment has been improved for the slum dwellers in Kampala City as

explained in the Public-Private Partnership section below. Access to the fishing communities has

not been addressed due to limited resources.

Public-Private Partnerships: The MoH developed the National Policy on Public-Private

Partnership in Health which was approved and launched in 2012. The MoH is in the process of

finalizing the policy implementation guidelines. The private health sector in Uganda includes the

private-not-for-profit (PNFP subsector), the for-profit private health practitioners (PHP

subsector), and the traditional and complementary medicine practitioners (TCMP subsector).1

The partnership with the private-not-for-profit sub-sector has advanced and its representatives

are involved in policy formulation and reviews at national level. The government provides

financial subsidies to the PNFPs and this has helped to increase access, quality, equity and

efficiency in the delivery of health services. The PHP sub-sector has come on board though their

involvement is still very minimal. Currently, the PHP sub sector is represented through PHP

Umbrella and professional Organizations at national level in governance structures such as the

Health Policy Advisory Committee (HPAC) and the MOH Technical Working Groups including

the Public Private Partnerships for Health (PPPH) coordination structures. It is through these

structures that PHPs are engaged in national policy and strategy formulation.

In regard to TB control, partnership with the PNFP sub-sector is advanced. PNFP health facilities

receive free anti-TB medicines and laboratory reagents from the Government sector. The NTLP is

making progress towards engagement of the PHP sub-sector in TB control although their

involvement is still minimal and mainly concentrated in Kampala City. Before 2011, only 6 out of

over 1000 PHPs in Kampala city were engaged in TB diagnosis and treatment. In 2011, the NTLP

together with Kampala City Council Authority (KCCA) partnered with an additional 70 PHPs to

scale up TB diagnosis and treatment in the slums of Kampala city with support from partners. As

a result of this partnership, an additional 600 pulmonary smear positive TB patients were

detected and started on treatment in a period of one year. 1 The NTLP is going to scale up

partnerships with the PHP subsector especially in the urban districts using lessons learned from

the slum PPM project.

29

Community level service delivery: TB services are decentralized to the community level

with Health Centre IVs and IIIs providing TB diagnosis and treatment. The GF health systems

strengthening grant to MOH Uganda is being used to strengthen the capacity of village health

teams (VHT) to carry out community education and mobilization activities for HIV, Malaria

and TB. Of the 58,000 villages in Uganda, only about 50 percent have been covered with

Village Health Team (VHT) training and community interventions. As a means to expand

community level interventions that contribute to the attainment of program objectives for HIV,

TB, Malaria and MDGs 4, 5 and 6, the GoU with support from GF round 10 Health systems

strengthening grant will increase the coverage and improve functionality of VHTs in uncovered

districts. In addition to training, VHTs will be provided with performance-related honoraria

which will be harmonized across the districts to ensure sustained motivation, retention and

enhance performance towards program objectives. A consultant has been engaged to conduct a

baseline survey to 'assess the functionality and effectiveness of VHT systems' across the

country. A report will be available by end of October 2013.

Infrastructure and Equipment

Laboratory: With support from partners, the National TB Reference Laboratory (NTRL) was

renovated, equipped and supported to gain a status of a Supranational Laboratory in April

2013. It is the second Supranational Laboratory in the WHO-AFRO region. The NTRL is

challenged with 90% of its staff salaries supported by partners, a situation that is

unsustainable.

With support from TB SSF, 200 binocular and 50 fluorescent microscopes and 30 LED kits

were procured and distributed to diagnostic Units. All the 13 regional referral hospitals and 37

district laboratories have received fluorescent microscopes. With support from partners,

laboratories at regional referral hospitals have been renovated.

In the past two years, new innovative diagnostics, notably, the Xpert MTB/RIF were introduced

in the country with support from World Bank and in-country partners. By the end of July

2013, there were 43Xpert MTB/RIF machines in the country, of which, 26 were in Government

health facilities. There has been a challenge of maintaining constant supply of cartridges for

the Xpert MTB/RIF machines in the past but this gap has been filled by partners. Calibration

of the machines and maintaining constant supply of power in some health facilities especially

those situated in rural areas remain challenges. At the district level, human resources including

laboratory personnel have been recruited for Health Center IVs and IIIs. The newly recruited

laboratory personnel need training on new diagnostic tools introduced in the country. The

country has inadequate funding to conduct trainings and regular support supervision to all

laboratories. NTLP will continue to advocate to partners to finance trainings and supervision

visits to laboratories.

30

Monitoring and Evaluation

Health Management Information System: The National TB program adopted the WHO

standard recording and reporting system, which is used in all TB Diagnostic and Treatment Units

(DTU) country wide. However, there were weaknesses in the health management information

system that included poor recording and reporting, missed notifications and incomplete

evaluation of treatment outcomes leading to low case detection and treatment success rate. To

improve the health management information system, the Ministry of Health is in the process of

integrating all stand alone disease reporting systems into one District Health Information System

(DHIS-2). This will increase efficiency while ensuring sustainability of reporting to the national

level. With Government of Uganda and partner support, the TB recording and reporting tools

have recently been revised according to new guidance from WHO.

With support from GF, an M&E specialist and Data Manager were recruited to support the

national TB program to collate and analyse data reported from the districts. Additional staffs have

been provided by partners to support the NTLP to improve recording, reporting and utilization of

TB data at all levels of the health system. As a result, standard operating procedures (SOPs) have

been developed to guide health facilities, district, zonal and national level officers to improve data

completeness, quality and utilization for performance improvement at different levels.

Preparations are ongoing to finalize the SOPs. In addition, the quarterly review meetings, initially

supported by GF and later supported by partners, have helped to improve the accuracy of the data

and timeliness of reporting. During the quarterly review meetings at the zonal level, the District

Supervisors exchange definitive outcomes of patients transferred from one district to another and

the Zonal Supervisors validate the reports before submission to the national level. The District

Local Governments have recruited Biostasticians to improve collection, analysis and utilization of

health information at the district level. The Biostaticians will support the district TB supervisors

to improve timely reporting through the DHIS-2 and analysis of TB data for performance

improvement.

Pharmaceutical Sector

The drug procurement, supply and management system has been strengthened at the national

level although a few challenges still need to be addressed. The parallel TB drug procurement,

supply and management system that was managed by the NTLP was integrated into the Essential

Medicines and Health Supplies (EMHS) supply chain managed by the National Medical Stores

(NMS) in 2011. This was done to streamline all drug procurement and supply chain management

into one national procurement and supply chain so as to increase efficiency while ensuring

sustainability of operations.

The Quantification and Procurement Planning Unit (QPPU) of the Pharmacy division of Ministry

of Health is responsible for quantification of anti-TB medicines in consultation with the national

TB program. The national TB program is responsible for analyzing supply chain information from

NMS and providing feedback to the relevant stakeholders. The Joint Medical Store (JMS)

manages the procurement and supply chain for the private not for profit subsector. The QPPU

compiles a bi-monthly stock status report and shares it online with all stakeholders. However,

information in the stock-status report is based on stock at national level and does not reflect stock

at health facility level. The lack of information at the national level on stock status at facility level

makes it impossible to analyse the stock available at different facilities and to tailor support

supervision to the health facilities with significant problems. This problem has been addressed by

recruiting a data officer ( with support from partners) who is based at NMS and is responsible for

analyzing health facility reports, collating data on stock status and writing reports that will be

shared with all stakeholders including NTLP.

31

Please elaborate on any lessons learned and what health system gaps remain in scaling up the disease program.

To improve coordination among partners supporting strengthening of the supply chain, the

Pharmacy division of Ministry of Health set up a Commodities Security Group (CSG), which

meets on a monthly basis to review stock levels and challenges in the management of the supply

chain.

The management of the supply chain at the health facility level still has a number of challenges

that need to be addressed through training, mentoring and support supervision as explained in

section 4.2 below under the subsection on ‘progress on goal and objectives’.

The following section elaborates the lessons learned and the health system gaps that remain to

be addressed in order to scale up TB control interventions.

Increase in health financing towards TB control through the GoU, GF and partners

coupled with improved coordination of partners at national level has improved service

delivery towards TB control. However, more financing is required to implement all the

priority interventions in the TB strategic plan.

Recruitment of health workers for Health Center IVs and IIIs will help to improve the

quality of TB control services offered at this level. However, the newly recruited health

workers need to be trained, mentored and supervised.

Government partnerships with international and national development partners have

helped to scale up new diagnostic tools for TB. However, interruptions in the supply of

cartridges, difficulties in calibration and interruptions in power supply in the rural

areas remain to be addressed in order to effectively utilize the new technologies.

Decentralizing Programmatic Management of Drug Resistant TB (PMDT) will remain a

challenge as long as regional referral hospitals and general hospitals are not remodeled

to create isolation wards for MDR patients and to address infection control in the

health facilities. There is a gap in infrastructure development for the management of

MDR patients in 6 regional referral hospitals and 01 general hospital.

Partnering with the PHP subsector in TB control improves access to TB diagnosis and

treatment for the population that seeks health services in this sub sector, contributing

quickly to improved case finding. More financial resources are needed to scale up

public private partnerships in Kampala city and other urban districts.

Engaging the PHP subsector requires minimal capital investment that includes

equipping the private facilities with the appropriate diagnostic equipment. The human

resources and the minimal infrastructure for TB diagnosis and treatment exist in the

PHP subsector. Scale up requires training, support supervision, provision of guidelines,

recording and reporting tools and anti-TB medicines and laboratory reagents which

can be provided from the public sector.

32

SECTION 4: Program OVERVIEW

4.1 Financial Gap Analysis, Counterpart Financing and Additionality

Please provide an update of the financial needs, actual and planned sources of funding, and financial gap of the disease/HSS program.

CCMs must use the ‘Financial Gap Analysis and Counterpart Financing’ table to provide financial information pertaining to the national program that implements the national disease strategy. Detailed instructions on how to complete the Financial Gap Analysis and Counterpart Financing table are provided is in the Financial template provided with the CCM Invitation package: Renewals_Financial Template_ FinancialRequest_ResourcesAvailable. 4.1.1 Overview of Government Financing of the National Program

Please specify the levels of government (central, regional, local) that incur spending on the disease programs and the major agencies through which government funds are spent. Elaborate on the availability of earmarked budget line items to capture government disease spending and the extent to which these budget line items capture total government spending on the disease program.

The Government health sector spending is channelled through Ministry of Finance, Planning and

Economic Development (MoFPED) as a source of funds and expenditures occur at three levels of the

National Health sector structures;

1) The Central level- Ministry of Health,

2) National Referral Hospitals Level

3) The District Local Government level

Financial expenditures at central level occur at the Ministry of Health headquarters and National

Medical stores which is an autonomous body for procurement and distribution of pharmaceutical

products. The Ministry of Health headquarters is the main agent for central level ministry activities,

regional referral Hospitals and health research institutions. Ministries of Internal Affairs and Defence

have their own budget votes for health activities in Police, Prisons and Defence Health Services.

Community involvement in TB control is very important in increasing community

knowledge on TB and supporting patients to adhere to treatment through DOT, thereby

preventing development of drug resistant strains. Currently there is need to increase

engagement of the civil society organizations in TB control.

The disease specific health management information systems (including TB) will benefit

from an integrated District Health Management Information System (DHIS-2) that is

computerized and supported by highly trained personnel in data management

(Biostaticians). This will increase efficiency in management and utilization of health

information at all levels. The NTLP is currently working with the MoH Resource centre to

integrate TB reporting into the DHIS-2.

Procurement and management of the supply chain for TB medicines and commodities

can be successfully integrated into the national essential medicines procurement and

supply chain. This improves efficiency and guarantees sustainability since the

Government does not have to fund and manage multiple supply chains. There are still

gaps in the management of the supply chain at the health facility level that need to be

addressed through training, mentoring and supervision.

33

National referral hospitals are autonomous bodies and are indeed agents of their own. They receive

and account for funds direct to the MoFPED.

District Local government offices act as financing agents for all health expenditures that occur at

districts health administrative offices, at general district hospitals and expenditures that occur at all

lower level health facilities/units providing primary health care services.

Government spending to the health sector and TB National program

The Uganda government supports the health sector and National TB program through two

mechanisms;

1) Budget support; This is a mechanism whereby resources for health financing are pooled

as a joint support to finance disease needs altogether. A big portion of the funds target

lower levels of health care that provide primary health care services. The funds are spent

in terms of three expenditure categories; recurrent wage, recurrent non-wage and capital

development expenditures. The government earmarks some of the funds to support

specific needs of programs. It earmarks funds from the recurrent non-wage expenditure

category to purchase pharmaceutical products to address some needs for specific diseases

including pharmaceutical products for the National TB Program. The funds are

administered through the offices of National Medical Stores. In addition, additional

recurrent non-wage expenditures are earmarked to support all national programs for

specific diseases at the central Ministry of Health. Central activities of National TB

program are supported through such allocations.

2) Project approach; The government secured a loan from International Development

Association (IDA/World Bank) and uses a project approach to finance particular needs of

the strengthening systems of the health sector and this kind of support is addressing

specific health systems components and service delivery areas within the Health Sector

Strategic and Investment Plan (HSSIP III). The project funds are spent on systems of

different specific disease needs including the National TB program. The funds are easily

earmarked by disease spending as this is not clearly outlined in the project appraisal

reports.

Therefore, the following put together gives the total government spending on the national TB

program;

A) Earmarked Funds

1) Funds to purchase TB pharmaceutical products

2) Funds to support National TB program activities at the central Ministry of Health

B) Non- Earmarked Funds

1) Portion of government spending for joint primary health care expenditure attributed to

TB prevention

2) Funds allocated from Budget support National for capital development and recurrent wage

, if can be attributed to TB program activities

3) Government spending from health system strengthening project ; Human resource or

capital development not earmarked as for TB spending

34

4.1.2 Estimation of Current and Anticipated Domestic and External Funding

Describe how contributions from various sources of funds were estimated, including reference to:

a. Methodology for estimating current and anticipated funding; b. Composition of reported government spending (part or all of government spending; programmatic costs alone or

includes apportioned health system costs; recurrent costs alone or includes capital costs); c. Whether amounts contributed by each source for the current and previous years pertain to budget, disbursement,

expenditure or an estimate of spending; d. Whether amounts forecast from each source for the future years pertain to estimation or commitment.

Steps to estimate government current and anticipated domestic

funding

In coming up with estimates for the current and anticipated government domestic

funding, the country took up the following steps;

1) Reviewed the overall landscape of government resources in terms of sources of

revenue and expenditures. Got the total government revenue by sources

2) Reviewed the government budget/expenditures and nature of contributions to

the health sector. The CCM reviewed documents of Ministry of Finance,

Planning and Economic Development (MoFPED) Medium Term Expenditure

Framework (MTEF) papers that included; Indicative Revenue and Expenditure

Framework from National Budget Framework Paper FY 2013/14 – FY

2017/2018; April 2013; Background to the budget 2013/14 Fiscal year; June

2013; Performance of the Economy Report, June 2013; Reports on overall Fiscal

Operations Year July 12- June 2013. Health Ministerial Policy Statement. Got

the health budgets by sources

3) Defined government budget on health and separated it from Overseas

Development Assistance (ODA) budgets

4) Identified all sources that go through budget support and projects.

5) Identified earmarked budget/expenditures for various sections of the health

sector that include the Central Ministry of health, referral hospitals and local

government general hospitals and primary health care facilities and disease

programs

6) Separated capital development and wage expenditures from recurrent

expenditures by source of financing. To get government funding for these

components.

7) Identified earmarked funds for TB support under government revenue and ODA

support in different past years of implementation. Got what earmarked for TB

8) Project all domestic/government funding by using an assumption that the

funding will grow in line with the country projections of the growth in general

government expenditures and then factor in an additional reallocation of

resources to the health sector using (a) Growth in National budget and (b)

annual increase in the health sector budget allocations

Estimation of external funding

1) Reviewed overall Overseas Development Assistance (ODA) to the health sector

that come through government budget support and projects support

2) Identified earmarked funds for TB support from ODA support.

3) Identified committed funds for TB support from ODA support in the next 3

years of grant implementation.

4) Requested partners’ past financial support to National TB program and their

future commitment during phase 2 grant implementation.

35

Projected Government Funding Fi= Fi-1(1+ α g)

Where Fi is the projected government funding for the ith year, gi = growth in

National budget and α= annual increase in the health sector budget

allocations=factor of additional allocation of resources

Projection factors 2014/15 2015/16 2016/17 2017/18

Growth in Uganda

Annual budgets

2011/12-2017/18 11.1% 14.9% 14.6% 16.8%

Growth in Uganda

Annual budgets

2011/12-2017/19

factored additional

allocation of

resources (0.4%) 11.1% 15.0% 14.6% 16.9%

The following are three major sources of data used to complete the financial gap analysis;

1) Budget framework papers of Ministry of Finance, Planning and Economic Development

(MoFPED) for overall national budget and macroeconomic indicators

2) Ministerial budget framework paper; Health budgets; Budget support and health projects

under Medium Term Expenditure Framework (MTEF)

3) Sources financing the health sector outside the government systems; Off MTEF; Health

projects implemented by NGOs funded by donors.

Government budget support/ Health projects include;

i) Government revenue from taxes and non-taxes; Data was obtained from Ministry of

Finance, Planning and Economic Development (MoFPED) under MTEF

ii) Government revenue from debt relief; Data obtained from Ministry of Finance. ; Indicative

Revenue and Expenditure Framework from National Budget Framework Paper FY

2013/14 – FY 2017/2018; April 2013;

iii) Government loans from Overseas Development Assistance to support the health sector;

Sources of data obtained from MOFPED and Ministry of Health; Ministerial Policy

Statements that include vote allocations. ; Indicative Revenue and Expenditure

Framework from National Budget Framework Paper FY 2013/14 – FY 2017/2018; April

2013;

iv) Grants for health budget support donated by overseas development assistance; Data

obtained from ; Indicative Revenue and Expenditure Framework from National Budget

Framework Paper FY 2013/14 – FY 2017/2018; April 2013;

v) Earmarked funds for TB drugs from government commitment ; National Medical stores

Health sector support outside the government system includes;

i) Donor projects supporting the national TB program but do not channel their support

through the government; Obtained from development partners.

36

4.1.3 Financial Gap and Counterpart Financing Data Sources; The country has not yet carried out a resource tracking study to establish actual spending and specific

disease spending. National health accounts 2010/11 did not capture disease specific spending.

Earmarked funds for TB support are for purchase of drugs committed by the government.

Accessibility to partner’s databases was a main challenge. Data submitted from partners

implementing TB programs outside government systems seem to portray a lower picture of their

expenditures. Annual budgetary performance framework reports have been used. Data system

Limitation:

1) Insufficient existing mechanisms of sharing information between the TB program and

partners implementing TB programs outside the government funding mechanisms.

2) Lack of established database at the NTLP.

3) Budget support spending not earmarked by diseases

The national TB program employed a data manager whose responsibility will be to collect , analyze

and archive relevant data regarding the financing and implementation of the National TB program

and the data will include financial data as well. The data manager will develop standard data

collection tools and collaborate with partners implementing TB program outside the government and

be able to collect relevant data for the program. The data will be analyzed and store electronically.

4.1.4 Compliance with Counterpart Financing Requirements

Describe whether the counterpart financing requirements have been met as listed below. If not, provide justification which includes actions planned during the next Phase/Implementation Period to move towards reaching compliance.

a. Minimum threshold for counterpart financing Percentage in Line M of the ‘Financial Gap Analysis and Counterpart Financing’ table must be greater than or equal to the minimum threshold that applies to the applicant’s income level.

b. Increasing government contribution to national disease program over the next Phase/Implementation Period Figures in Line B of the ‘Financial Gap Analysis and Counterpart Financing’ table must increase over time.

c. Increasing government contribution to the overall health sector over the next Phase/Implementation Period Figures in Line I of the ‘Financial Gap Analysis and Counterpart Financing’ table must increase over time.

a) Minimum threshold for counterpart financing; The Gap analysis indicates

that in Line M of the ‘Financial Gap Analysis, Counterpart Financing is 29% which is

greater than 5% requirement for a country like Uganda. This is due to government

commitment to purchase TB drugs annually at a cost expected to be approximately

$2M annually. This increased the TB program budget tremendously for nearly twenty

times.

Source Ministry of Finance, planning and Economic Development; Budget framework paper

2013/14

37

b) Increasing government contribution to national disease program over the

next Phase/Implementation Period

As indicated in the gap analysis, government contribution to the NTLP is expected to

grow and the growth will depend on continued government commitment to earmark

funds for purchase of drugs and overall annual increment in the health budget. The

health budget is expected to continue to growing in absolute terms based on national

budget increases in values. Below is the expected increase in government contribution

to national TB program and the contribution is expected to double in 2017/18 as

compared to 2012/13 financial year.

Out turn

2012/13

Projected

2013/14

Projection

2014/15

Projection

2015/16

Projection

2016/17

Projection

2017/18

Estimates for

Government

funding to TB

$

2,111,144.8 $ 2,469,964.4

$

2,744,303.6

$

3,155,014.8 $ 3,617,147.6 $ 4,227,212.7

Annual Increase

in Government

funding to TB 0% 17% 11% 15% 15% 17%

Increase in

Government

funding to TB

( base year

2013/14) 0% 17% 30% 49% 71% 100.23%

c) Increasing government contribution to the overall health sector over the next

Phase/Implementation Period

The share of Government funding allocation to the health sector spending (including TB

control) appears to remain low as indicated in the left figure for Total Health expenditure as

compared to overall national expenditure, this share is indeed below the expected 15% Abuja

minimal requirement for budget support towards Health. However as mentioned above, in

absolute value terms, the country’s health budget is expected to grow annually and from the

gap analysis it is projected to grow by more than 40% in absolute values annually during the

next period of phase 2 implementation. The figures below compare shares of government

contributions to the health sector and shares of the health sector to National budgets

38

Ministry of Finance , planning and Economic development; Budget framework paper 2013/14

Projections from fugures of gap analysis

39

4.2 Progress towards Proposal Goals and Impact/Outcome

Please refer to the results reported by the PR(s) for impact/outcome indicators included in the Performance Framework and provide additional updates if recent information is available (e.g. survey reports, impact assessment studies, etc.)

The Goal of the TB SSF is to reduce the morbidity and mortality attributable to tuberculosis in

Uganda. The Impact indicator being TB prevalence rate per 100,000 population was not

assessed as the TB prevalence survey was not conducted. The Uganda TB program has

completed preparations for the prevalence survey and field activities are expected to commence

in October 2013. Outcome indicators included: Notification rate of all forms of TB cases (per

100,000 population); treatment success rate for new smear positive TB cases; and treatment

success rate, patients with laboratory-confirmed MDR-TB.

In the period 1 January to 30 June 2012, the PR achieved 93% and 90% respectively on case

notification (all forms) per 100,000 population and treatment success rate for new smear

positive cases. For the period July-December 2012, the performance of the two indicators

reduced to 88% and 89% respectively and between January to June 2013, it improved to what

was reported in first semester (93%, 90%). Figure 1 below summarizes progress on achievement

of outcome indicators against the GF targets.

Figure 1: Performance Achievement on Case Notification and Treatment Success Figure 1: Per

CN= Case Notification

The NTLP consistently performed above 85% against the set outcome indicator targets for phase

1 TB SSF.

40

The table below provides a summary of progress towards the goal, impact and the outcome. Impact/Ou

tcome Indicators

Baseline 2012 2013 2014

Date Baseli

ne Target Result

Target

Result

Target

Result

TB Prevalence

Rate/100,000

population 2010

193 (Global

TB Report 2011)

TBD ( based on prevalence

survey) 183

(Global TB report 2012) TBD - - -

Notification

Rate of all

forms of TB

cases / 100,000

population

2010 134 147

131 (R&R TB system, 2012

data)

148 - 149 -

Treatment

Success Rate:

New Smear

Positive Cases

2009 69% 85% 77.5% ( R&R TB system,2011

cohort)

85%

85%

Treatment

success rate:

laboratory-

confirmed

MDR-TB

N/A N/A N/A N/A N/A N/A

60%

Global TB Report, 2011 and 2012; and National TB Recording and Reporting system, 2012 data

Note: Disaggregated data by age and sex is not available for the impact and outcome indicators of this grant.

Please confirm if the method of data collection and data source is consistent with the M&E framework agreed at the time of signing the Grant/SSF Agreement(s).

The methods of data collection for the results reported are consistent with the M&E framework agreed at the time of signing the TB SSF grant Agreement. 22 Is there a recent report analyzing information regarding heath impact and outcome available? Yes

If yes, when was it conducted? The Joint External Review of the National TB Programme in the Republic of Uganda, 04-

17, September 2013 Please summarize the main findings and include a full copy of the report with the CCM Request.

22

The TB SSF grant is a consolidation of GF phase 2 round 6 and phase 1 round 10.

The main findings from the joint external review of the NTLP in Uganda conducted between 04-

17, September 2013 include the following:

1. Stable TB notification trend between the years 2006 and 2012 with minor year-to-year

fluctuations, for all categories of TB. The most affected is the age group which is economically

productive (Peak age: Men 25-44 years, and Women 15-35 years). The age group under 15 years

accounts for 50% of Uganda’s population and only 3% of the notified smear-positive TB cases.

41

2. Three-quarters of smear-positive TB patients successfully completed treatment in

2011, which is below the regional average of 85% for Africa, as well as the 90% Stop TB

Partnership target set for 2015. Default rate is consistently high, in the range of 11-13%.

3. NTLP is well structured within the MOH network. There is a Central Unit and 9 functional

Zones supporting 112 districts. TB control is fully integrated within the district Primary Health

Care (PHC) system. All patients are treated free of charge. The MoH mobilizes resources for TB

control largely through funding partners and facilitates import of drugs and laboratory

equipment. Staff establishment within the NTLP Central Unit is not enough to adequately

manage all components of TB control. The MoH senior management recognizes that the current

level of domestic financial support received by the NTLP is inadequate.

4. The NTLP has developed guidelines on all major strategic interventions. There is a

national strategic plan to control TB for the period 2012-2015. The annual implementation plan

is in line with the national strategic plan.

5. The Uganda Stop TB Partnership (USTP) currently has 47 member organizations with

27 more active in correspondence and meeting attendance. The partners include: NGOs, FBOs,

CSOs and partners' projects. Financial support to the Secretariat has been secured through GF

grant phase-I till June 2014, phase-II includes support for 2½ years. The coordination of

partners has allowed establishment of 3 Working Groups (DOTS Expansion, ACSM and

TB/HIV). Their activities included: review of national guidelines on DOTS, community care and

TB/HIV, formulation of a communication strategy. The USTP has a plan to working group on

PPM. USTP has also facilitated CSOs' engagement with the NTLP.

6. In regard to quality of DOTS, the human resources for TB control are low in both numbers

and skills; the quality of technical supportive supervision (planning, frequency, coordination,

feedback) is poor, and M&E is still weak (completeness of registers, analysis and use of data at

source not optimum)

7. In regard to Procurement and Supply chain Management (PSM), there is increasing

Government and donor commitment to strengthen the PSM. SOPs for the procurement process

have been developed. TB medicines have been integrated into the National Medical Stores

(NMS) PSM system. Most of the Health Workers handling medicines have been trained on

logistic TB management. However, there are a number of challenges: weak coordination among

MOH stakeholders; limited access to TB stock status reports from treatment sites by NTLP and

QPPU; lack of data verification at district level before sending reports to NMS to ensure quality

data are reported; long procurement lead time (GDF procured TB drugs); overstocking of some

TB medicines at facility and central level (pediatric and second line TB drugs) caused by the

“push” system; stock outs at central (RH and RHE)level and in some facilities(streptomycin,

INH, Pediatric); expiries and short dated medicines, and lack of understanding of ordering

instructions by some staff.

8. Laboratory capacity: The National TB and Reference Laboratory (NTRL) is recognized as

WHO-Supranational Reference Laboratory. It has adequate technical expertise and operational

capacity for External quality assessment (EQA) of sputum microscopy, culture/DST (first and

second line drugs). It has established a country-wide referral system for Culture/DST for MDR-

TB. A National partner coordination mechanism has been established for the Xpert MTB/RIF.

The TB laboratory network (1 microscopy lab for about 25,000-30,000 populations) has been

decentralized up to sub-county level (HC III). Over 1000 labs providing TB diagnostic services

are functional, providing access at different health services levels in the country.

42

However, only 3 full-time permanent staff at the NTRL are on the MoH payroll. The NTRL is

highly depending on donor/partnership resources for its operations. There is suboptimal

utilization of Xpert MTB/RIF (regional and district levels) and EQA for microscopy is

centralized.

9. Health Information System: There is a dedicated M&E team within NTLP, and a

functional recording & reporting structure all the way to TB treatment centers. TB reporting

formats are consistent with WHO guidelines; and revised TB data collection tools have been

developed in line with the latest WHO recommendations. TB/HIV data for most indicators

(HCT, CPT, ART) are captured at point of service delivery and regularly reported. There are

recent efforts to streamline and integrate TB recording and reporting into the UDHIS2 system.

Knowledge gaps on TB recording and reporting (TB R&R) were noted at health facility level,

TB registers were not up to date and suspect registers and Intensified Case Fining (ICF) forms

were rarely used. There were no written data quality assurance procedures at facility level.

There were no standard operating procedures and guidelines for TB R&R. Under-diagnosis

and under-reporting of TB in children, high levels of under-reporting of cases at treatment

centres and insufficient mortality measurements for understanding trends are some of the

challenges that were noted.

10. TB-HIV collaboration: TB/HIV committees were established at the health facilities,

staff at both TB and HIV sites were well trained on the management of TB/HIV, there was

strong recording and reporting of TB/HIV activities in both TB and HIV services, good uptake

of HIV services in TB clinics with the exception of ART and increasing uptake of TB screening

in HIV services.

11. Pediatric TB control: Pediatric TB is being prioritized. A pediatric technical WG has

been formed and is adapting the International Union Against TB and Lung Disease (The

Union) desk guide on management. New WHO guideline recommendations have been

adopted-(dosing of INH and RIF, use of EMB in smear-). Opportunities to improve diagnosis

of child TB using Xpert MTB/RIF have started and routine pediatric HIV testing done. The

challenges are: no performance indicators for pediatric TB; limited support from partners for

pediatric needs; no training/job aids and pediatric algorithms; pediatric specific diagnostic

techniques are rarely used; poor linkages for pediatrics to adult services for Isoniazid

Preventive Therapy (IPT), and low implementation of contact screening.

12. Programmatic Management of Drug resistant TB (PMDT): PMDT guidelines

were developed; there is quality-assured laboratory capacity at central level; rapid diagnostic

scale up is under way; second line drugs are available; National DR TB unit infrastructure

(Mulago) is completed; 9 MDR TB treatment sites are established, and 245 multidisciplinary

Health workers were trained in PMDT. The challenges include: a critical human resource gap;

lack of Case Management and M&E implementation guidelines; lack of implementation of

SOP; monitoring tests not always available; inadequate laboratory information flow;

inadequate MDR initiation center infrastructure and Infection Control; and inadequate

nutritional and social economic support.

The Preliminary findings are attached as Annex 7. The final report is expected in October 2013.

43

The key drivers contributing to the observations:

1) A decentralized laboratory network for diagnosis of TB; countrywide access to quality assured

and free of charge anti-TB medicines at all public and PNFP health facilities.

2) Increased access to HIV testing and treatment (including antiretroviral therapy) to the general

population and specifically for TB-HIV co-infected patients.

3) Increasing financing from GoU, international and national development partners towards TB

control.

The critical contextual factors in program implementation that influenced the trends observed were

mainly in two areas;

1. The recognition that TB is an emergency in the AFRO region, which attracted more

international and national funding towards TB control in TB high burden countries.

2. Health system strengthening mainly in the area of Governance, Coordination, laboratory

network, procurement and supply management, health workforce, equitable distribution of

services and private sector engagement especially the PNFP subsector.

The Global Fund provided additional funding to the country to strengthen the health system and to

specifically implement TB control interventions since round 2 GF which was implemented in

2003/04. It is recognized that Global Fund provides substantive funding for TB control in Uganda

and has therefore contributed significantly to the performance observed.

Do you consider the program is making progress towards the goals and objectives of the proposal? If not, provide justification and explain how you intend to address the issues.

The NTLP is making progress to the goals and objectives of the proposal. The section below describes

progress in achievement of the six objectives of the proposal.

Objective 1: To expand and consolidate high quality DOTS

Four indicators were used to monitor progress on objective 1. These included: case notification of all

forms of TB; case notification of new smear positive cases; treatment success rate of new smear

positive cases; and number and percentage of districts/units reporting no stock outs of first line anti-

TB drugs. Figure 2 below summarizes progress on Case notification of all forms of TB and smear

positive TB cases and Figure 3 summarizes the progress on Treatment success rate and reporting

units reporting no stock outs of first line anti-TB medicines.

44

Figure 2: Performance achievement on Case notification of TB cases

CN all forms = Case notification of all forms of TB CN Smear + = Case notification of smear positive TB cases

Performance on the two indicators of case notification of all forms of TB and case notification of smear positive TB cases consistently remained above 85% against the set targets for phase 1 TB SSF. Figure 3: Performance achievement on TB Treatment Success and reports on no stock outs

TSR= Treatment Success Rate

Performance on Treatment Success Rate (TSR) consistently remained above 85% of the set target for

phase 1 TB SSF.

The indicator on "number and percentage of districts/reporting units reporting no stock-out of first-

line anti-TB drugs during the reporting period" did not have any results because at the time of grant

application in 2010, the storage and distribution of first line anti-TB drugs was mandated to NTLP.

However, this responsibility was transferred to the National Medical Stores (NMS), in 2011 by

Ministry of Health (MoH). With this transition, the NTLP faced challenges obtaining district level

data as NMS delivers medicines direct to the health facilities. In view of the above, it was suggested

by the GF23 that the PR should find a way forward to facilitate the NTLP in accessing data such as the

use of Health Management Information System (HMIS). To solve this problem, a data officer based at

NMS was recruited in July 2013 with support from partners to analyze health facility reports, collate

data on stock status and write reports that will be shared with all stakeholders including NTLP. The

23

Pre-Assessment Summary UGD-T-MOFPED Periodic Review-December 2012

45

MoH is planning to integrate the reporting and ordering of TB medicines, laboratory reagents and

related supplies into the web-based ordering system used by the national HIV/AIDS control program

(WAOS). This activity will be supported in hospitals and HC IVs that already have computers and

internet access. This will ease reporting and ordering of TB medicines and related supplies and will

provide timely information on stock status to all stakeholders at national and district level. To

minimize stock outs of medicines, laboratory reagents and related supplies at the lower health

facilities which have low capacity to requisition, the MoH through the Commodity Security Group

(CSG) recommended to use a push method for distribution of medicines, laboratory reagents and

related supplies to Health centre IIIs and IIs. The pull method was maintained for the higher level of

health facilities (hospitals and health centre IVs) which have adequate capacity to requisition for

medicines and related supplies.

The weaknesses identified at the health facility level included: inadequate knowledge, skills and

supervision of health workers which contributed to lack of minimum and maximum stock levels for

TB medicines at health facilities; failure to systematically update the commodity stock cards on

receipts or issues of products; failure to link information on the stock cards to requisition and issue

vouchers, and non-uniform Logistics Management Information System (LMIS) tools at health

facilities. The LMIS tools were not uniform across all health facilities because they were produced by

various implementing partners24 who did not consult with the NTLP on updated versions. These

weaknesses will be addressed in phase 2 TB SSF through central procurement of LMIS tools and

training, mentoring and supervision of health workers.

Despite the above challenges, some progress was made in strengthening the procurement and supply

chain management (PSM). The stand alone procurement and supply chain management for TB

medicines and commodities was integrated into the essential medicines procurement and supply

chain managed by NMS in 2011, as explained in section 3.3 on health systems analysis. Phase 1 TB

SSF was used to secure First Line Medicines (FLM) for drug susceptible TB patients for two years and

second line anti-TB medicines for 200 MDR patients. Coordination among partners supporting

strengthening of the supply chain improved when the Pharmacy division of Ministry of Health set up

a Commodities Security Group (CSG), which meets on a monthly basis to review stock levels and

challenges in the management of the supply chain.

In regard to High quality DOTs, political commitment for TB control increased as demonstrated

by increased advocacy for TB control at the national level and financial commitment from

Government of Uganda to procure anti-TB medicines (second line medicines). The GoU procured TB

first line medicines for all patients for a period of 6 months and 100 courses of second line medicines

for MDR patients. Thus the medicines for TB patients have jointly been provided by the GoU and GF.

The TB diagnostic laboratory network expanded and was strengthened with new diagnostic tools

through support from GoU and different partners. Health facilities providing Ziehl Neelsen (ZN)

smear microscopy services increased from 1091 in 201125 to 1158 by end of June 2013. External

quality assurance (EQA) for ZN smear microscopy was done for 90% of the diagnostic units. EQA for

fluorescent microscopy is conducted for the 100 diagnostic units with fluorescent microscopes.

Although the majority of ZN smear microscopy centres have received binocular microscopes, 15% still

have microscopes that are poorly functional or monocular. This gap will be filled by the GF health

system strengthening grant which will be used to procure additional binocular microscopes. By end

of June 2013, smear microscopy using LED microscopes had been introduced in 130 facilities. The

24

Although the health facilities are managed by the MoH and District local governments, the implementing partners fill gaps in health service delivery e.g printing of stationery which includes LMIS forms. 25

Ministry of Health, Uganda National Tuberculosis and Leprosy Control Program, Strategic Plan, 2012/13-2014/15

46

Xpert MTB/RIF has been introduced by World Bank and partners in 32 health facilities by end of

June 2013 and an additional 11 machines have arrived in the country and will soon be distributed to

health facilities. Scale up of the Xpert MTB/RIF will help to increase detection of TB among HIV

infected patients in addition to detecting patients with Rifampicin resistance. The Xpert MTB/RIF

will also be used to improve detection of TB in children. This will require training of clinicians and

nurses to safely induce sputum from children. The capacity of health workers at the regional referral

and general hospitals to diagnose TB in children will be enhanced with support from phase 2 TB SSF.

Although the country is scaling up Xpert MTB/RIF, there have been challenges of maintaining a

constant supply of cartridges and underutilization of existing machines. In-country partners have

committed to provide adequate supplies of cartridges for the next 2-3 years. The underutilisation of

Xpert MTB/RIF machines has been due to: lack of a referral network between the health facilities

with and without machines; lack of adequate sensitization of clinicians on when to use the test, and

poor coordination between the Government and implementing partners. The referral network has

been established and the national Xpert MTB/RIF implementer’s committee coordinated by the NTLP

was put in place to improve coordination among partners and sharing of information. A draft Xpert

MTB/RIF implementation plan was developed to guide planning, scale up and implementation of

Xpert activities. Training of health workers has been conducted for all health facilities with machines

and for health facilities with newly introduced machines, the training is ongoing. Standard Operating

Procedures (SOPs) for health workers to make decisions on the patients that need the Xpert tests were

developed. Support supervision visits to the health facilities will improve adherence to the SOPS

which is envisaged to improve utilization. To support the scale up plan for the Xpert MTB/RIF, 20

machines will be procured with support from phase 2 TB SSF.

In regard to facilitation of sub-county health workers to identify and supervise community treatment

supporters for TB patients, delivery of the funds to the sub-county health workers (a public health

worker who links the formal health system to the community) was difficult to administer because of

their wide geographical spread. This activity was to be undertaken by partner NGOs but as there was

no management cost for the implementing NGOs it never got executed. Partners are supporting this

activity in six out of nine zones (North, SW, SE, East, West and Kampala). With TB SSF Phase II, the

program will facilitate sub-counties in three underserved regions (NW, NE and Central) in the first

year and subsequently expand to additional districts as partners’ support phases out (49 in year 1, 80

in year 2 and 112 in year 3). The sub-county health workers will deliver medicines in the communities

and identify community treatment supervisors. Management costs for delivering the facilitation

funds to the sub-county health workers in the zones have been included in the TB SSF Phase II

budget. Through another GF health systems strengthening grant to MOH Uganda, the MoH is

strengthening the capacity of Village Health teams (VHT) to identify and support treatment

supporters for TB patients. Expanding the coverage of VHTs and strengthening their capacity to

support TB patients will complement the support provided by sub-county health workers and improve

treatment outcomes while reducing the risk of development of drug resistant TB. Facilitation for the

VHTs will come through the GF Health Systems Strengthening Grant to MoH. The NTLP will

proactively monitor the VHT and sub-county health workers related activities to ensure that the TB

community activities are effectively implemented.

47

A network of VHTs has been established in Uganda which is facilitating health promotion, service

delivery, community participation and empowerment in access to and utilization of health services.

VHTs have been established in 75% of the districts in Uganda but only 31% of the districts have trained

VHTs in all the villages2. The VHTs are responsible for:

• Identifying the community’s health needs and taking appropriate measures;

• Mobilizing community resources and monitoring utilization of all resources for their health;

• Mobilizing communities for health interventions such as immunization, malaria control, sanitation

and promoting health seeking behavior;

• Maintaining a register of members of households and their health status;

• Maintaining birth and death registration; and

• Serving as the first link between the community and formal health providers.

(Health Sector Strategic and Investment Plan 2010-2015, Government of Uganda)

Objective 2: To strengthen implementation of TB/HIV collaborative activities

The two indicators for objective 2 were; TB patients who had an HIV test result recorded in the TB

register among the total number of registered TB patients, and HIV-positive TB patients who start on

or continue previously initiated antiretroviral therapy, during or at the end of TB treatment, among all

HIV-positive TB patients registered over a given time period.

Access to HIV services for TB patients improved and the performance was sustained above 90%

against the phase 1 TB SSF targets. HIV testing for TB patients increased from 81% to 87% and

Cotrimoxazole Preventive Therapy (CPT) for the co-infected patients from 90% to 94% between 2010

to 2012 respectively. Although the proportion of TB-HIV co-infected patients that received

antiretroviral treatment (ART) increased from 34% in 2011 to 60% in June 2013, it is still low to

prevent significant deaths among co-infected patients. Figure 4 below summarizes progress on

achievement of TB/HIV indicators against phase 1 TB SSF targets.

Figure 4: Performance achievement on TB/HIV collaboration. Figure

Uptake of ART among TB-HIV co-infected patients remained sub-optimal due to; the lack of an

integrated model for delivery of TB-HIV services in the majority of health facilities; and more

48

decentralization of TB diagnostic and treatment services to lower health facilities as compared to

ART services. Other African countries have successfully provided ART to over 80% of the TB-HIV co-

infected patients through an integrated model of TB-HIV services which is implemented in the

majority of their health facilities. 26,27

In this context, Uganda has embraced the need to implement an integrated model for TB-HIV

services. The National Policy for TB/HIV collaborative activities has been revised to include a policy

recommendation on an integrated model for TB-HIV services. With support from partners, the MoH

will implement the integrated model described below starting with the 14 regional referral hospitals

and the general district hospitals. Successful implementation will require development and

dissemination of implementation guidelines together with training and supervision of health workers.

The NTLP will be working with relevant stakeholders towards development, printing and

dissemination of implementation guidelines for an integrated model of TB-HIV services with support

from phase 2 TB SSF. The HIV program will support TB clinics to get accredited for provision of ART

and will support the accredited TB clinics to access ART and medicines for treatment of opportunistic

infections.

Proposed model for integration of TB-HIV services

1. All TB standalone clinics will be transformed into TB-HIV clinics and will provide the

following services.

TB diagnosis and treatment

Rapid HIV testing

Initiation of ART and follow up

Treatment of opportunistic infection.

On completion of TB treatment, the patient will be referred to the HIV clinic to

continue chronic HIV care.

2. The HIV clinics will continue to provide the HIV testing, care and treatment services. In

addition, they will provide the following TB related services.

Active TB screening among HIV clients (Intensified TB case finding)

Provide Isoniazid Preventive Therapy to HIV clients without TB symptoms

Refer HIV clients confirmed to have active TB disease to the TB-HIV clinic to

start and continue TB treatment. This will help to reduce the risk of

transmission of TB within HIV clinics given the current infrastructure

challenges for airborne infection control.

Objective 3: To Establish Program Management of MDR-TB (PMDT)

The indicators that were used to monitor this objective are: TB cases with results for diagnostic drug

susceptibility testing for MDR-TB among those eligible for drug susceptibility testing according to

national policy during the specified period of assessment; Laboratory-confirmed MDR-TB cases

enrolled on second-line anti-TB treatment during the specified period of assessment, and MDR-TB

cases initiated on a second-line anti-TB treatment who have a negative culture at the end of six

months of treatment during the specified period of assessment. Figure 5 below summarizes progress

on achievement of MDR indicators against targets.

26

International Union Against Tuberculosis and Lung Disease, Implementing Collaborative TB-HIV Activities, A Programmatic Guide, 2012. 27

Presentations on country experiences, Namibia, Rwanda, Tanzania; 18th Core Group Meeting of the Global TB/HIV Working Group and workshop to scale up the implementation of collaborative TB/HIV activities in Anglophone Africa 10-11 April 2013, Maputo, Mozambique .

49

Figure 5: Performance achievement on DST and MDR indicators

DST-MDR= Drug susceptible testing for Multidrug Resistance TB MDR= Multi-Drug Resistance TB

The NTLP is expected to start reporting on the indicator on “MDR-TB cases initiated on a second-line

anti-TB treatment who have a negative culture at the end of six months of treatment during the

specified period of assessment” at the end of December 2013.

Although the country met the target on the indicator pertaining to DST for eligible patients, it

recognizes that MDR patients started on treatment were much fewer than what was targeted despite

availability of Second Line Drugs (SLDs) from GF and GoU.

The program did not do well on enrolling MDR TB patients on treatment because of the following

reasons;

1. At the time of grant application in August 2010, 300 MDR cases were waiting to be put on

MDR treatment. Once the medicines were available, NTLP made efforts to clean the

waiting list and trace all the patients to be put on treatment. After cleaning, double entries

were removed and 197 patients were eligible for tracing. Out of the 197, only 66 were traced

and found alive28. The reasons why the patients could not be traced included; death,

wrong contact numbers and failure to locate patients at the given physical addresses.

2. There was a delay in starting all MDR patients on treatment because the patients were

spread across the country and there were insufficient financial resources to maintain these

patients at the centrally located treatment centre (Mulago National referral hospital). To

reduce the distance between the patients and the treatment sites, the treatment has been

decentralised to 8 additional sites based at 6 regional referral hospital and 2 district

hospitals. Partners have provided support for patients (transport, nutritional support,

communication, home visits) to the treatment sites that have been established. The

decentralization of MDR treatment and the support from GoU, GF and Partners enabled

28

NTLP report on MDR, April 2013

50 150

50

120 patients to start treatment by end June 2013. However, given that partner support is

confined to pre-determined geographical coverage, not all patients could be reached. The

country is preparing an additional five treatment sites to expand the geographical coverage

and further improve access. Partners will continue to support the NTLP to prepare the

additional sites with relevant requirements. This will bring the total MDR TB treatment

sites to 14 by end of December 2013. Standard guidelines on case management will be

developed with support from partners and shared with the health workers at MDR

treatment centres and follow up sites. This will help to standardize case management at all

treatment centres. Partners have committed to support NTLP to develop 2 Centres of

excellence for management of MDR patients. Other treatment centres will learn from these

centres and improve the management of MDR patients.

3. At the time of grant signing, the country was implementing a hospitalization model for

MDR TB management. This limited the number of patients who could be initiated on

treatment because of lack of adequate hospitalization facilities. On the recommendation of

WHO, the county adopted a mixed model of care which integrates hospitalization and

ambulatory management of MDR patients.29 Thus, patients that do not require

hospitalization are managed at the nearest private or public facility to the patient’s home

which is referred to as a follow up facility. Once clinical and laboratory assessment is done

and treatment is initiated at the MDR treatment site, the PMDT team at the treatment

site together with the patient identify a follow up health facility where the patient will

continue treatment. The follow up site is prepared through training and mentoring and

provided with the medicines and related supplies to continue treatment for the patient.

Follow up and support supervision to the follow up site is done by the PMDT team

monthly. The change in policy has facilitated NTLP to increase the number of patients on

MDR treatment and it is envisaged that the targets set for TB SSF phase 2 will be achieved.

The follow up sites need infrastructural improvements for both airborne and blood borne

infection control, logistics in terms of transport for rapid follow up of patients, and

enhanced training and supervision to reinforce their knowledge and skills. Partners will

support training of heath workers at follow up facilities in the catchment area of 9

treatment sites. Training for the health workers in follow up facilities in the catchment area

of the remaining 5 treatment units will be prioritized under phase 2 TB SSF. Transport

refund for patients that initiate treatment at the five treatment units without partner

support will be supported under phase 2 TB SSF.

4. Inadequate human resource capacity at the treatment units in terms of numbers and

technical skills of health workers affected enrolment of patients on treatment. Financial

resources were not readily available at the start of implementation of TB SSF phase 1 to

train health workers. NTLP mobilized financial and technical support and trained health

workers at the 9 treatment units. Partners provided support for additional human

resources in 3 treatment units and this remains a gap in the remaining 11 treatment units.

The GoU is expected to recruit health workers at regional and general hospitals in 2014/15

and it is envisaged that this will reduce the gap. To improve motivation of health workers

who are treating MDR patients and are at a higher risk of acquiring MDR TB, the program

will provide a top up on staff remuneration to the health workers treating MDR TB

patients in the 14 treatment units with support from Phase 2 TB SSF.

29

World Health Organization, Guidelines for Programmatic Management of drug-resistant tuberculosis, 2011. WHO/HTM/TB/2011.6

51

Other reasons that affected the quality of the PMDT program were ; inadequate infrastructure to

admit and isolate MDR patients as well as ensure infection control; delayed procurement of food,

transport refund and laboratory services. Two treatment sites were remodelled with support from

partners and partners have committed to remodel 07 additional sites by end of December 2013. A gap

remains for the remaining 5 treatment units. The delays in procurement partly affected the

absorption rate of TB SSF Phase 1 grant. A concept paper on internal controls to manage the food and

transport refund for patients was drafted by the NTLP and approved by the GF (Annex 8). The MoH

has initiated the procurement process to identify suppliers to manage the food and transport refund

for patients and to provide laboratory services.

The National Medical Stores (NMS) procures medicines for management of side effects as part of the

essential medicines list. Procurement of these medicines will be done with funding from GoU. During

supervision visits to the MDR treatment units, health workers will be supported to strengthen their

capacity to requisition for these medicines together with other essential medicines from NMS.

Despite the above challenges, the country progressed in the following areas;

1. A population based national survey on anti-TB drug resistance carried out in December 2009

and February 2011 showed that Multidrug Resistance TB (MDR-TB) among new sputum

smear positive cases was 1.4% and 12.1% among previously treated cases (relapses, treatment

after loss to follow up, and treatment failures). Resistance to any anti-TB drug was 10.3%

among new cases and 25.9% among previously treated cases. The survey results showed no

association between anti-TB drug resistance and HIV infection.30

2. In line with findings from the Drug Resistance Survey, 334 MDR cases were expected to have

been identified from smear positive retreatment cases in the year 2012. The TB Specimen

Referral System (TSRS) was established to facilitate transportation of sputum samples from

peripheral Diagnostic and Treatment Units (DTUs) to the National TB Reference Laboratory

(NTRL) for drug susceptibility testing (DST). The TSRS network expanded from 264 DTUs in

2010 to 325 in 2011 and 400 by end of June 2013. Among the 1,389 previously treated TB

patients that were eligible for DST by end of June 2013, 922 (66%) received DST. Further, 87

MDR cases were identified from those that received DST. Shortage of human resources affects

services at the National TB Reference laboratory which is responsible for confirming MDR

patients and conducting follow up laboratory tests. The National TB Reference Laboratory

(NTRL) is receiving funding from GF and other partners for the TB Specimen Referral

System (TSRS), which is enabling eligible patients to receive DST at the NTRL. This support

was mainly targeted towards courier services and transport allowances etc but does not

support the requisite human resource needed to run NTRL efficiently. NTRL will work closely

with the Central Public Health Laboratory (CPHL) to link the TSRS to the Hub system which is

used to transport specimens for laboratory testing from lower health facilities to higher health

facilities with adequate laboratory infrastructure. This will help to further decentralize this

service to more health facilities and is more sustainable. NTLP will support two additional

human resources for the NTRL through TB SSF phase 2.

3. Since 2009 up to-date, in-country international partners have supported salary of a medical

officer who has been coordinating PMDT activities at national level but now NTLP is in the

30

Lukoye D, Adatu F, Musisi K, Kasule GW, Were W, et al. (2013) Anti-Tuberculosis Drug Resistance among New and Previously Treated Sputum Smear-Positive Tuberculosis Patients in Uganda: Results of the First National Survey. PLoS ONE 8(8): e70763. doi:10.1371/journal.pone.0070763

52

process of recruiting a full time medical officer to coordinate the PMDT program at the

national level with GF support.

Objective 4: To strengthen TB control in Uganda Prisons Services

The indicator that was used to measure this objective was, number and percentage of prisoners

screened for TB on entry. Although the PR reported that 43% of the prisoners were screened on entry

for the semester July-December 2012, the Global Fund did not consider the results for this indicator

because there were no supporting documents availed to verify the results31.

In order to address the verification issue, the NTLP agreed with Uganda Prisons Services (UPS) on a

mechanism to transmit data from UPS to the NTLP. The procedure for collection, collation and

reporting from the prison units up to the Uganda Prisons Services headquarter and to the NTLP is

summarized below:

On entry, all new prisoners are screened for TB and data is recorded in the on-entry screening

register at all the Prison Health Units.

The data at the prison health unit are aggregated on a monthly basis and sent to the Regional

Health Office for the attention and action of the Regional Health Coordinator (RHC) and the

Regional Data Clerk (RDC). A prison health unit reporting form is used by all Prison health

units to submit monthly reports to the region office.

The RHC and RDC aggregate data from the health unit reports and compile a regional report

on entry TB screening and send it to the Prison Health Office at Prison Headquarters for

attention of the M&E officer. A regional on-entry TB screening reporting form is used by all

regional health offices to submit reports to the headquarter office.

The Prisons headquarter M&E officer compiles the national prisons monthly entry TB

screening report from information in regional reports. The national prisons report is sent to

NTLP for the attention of the NTLP Program Manager.

For the period of Jan –June 2013, 72% of inmates in 35 prisons were screened on entry. The

documents have been verified by the Local Funding Agent (LFA) of GF. On-entry and annual mass

screening will continue in the 35 prison units with support from Phase 2 TB SSF. Outreach services

for mass screening will be extended to prison units without laboratory services. The UPS will receive

one of the xray machines after completion of the TB prevalence survey and will need funds to procure

xray films.

The Uganda Prisons Service (UPS) has an average population of 35,000 inmates, with a turnover of

over 100,000 annually. The burden of Tuberculosis is high in UPS with an estimated prevalence of

654/100,000 population32. Annual notification of TB from prisons services is about 500 cases of all

forms. Efforts to control TB in UPS are complicated by the high HIV prevalence (11%), high HIV/TB

co-morbidity, prison congestion, poor nutrition and inadequate infrastructure, limited TB awareness

and a weak prison health system.

TB interventions in prisons are in line with the NTLP strategic direction. To prevent and control TB in

prisons, UPS has implemented a range of TB strategies and interventions that include: provision of

high quality TB DOTS and TB/HIV collaborative management at 13 TB treatment units ( out of 35) ;

31

Pre-Assessment Summary UGD-T-MOFPED Periodic Review- December 2012, page 5. 32 Uganda Prisons Services, A Rapid Situation Assessment of HIV/STI/TB and Drug Abuse among Prisoners in Uganda, 2009.

53

strengthened the prisons health systems through recruitment of health workers and capacity building

for TB management and operational research; engaged NGOs, CSOs and community TB care

providers to extend TB care to prison units; empowered prisoners suffering from TB to support peer

education of inmates; and promoted prison community participation in TB care.

In order to swiftly identify inmates that could transmit TB infection to others, UPS conducts on-entry

TB screening and annual TB mass screening. All TB suspects are tested for TB and all confirmed with

TB are put on treatment which is supervised by the health workers and prisoners. UPS has also

identified cough monitors among inmates and trained them on suspect identification. On entry TB

screening was supported in 35 out of 233 prison units, by GF while the annual TB mass screening was

supported by partners. However, support from partners for mass screening ends in March 2014. As a

result of on entry screening, between July 2012-June 2013, 175 TB patients were identified and

started on treatment.

With support from GF and partners, UPS received 01 fluorescent kit, 10 Zeiss Light microscopes,

three CX 21microscopes, one Xpert MTB/RIF machine, 02 Pima and Facs count machine (MBH) used

for CD4 cell count. These have contributed to increased TB case finding in prisons.

TB awareness is limited with only 61%33 of prisoners knowing that TB is airborne. Financial support

is needed for health education sessions, IEC materials and periodic Knowledge, Attitude and Practice

(KAP) surveys to inform IEC programming.

Other challenges include inadequate laboratory services, lack of isolation facilities for TB suspects and

patients, inadequate health worker knowledge and skills on TB/HIV co-management and weak

recording and reporting at the health facility level.

Objective 5: To strengthen partnerships to scale up TB control interventions

This objective does not have any specific indicators. However, it contributes to the outcome

indicators. Activities under this objective in phase 1 related to strengthening of the Uganda Stop TB

Partnership (USTP) and Advocacy, Communication and Social Mobilization (ACSM). In Phase 2 TB

SSF application, activities to strengthen the public-private partnership for TB control have been

introduced.

The USTP coordinates implementation of TB control activities among its 41 Partners, 27 of whom are

active. The partners implement TB control activities according to their respective areas of expertise.

Well coordinated USTP will have a synergistic effect on scaling up and improving coverage of TB

control interventions nationally. In this regard, USTP shall continue to involve all TB stakeholders

with expertise in resource mobilization and implementation of TB control activities including ACSM

for improved TB control. During phase 2 TB SSF USTP will undertake mapping of partners with a

focus on community-based organization and strengthen their capacity to contribute more effectively

towards TB control. Further USTP will also leverage and mobilize more resources for TB control in the

country.

For the USTP to effectively coordinate the partners, three fulltime Officials (an Executive Director, a

Technical Advisor and a Secretary) were recruited, office space, equipment and supplies were secured

for the USTP secretariat with support from phase 1 TB SSF. The team is supported by a part time

Executive Secretary. The fully constituted USTP secretariat will support the member organizations of

USTP to advocate and mobilize resources for TB control. In order to enhance USTP secretariat’s role

in respect to coordination and active engagement of partners, the USTP will continuously work with

33

Uganda Prisons Services, A Rapid Situation Assessment of HIV/STI/TB and Drug Abuse among Prisoners in Uganda, 2009.

54

the NTLP to advocate for additional resources and monitor the partners’ contribution to

implementation of the strategic plan.

Under phase 2 TB SSF, the USTP secretariat’s capacity in grants management, governance, advocacy

and resource mobilisation will be strengthened. It is envisaged that once USTP becomes fully

operational, it will contribute effectively towards management and follow up of TB patients at the

community level through community-based organizations. Further, NTLP envisages the extended role

for USTP to be contributing in harnessing the support from Private Health Practitioners and Private

not for Profit Practitioners.

The USTP monthly working group meetings and the general quarterly meetings have been supported

by GF and partners. In addition, the USTP will also organize an annual TB conference through

partner support, which will provide an opportunity to share best practices in TB control.

The major factors contributing to low case detection are; weak advocacy and low community

awareness on TB. Further, the high default rates are associated with poor patient education. To

address these gaps, and strengthen advocacy, communication and social mobilization, the

NTLP planned to address these problems by disseminating the TB and TB/HIV communication

strategies in addition to other community interventions. However, emerging issues like MDR TB,

changes in policies and management strategies especially in the area of TB/HIV collaboration

necessitated a revision of the communication strategies. The NTLP envisages harnessing support from

partners to revise the communication strategies and will use phase 1 TB SSF (already in the country)

to print and disseminate them. The NTLP will target health activists (community based

organizations) especially those that have successfully advocated for HIV prevention and treatment to

advocate for an increase in access to TB services including TB/HIV and MDR. This will require

orienting them to TB, TB/HIV and MDR control aspects. In addition a few successfully treated MDR

patients will be identified, trained and facilitated to support patient’ education and follow up of MDR

patients. Commemoration of World TB day will be supported under phase 2, as a key activity for

advocating for additional resources for TB control.

There is need to target the “bottom-of-the-pyramid” communities through non-conventional media

using grass root organizations and village health teams to convey TB messages including TB/HIV and

MDR. The messages will be theme based and tailored to the specific community’s dialect. This will

improve community awareness and create a knowledge-base that will help to de-stigmatize, motivate,

persuade and empower the communities to make rational decisions that will lead to action towards

early TB case detection and successful treatment. The grass root organizations will be facilitated with

funding from Phase II TB SSF to conduct community TB education and social mobilization. The non-

conventional media will be integrated with the Visual Acoustic and Motion (VAM) model where

resources allow. These activities will be conducted under the overall umbrella of the NTLP through

USTP.

In regard to involving the private sector, the NTLP has advanced in engaging the Private not for

Profit (PNFP) subsector. All PNFP health facilities are engaged in TB control and receive free anti-TB

medicines and laboratory reagents from the Government sector. The NTLP is working towards

engagement of the Private Health Practitioners (PHP), although their involvement is still minimal and

mainly concentrated in Kampala City. Before 2011, only 6 out of over 1000 PHPs in Kampala city were

engaged in TB diagnosis and treatment. In 2011, the NTLP together with Kampala City Council

Authority (KCCA) partnered with an additional 70 PHPs to scale up TB diagnosis and treatment in the

slums of Kampala city with support from partners. As a result of this partnership, an additional 600

55

pulmonary smear positive TB patients were detected and started on treatment in a period of one year. 34 This function will also be managed by USTP under the overall guidance of the NTLP.

TB case notification to the NTLP is higher in the urban settings in comparison to the rural areas.

Kampala city which is the capital of Uganda, accounts for 20% of total TB cases notified to the NTLP

annually. Case holding is a big challenge in urban areas leading to poor treatment outcomes. In the

2011 cohort, Kampala had a treatment success rate of 70% which was lower than the national average

of 77% for the same cohort. The default rate for Kampala was 21% compared to a national default rate

of 12%.35 A national household survey carried out in 2009/10 showed that 17% and 52% of the urban

population seek medical attention from pharmacies/drug shops and private clinics, respectively. The

high default rate in urban settings including Kampala could be explained by the fact that the majority

of people in urban settings continue to seek medical attention from PHPs yet the majority of them do

not have adequate knowledge on TB and will therefore not give appropriate counselling and care to TB

patients.

During phase 1, no support from the TB SSF was extended towards active engagement of PHPs as the

NTLP anticipated that in-country partners would support PPM to actively engage PHP facilities.

However, the program was not able to secure partners to support PPM beyond the 70 facilities

engaged by the SPARK TB project in Kampala’s slums. Well as the Ministry of Health has a PPPH

policy framework to engage the private health sector, the NTLP does require a PPM policy framework

and implementation guidelines. The NTLP will tap into the potential of PHP professional bodies or

Associations to scale up PPM in the PHP subsector.

Through the USTP and its member organizations representing the private sector and with support

from phase 2 TB SSF, the NTLP will develop a policy framework and implementation guidelines for

PPM and will actively engage the PHP professional bodies/associations to scale up PPM. PHP

Umbrella/professional Organisations will be engaged under the stewardship of the Federation of

Private Health Professionals (FPHP) to which most PHP professional bodies are members and have

entered membership agreements (MOUs). The Private Health workers will be trained on TB, TB/HIV

and MDR-TB with support from Phase II TB SSF.

Objective 6: To strengthen program capacity to plan, implement, monitor and evaluate

TB control

The indicator that was used to monitor M&E activities was the number (and percentage) of quarterly

TB reports received timely from districts/reporting units. The NTLP achieved 120% against the set

phase 1 TB SSF targets from Jan 2012 to June 2013 and sustained this achievement. Figure 6 below

shows the performance.

34

The International Union Against TB and Lung Disease, Annual Report for the Slum Partnerships to Actively Respond to Tuberculosis in Kampala District, 2012. 35

Ministry of Health , NTLP recording and reporting system, 2012

56

Figure 6: Performance on timely reporting

Additional human resources were provided with support from TB SSF and partners. Three program

officers (M&E officer, Program Officer and Data Manager) were supported by GF , 04 fulltime and 02

part time Program officers were supported by partners. The process of recruiting a National MDR

coordinator is ongoing. Additional staffs have enhanced the NTLP’s capacity to carry out its functions

more effectively. The staff supported by GF will continue to be supported under phase 2 TB SSF with

an additional of 02 staff for the NTRL.

In regard to monitoring of interventions and performance, three supervision visits were conducted

from the national level to the regional/district level. One visit was supported by TB SSF and in country

partners. These supervisory visits were conducted jointly with implementing partners. One quarterly

supervisory visit from the zones to districts was supported by TB SSF. Monthly supervisory visits from

the district to TB diagnostic and treatment units (DTUs) were supported with TB SSF for a period of 6

months. A double cabin pickup was procured with TB SSF to facilitate M&E activities.

The MoH was not able to mobilize adequate funding for national, zonal and district support

supervision visits, from GF and in-country partners. The supervision visits cover assessment of TB

control interventions including TB/HIV and MDR. Due to inadequate funding, some scheduled

supervision visits were not conducted and this affected monitoring of performance in TB control.

Performance review meetings were held at the national and zonal level. Performance review meetings

at the national level involved NTLP program officers, Zonal officers and partners and those at the

zonal level involve DTLS and partners supporting TB control in the zone. During the performance

review meetings, performance in regard to TB control is reviewed, best practices and challenges are

shared and solutions to close the gaps are discussed and agreed upon. At the zonal level, in addition to

the above activities that take place in the review meetings, data is exchanged and harmonized for

quarterly performance reports that are submitted to the national level. The phase 1 TB SSF supported

one performance review meeting at the national level and one meeting in each zone. Funding

available for performance review meetings at the national and zonal level is inadequate to effectively

conduct all the scheduled review meetings at the different levels. The country was not able to mobilize

adequate resources from partners for performance review meetings. The annual planning meeting

which brings together all stakeholders to review performance, share information on policies,

strategies and discuss challenges, opportunities and solutions, was not held due to lack of funding.

Data management at different levels has remained a weakness. To address this, Standard Operating

Procedures (SOPs) on data management have been developed. These will be printed with support

from Phase II TB SSF and will be disseminated during performance review meetings and support

supervision visits.

The 40 districts that were prioritized to improve case detection were advanced funding to implement

intensified TB case finding in Jan 2013.

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To enhance learning from other countries, 3 officers from NTLP were supported to attend two World

Union Conferences with support from partners.

The NTLP central unit does not have adequate financial support for communication, coordination and

to undertake supervision visits to zonal offices, partners and implementing teams at the district level.

This affects coordination and monitoring of performance at all levels.

To improve program performance in the 5 objectives above, supervision and performance review

meetings will be conducted at the different levels of the health system. During supervision and

program review meetings, districts will be supported to align their district plans to the HSSIP III and

the TB National Strategic Plan and Global Fund supported activities will be incorporated into district

plans. In addition the MOH regional planning meetings will be used as an opportunity to align district

plans to the priorities of MOH, TB strategic plans and GF supported activities. The current TB

strategic plan ends 30 June 2015. The NTLP will develop a follow 0n strategic plan for the period 01

July 2015 to 30 June 2020 with support from Phase II TB SSF.

4.3 Program Effectiveness 4.3.1 Aid Effectiveness Did you discuss within the CCM how to improve the aid effectiveness of implementation arrangements of Global Fund financing? Yes The CCM proposed to improve aid effectiveness of implementation arrangements of Global Fund

financing in the country through strengthening the roles and management responsibilities of the

government Principle Recipient (PR) FCO, as well through enhanced constituency engagement in

oversight of Global Fund activities.

1) Strengthening Government PR roles and responsibilities

A capacity needs assessment of the PR/FCO was conducted by CCM/LFA that identified issues

affecting grants management including processes of communication between the PR, the sub-

recipients and GF. Based on the recommendations a plan was developed to improve on these two

areas and implementation was started with immediate effect. This involves reorganization of the

management structures of FCO, communication protocols, grants management procedures, trigger

acceleration of disbursements in time, create a more effective monitoring and enabling environment

of CCM grant oversight and enhance proper mechanisms on reporting on expected results.

The CCM has started to work with the government to harmonize operational systems of FCO under

LTIA36 and untie unnecessary processes that affect grant implementation, such as;

a) Streamline FCO reporting lines to enhance performance based reporting requirements,

b) Establishment of operational standard procedures to accommodate project based

implementation requirements, and

c) Reorganization of FCO operational systems to enhance grants management and help the CCM

to do grant oversight in a manner that is more efficient and effective.

d) MoFPED to have a more proactive role in monitoring of the grant.

36

In 2007, the Ministry of Health created a new system called the LTIA for management of Global Health Initiatives. This arrangement was meant to promote institutionalization of Global Health initiative assistance into the national institution framework of financing the health sector. The Long Term Institutional Arrangement (LTIA) was established as a new innovative approach to safeguard investments from Global Health Initiatives after grant suspension of Global Fund grants in 2005, its implementation arrangements have some limitations.

58

2) Promoting constituency engagement to involve more stakeholders in implementation and

oversight of Global Fund activities.

To improve aid effectiveness of implementation arrangements of Global Fund, the CCM is

emphasizing grant oversight by engaging constituencies’ stakeholders. This is being done through

establishment of CCM strategic modalities and channels of communication to reach networks of

stakeholders involved in coordination of HIV/TB and Malaria activities. The CCM will create a

website that will create a hub of information sharing windows with stakeholders. Establishment of a

website is awaiting disbursements for CCM Support.

Based on your discussion did you identify any major risks? If so, please describe them

and how you plan to address and monitor each in the next Phase/Implementation

Period.

While preparing the renewal request, NTLP undertook an in-depth exercise regarding all the

activities. All existing and new activities were assessed as to their level of impact and level of risk. The

risks identified were related to the GF identified risks of misuse of funds for training, communication

and M&E activities. For the risk prone activities, the PR will identify a Financial Management Agency

as a sub-recipient to manage the funds. In order to have a more robust inbuilt accountability system,

the CCM has urged MoFPED to have a more proactive role in financial monitoring of the grant. As

regards the programmatic side, all GF activities are in line with the NTLP Strategic Plan.

4.3.2 Equity

Did you conduct an equity assessment, or was an equity assessment conducted by the national

program or other stakeholders, in the current Phase/Implementation Period? No

Equity assessment was not conducted as key TB services are offered to all populations in need,

regardless of age, sex, sexual orientation or gender identity, drug use, socio-economic status,

geographical location or any other determinants through various tiers of the health service delivery

network of MoH. Further, it is worth mentioning that MoH render services through an integrated

health service delivery network from tertiary hospitals to community based clinics. TB is part of the

HSSIP III.

It is worth mentioning that currently, TB Prevalence survey is on the way through GF Phase 1 grant.

The findings will give a clear picture as to the extent and pattern of the disease in the country.

Preliminary finding as well as the report will be shared with the GF Secretariat.

4.3.3 Value for Money

Economy:

In working towards provision of key TB services to the population especially MDR, NTLP has

made effective use of the available funds. In view of the delayed disbursements and challenges

pertaining to blocking to M&E funds, NTLP has very effectively undertaken activities in

collaboration with the international partners to support the activities. There has also been

successful integration of TB control services within the general health system; integration of the

management of the procurement and supply chain of TB medicines and related supplies into the

essential medicines procurement and supply chain management; multi-tasking and task- shifting

at the health facility level; implementation of the community TB care model helped to reduce

costs for hospital admission and promotion of ambulatory management of MDR patients has

helped to minimize costs for hospital admission.

The NTLP will further minimize costs by: integrating the requisition and reporting on anti-TB

medicines into the web-based system of requisitioning and reporting on HIV medicines and

related supplies; integrating TB reporting into the District Health Information system (DHIS-2),

and integrating community TB care into the Village Health Team structure at the community

level.

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Efficiency:

The programme has been leveraging costs thereby ensuring achievement of results within the

available funds and complementing it through collaboration with government and international

partners.

1. The GOU and the NTLP have put in place coordination mechanisms to ensure that public

and partner supported activities are aligned to the Health Sector Strategic and HSSIP III and

the National TB strategic plan which have clear goals and objectives.

2. The MoH has a Quality Assurance Department which has developed policies and guidelines

for quality improvement. With support from the GoU and partners, health workers have been

trained and supported to implement quality improvement initiatives like the Yellow Star

program and the Performance Improvement Approach for TB control. These initiatives have

improved the quality of health services and minimized the costs of health care.

3. TB control has been integrated into the general health system at the district level and

primary health care facilities and will soon be fully integrated into the community health

system (Village Health Teams). Integration of TB control in the Village Health Team

structure will reduce the costs that have been incurred in the past to facilitate sub-county

health workers to carry out community TB care services.

4. Public Procurement and Disposal of Assets (PPDA) guidelines are followed and adhered to

during procurement of health products/services. This has helped to standardize procedures

for procurement and to create more value for money. The PPDA guidelines have also helped

to reinforce the drive for efficiency.

Effectiveness:

The NTLP implemented the grant through the program approach and activities were designed to

achieve the objectives and correspond to what needed to be done given the disease and local

context. However, the health system challenges (most especially infrastructure and human

resources) affected implementation of MDR activities and the change of mandate from NTLP to

NMS for management of the supply chain for anti-TB medicines that affected performance. The

NTLP mobilized support from partners to improve the infrastructure for the MDR treatment

sites and with support from phase 2 TB SSF will provide performance based honoraria to health

workers that treat MDR patients. In order to strengthen the stock out reporting mechanism,

NTLP will integrate reporting on stock status into the web-based system of reporting on HIV

medicines and related supplies.

In order to standardize the TB service delivery, NTLP has developed Standard Operating

Procedures (SOPs) for TB laboratory services which have simplified processes for diagnosis of TB

and reduced wastage of reagents and personnel time. The SOPs have been shared with all

diagnostic facilities. SOPs have also been developed to standardize and simplify processes for TB

data collection, quality assurance, analysis and reporting at various levels. The SOPs will soon be

piloted and shared with TB diagnostic and treatment units.

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Have any major risks been identified related to value for money? Yes

There were cases of misuse of funds related to trainings, supervision, fuel, communication, perdiem,

radio messages, talk shows in another grant managed by MoH. MoH has since started putting in

place measures to address the related weaknesses.

If yes, describe how you plan to address those risks and monitor progress in the next

Phase/Implementation Period.

In Phase 2, TB SSF, a non public sector sub-recipient with adequate internal controls will be identified

to safeguard the financial resources from GF and ensure that training, communication and M&E

related activities are carried out as planned. The sub recipient will receive the funds from the PR,

provide the funds to the earmarked implementer upon an approved work plan and budget and trace

accountability. The NTLP will provide programmatic technical support for the activities. This will

help to mitigate the risks that were identified by GF and ensure value for money. A memorandum of

understanding that articulates the responsibilities of MoH/NTLP and the sub recipient will be signed

by the PR and the sub recipient. The PR will retain the responsibility of accountability and the CCM

will have an oversight role.

This section is not applicable for a cross-cutting HSS grant/programs. Please continue to section 4.5 ‘Partnerships’ if you are submitting the CCM Request for a cross-cutting HSS grant/program.

Please comment on systems to manage quality (quality improvement/quality assurance) that ensure adherence to national guidelines and Standard Operating Procedures (SOPs).

The systems to manage quality and ensure adherence to national guidelines and Standard Operating

Procedures (SOPs) are embedded in the routine support supervision visits conducted at different

levels of the health system. Performance is measured against the program based indicators for TB

control. The central unit of NTLP conducts both routine and targeted supervision to 9 zones and

districts. Currently the zones recognised by NTLP are not aligned to the regions recognized by

Ministry of Health (MoH). The NTLP is in the process of harmonizing and aligning the 9 zones into

the 12 regions recognized by MoH. The MoH has established regional teams which include a TB focal

person that will help to supervise and support districts within the regions to adhere to national

guidelines and SOPs and improve performance. The Zonal TB and Leprosy supervisors (ZTLS)

supervises districts in their zones on a regular basis and support District TB and Leprosy Supervisors

(DTLS) to improve their function of supporting Diagnostic and Treatment Units (DTUs) to improve

performance, including timely reporting on TB control activities. The DTLS monitor activities at the

health subdistricts and DTUs. The DTLS specifically monitor whether health workers at the DTUs are

adhering to national guidelines and SOPs. Some health subdistricts have focal persons for TB who

reinforce the support provided by the DTLS.

Quarterly review meetings at different levels are also held to review performace and discuss solutions

to close the gaps identified.

When national guidelines or tools are produced or revised, they are disseminated to all stakeholders

and health workers are trained to be able to implement the strategies in the guidelines or SOPs.

The National TB and Leprosy Control Program (NTLP) through the National TB Reference Laboratory

(NTRL) conducts External Quality Assessment (EQA) for ZN smear microscopy diagnostic centres.

The number of diagnostic facilities that benefit from EQA has risen from 839 in 2009 to 1165 by end

4.4 Quality of Services Assessment

61

of 2012. Blinded rechecking for a specified number of TB slides is carried out for each diagnostic

centre per quarter. Slides are received and rechecked at the district which is the first control and at the

NTRL which is the second control. Feedback reports are provided to all facilities that participate in

EQA. Targeted support supervision and mentoring is done for diagnostic facilities with major errors

that include high false positives and high false negatives and for centres with many minor errors.

During supervision, adherence to Standard Operating Procedures (SOPs) is checked and reinforced.

Support from the Global Fund strengthened the laboratory network and EQA system through

procurement of light and fluorescent microscopes and training of laboratory personnel in the use of

fluorescent microscopes.

Please comment on major quality of services risks which have or could have a negative effect on

performance, if any.

1) Suspension of funding from GF for supervision, training and quarterly review meetings is a major

risk to quality of TB services given that GOU and in country partners do not have adequate funding to

support these activities. Lack of adequate funding for these important support activities is greatly

affecting performance towards TB control at all levels of the health system.

2) Most of the EQA quality improvement/quality assurance activities (purchase of slide boxes and

sampling books, targeted supervision and mentoring to laboratories with major errors and

maintenance of laboratory equipment) are funded by partners who provide short term funding. When

funding from partners stops, there will be a challenge to sustain these activities.

Describe how you plan to address those risks and monitor progress in the next Phase/Implementation Period.

Although the GoU made a decision to buy commodities with GF grants and find additional resources

from GoU and partners for activities like training, supervision, review meetings etc, the government

was not able to find adequate financial resources to fund these activities. This has greatly affected

performance of the program especially in the area of monitoring performance and ensuring quality.

In order to have financing for essential M&E activities (supervision, performance review activities),

the country will engage a non-public sector sub recipient with adequate internal controls to safeguard

the financial resources from GF and ensure that training and M&E activities are carried out as

planned. The sub recipient will receive the funds from the PR, provide the funds to the earmarked

implementer upon an approved work plan and budget and trace accountability. The NTLP will

provide programmatic technical support for the training and M&E activities. This will help to

mitigate the risks that were identified by GF and ensure value for money. A memorandum of

understanding that articulates the responsibilities of MoH/NTLP and the sub recipient will be signed

by the PR and the sub recipient. The PR will retain the responsibility of accountability and the CCM

will provide an oversight role.

To improve on grant performance including accountability, the country has developed a grants

implementation/ operational manual that is guiding the PRs and the SRs towards effective utilization

and accountability of GF resources.

In regard to sustaining quality assurance activities at the NTRL, the Government got a loan from

World Bank to strengthen health systems including quality assurance of the laboratory network. The

MoH has started a process to integrate financing of the NTRL activities into the GoU budget support.

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If the RSQA (Rapid Service Quality Assessment) assessment was not conducted in your country, please continue to section 4.5 ‘Partnerships’ Please refer to the latest available information on quality of services annexed to the CCM Invitation Letter and provide updated information (updated national guidelines/protocols), if available.

Rapid Service Quality Assessment was not conducted.

4.5 Partnerships

Using the table below, please indicate the technical assistance (TA), if any, already received in the current

Phase/Implementation Period or confirmed to be conducted in the next Phase/Implementation period by the PR(s) and /or

SR(s).

TA source/TA category Current Phase/Implementation Period Next Phase/Implementation Period

Bilateral √ √

Multilateral √ √

CSO √ √

Private Sector □ √

Academic Inst. √ □

Mixed/other (specify) □ □

Describe any current gaps and/or needs in the capacity building that are not being met by the existing TA providers.

1) Financial management

To develop capacity of the NTLP on financial data management to enforce traceability.

2) Procurement and supply management (PSM)

TA is to integrate ordering and reporting on TB medicines and related supplies into the web-based ordering system

3) Program Management of Drug resistant TB (PMDT)

Strengthen country capacity for training in PMDT

Build capacity for the MoH staff to conduct infrastructural assessment for PMDT.

Assessment of the quality of implementation of decentralized PMDT

4) Advocacy Communication and Social Mobilization (ACSM)

Building capacity of NTLP and CSOs in TB ACSM concepts and strategies

5) USTP

Building capacity of the USTP in Governance, financial management, grants

management and resource mobilization.

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6) NTLP central unit

Strengthen the capacity (infrastructure and knowledge) of the M&E unit at the central

unit of NTLP.

Building capacity of the NTLP central unit in leadership and management (strategic

planning, finance management, advocacy)

SECTION 5: CURRENT PHASE/IMPLEMENTATION PERIOD PERFORMANCE (PR 1)37 5.1 Programmatic Achievements and Management Performance 5.1.1 Programmatic Achievements Provide an overall assessment of the progress of the PR during the current Phase/Implementation Period based on the key programmatic indicators in the Performance Framework.

The implementation period for the TB SSF grant started 1 January 2012 and the first phase is

expected to end 30 June 2014. Performance assessment have been conducted for three

implementation periods i.e. 1 January to 30 June 2012, 1 July to 31 December 2013 and 1 January to

30 June 2013. The Performance update reports have been submitted by the PR to GF.

The section below provides an overall assessment for the period ending 30 June 2013.

Since the start of the grant the performance has been B1.

In the period 1 January to 30 June 2013, the notification rate for all forms of TB cases was 129 against

a target of 147 per 100,000 population, translating into 88% achievement. The treatment success rate

of new smear positive pulmonary TB cases was 77% against a target of 85%, translating into 91%

achievement.

In the period 1 January to 30 June 2013, the performance remained at B1. However, the average

performance for all indicators rose from 78% in December 2012 to 88% in June 2013. The average

performance for Top 10 indicators rose from 73% in December 2012 to 92% in June 2013. Poorly

performing indicators e.g. the enrollment of MDR-TB patients on treatment, and the failure to obtain

data on: 1) stock status from health facilities; had a negative impact on the overall rating of the grant.

In particular, the following results were attained during the period ended 30 June 2013.

1. 22,792 TB cases (all forms) were notified to the national health authorities against a target of

25960 leading to 88% achievement. The target was not met possibly due to incomplete

recording of patients registered in the health unit TB registers into the district TB register,

thereby contributing to underreporting on the case notification.

2. 12,817 were notified to the national health authorities as new smear-positive TB cases against a

target of 14200, (90% achievement), a decline of 3% from the achievement attained in

December 2012. The same reason given above explains underperformance on this indicator.

3. 9,793 new smear-positive TB cases were successfully treated against a target of 12741,

translating into 91% achievement on this indicator. The treatment success rate marginally

37

Please fill out the section separately for each PR.

64

improved from 76% in December 2012 to 76.9 % in June 2013. Non-recording of definitive

treatment outcomes for patients transferred out of the districts they were registered in, is

greatly contributing to the low treatment success rate.

4. The indicator on number and percentage of districts/reporting units reporting no stock out of

first line anti-TB drugs, was not assessed because the transition of storage and distribution of

TB medicines from NTLP to NMS has resulted into medicines distributed directly to the health

facilities without storage at district level. As a result of this change, data on stock status at

district stores cannot be obtained. This indicator has been modified to measure stock status at

the hospital and Health Center IVs.

5. 21,504 TB patients had an HIV test result recorded in the TB register against a target of

24,143. Testing for HIV among TB patients has had a positive trend with 87% of the TB

patients tested in December 2012 and 89.1% in June 2013 (105% performance achievement).

This performance is attributed to availability of HIV test kits and improved recording and

reporting on HIV testing among TB patients.

6. 6,385 HIV-positive TB patients started on or continued previously initiated antiretroviral

therapy, during or at the end of TB treatment, among all HIV-positive TB patients registered

between 01 January 2013 and 30 June 2013. The indicator has had a positive trend with 53.5%

of the eligible HIV-positive TB patients on ART in December 2012 and 59.7% in June 2013

surpassing the set targets of 28 and 30% respectively (120% performance achievement). The

country has adopted the WHO recommendation of starting all TB-HIV co-infected patients on

ART. However, the lack of an integrated model for TB-HIV service delivery is contributing to

the suboptimal enrolment of TB-HIV patients on ART. In Phase 2, an integrated model of TB-

HIV service delivery will be implemented.

7. 922 TB cases had results for diagnostic drug susceptibility testing for MDR-TB among the

1,389 eligible for drug susceptibility testing. The ratio of 66% was higher than the target 55%

set for the period, translating into 120% achievement on this indicator. The TB specimen

referral system has been rolled out to more districts, leading to an increase in the number of

eligible patients that receive DST.

8. The indicator on number of laboratory confirmed MDR-TB cases enrolled on second-line anti-

TB treatment performance was at 41% as of 30 June 2013. 61 MDR patients were put on

treatment against a target of 150. Health system challenges most especially the inadequate

infrastructure and human resources greatly affected enrolment of MDR patients on second

line treatment.

9. 18302 prisoners were screened for TB on entry among 25271 prisoners that were admitted in

the period ending June 2013 translating into 120% performance. On-entry screening targeted

35 out of 233 prisons. The program performed much higher than what was expected.

10. 116 of the 117 of the districts/reporting units submitted their quarterly TB reports timely (110%

achievement). This indicator had a positive trend with 14 more districts/reporting units

submitting timely reports in the period ending 30 June 2013 in addition to the 102 that

reported in December 2012.

65

Please provide a description of the related actions the CCM/RCM/sub-CCM will take, in its oversight

capacity, to address these identified performance issues?

The performance gaps identified above will be addressed in the following ways:

1. TB case finding and treatment success rate will be increased by improving the quality of DOTS

and engaging the village health teams and grass root community organizations to improve

communication and social mobilization for TB. The CCM will play an oversight role to ensure

that village health teams are engaged in TB control at the community level, with support of the

GF Health systems strengthening grant.

2. The indicator 0n "number and percentage of districts/reporting units reporting no stock-out

of first-line anti-TB drugs during the reporting period" has been modified to “number and

percentage of hospitals and Health Centre IVs reporting no stock-out of first line anti-TB

drugs during the reporting period”. As a short term measure to get information on stock

status at facility level, a data officer has been recruited with support from partners and will be

based at NMS to analyze health facility reports, collate data on stock status and write reports

that will be shared with all stakeholders including NTLP. The long term plan is to integrate

ordering and reporting on TB medicines and related supplies through the web-based ordering

system which will be supported with Phase II TB SSF. The CCM will play an oversight role to

ensure that information on stock status is transmitted to NTLP from NMS. The PR has

formally requested GF to suspend assessment and reporting on this indicator during the

remaining period of Phase I TB SSF implementation period.

3. To improve the proportion of TB-HIV patients that are initiated on antiretroviral therapy, an

integrated model for TB-HIV services has been proposed in section 4.2 above. The NTLP will

develop, print and disseminate implementation guidelines for the integrated model of TB-HIV

services. Resources will be mobilized from partners to implement the model. The CCM will

play an oversight role to ensure that the NTLP and the National AIDS control program

collaborate effectively to successfully implement the proposed model.

4. The NTLP is on course in regard to increasing the number of laboratory-confirmed MDR-TB

cases enrolled on second-line anti-TB treatment. The NTLP will continue to promote

ambulatory management of MDR patients in order to enroll more MDR patients on treatment.

The NTLP has expanded the treatment sites from 5 units in April 2013 to 9 by end of June

2013 and is preparing an additional 5 sites. Increasing the treatment sites has increased the

number of cases started on treatment despite the infrastructure and human resource

challenges. The CCM will play an oversight role to ensure that the health system grant

addresses some of the health system issues that are affecting the PMDT program.

5. The NTLP has agreed with Uganda Prisons Services (UPS) on a mechanism to transmit data

from UPS to the NTLP. The procedure for collection, collation and reporting from the prison

units up to the Uganda Prisons Services headquarter and to the NTLP is summarized below:

On entry, all new prisoners are screened for TB and data is recorded in the on-entry

screening register at all the Prison Health Units.

The data at the prison health unit are aggregated on a monthly basis and sent to the

Regional Health Office for the attention and action of the Regional Health Coordinator

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(RHC) and the Regional Data Clerk (RDC). A prison health unit reporting form is used

by all Prison health units to submit monthly reports to the region office.

The RHC and RDC aggregate data from the health unit reports and compile a regional

report on entry TB screening and send it to the Prison Health Office at Prison

Headquarters for attention of the M&E officer. A regional on-entry TB screening

reporting form is used by all regional health offices to submit reports to the

headquarter office.

The Prisons headquarter M&E officer compiles the national prisons monthly entry TB

screening report from information in regional reports. The national prisons report is

sent to NTLP for the attention of the NTLP Program Manager.

The CCM will play an oversight role to ensure that the mechanism of reporting from UPS to

the NTLP is adhered to.

Please summarize the current challenges in M&E systems and capacity based on any recent assessment

undertaken during the current Phase/Implementation Period, and provide an update on status of

implementation of M&E systems strengthening recommendations supported through Global Fund

grant/SSFs and other partners during the current Phase/Implementation Period. Please also comment on

the expenditures on M&E (variances, if any) against approved funding under the Global Fund grant/SSF

during the current Phase/Implementation Period.

Current challenges in M&E systems and capacity based on the most recent assessment are

summarized together with the updates, in the section below:

Although a few TB indicators are included in the Ministry of Health (MoH) integrated health

information system (referred to as the District Health Information System (DHIS-2)), the

routine health facility reporting on the majority of TB indicators is still parallel. The NTLP has

shared with the MoH Resource center the TB indicators that will be integrated into the DHIS-

2.

The private sector facilities participating in TB diagnosis and treatment report through the

existing district administrative units who report block figures to the NTLP. The NTLP cannot

disaggregate the contribution from the private sector on case finding and treatment outcome.

As the NTLP strengthens the public private partnership for TB control, it will work with the

private sector professional associations/umbrella organizations to report data on TB diagnosis

and treatment from the private sector while avoiding duplication from the districts.

Although the NTLP has drafted Standard Operating Procedures (SOPs) to guide verification of

facility data on completeness and consistency, the verification is still weak and is not

conducted routinely. The NTLP is finalizing the SOPs and will soon disseminate them to all

stakeholders at national and district level. Data quality audits will be conducted every six

months to verify data completeness and consistency. Data quality assessments will also be

applied to MDR management. The health facilities will be supported through supervision to

improve the quality of data recorded and reported.

The SOPs include details of data collection, flow and management procedures at different

levels of the health system including data quality assurance procedures. The responsibilities of

health officers at different levels of the health system are described.

67

The country has not yet conducted a nationally representative survey that will provide precise

and accurate estimates for TB (TB prevalence survey). Preparations for the prevalence survey

are in final stages and the study is scheduled to start in October 2013.

The country does not have a vital registration system and is therefore currently unable to give

an accurate estimate of TB mortality. The United Nations Children’s Fund (UNICEF) is

supporting the country to develop a national vital registration system.

Data on TB in the routine reporting system is stratified by administrative units and by age and

sex for only smear positive pulmonary TB cases. The reporting tools have been revised to

disaggregate TB data by age and sex for all categories of TB patients. The NTLP will mobilize

financial resources from GoU and partners to print and disseminate the revised tools.

A program review was last conducted in 2005. A second comprehensive TB program review

was carried out between 04-17th September 2013 and the preliminary findings have been

considered in the proposed interventions for Phase II TB SSF.

Annual review of NTP budget and expenditure, by funding source and service area according

to WHO-Stop TB guidelines

In regard to weak coordination mechanisms at the NTLP, the program will improve its overall

coordination capacity by strengthening the internal management systems and coordination of

all key stakeholders in TB control through quarterly review meetings and coordination

structures at national level. The NTLP will hold regular meetings with the Ministry of Health

Resource centre which receives health information from the districts electronically.

Strengthening of coordination at the national level will contribute positively towards

strengthening the health information system and M&E reporting systems.

A capacity building plan to strengthen competency at all levels of the M&E system especially at

district and health center levels has been developed and shared with the GF.

An M&E unit has been established within the NTLP. A Data Manager has been recruited with

support from TB SSF to support the unit. However, there is need for technical assistance to

strengthen the infrastructure and human resource knowledge and skills for good data

management. A data base for storage of national TB data and a back-up system will be

procured and installed with support from phase 2 TB SSF.

Reporting on TB drug stock outs at health facility level is still a challenge. The NTLP will

incorporate ordering and reporting on TB medicines and related supplies into the web-based

ordering system used for HIV medicines and related supplies. This will be supported with

phase 2 TB SSF and will help to improve timely reporting on stock status at health facility

level.

Expenditures on the M&E activities was minimal during phase1 TB SSF because these activities

were classified as risk-prone and funding from GF could not be used to finance them unless strict

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mechanisms were put in place to safe guard the funds and ensure value for money. Out of USD

4,831,755 budgeted for M&E activities, only USD 1,254,660 was disbursed.

5.1.2 Grant/SSF Risk Management

Please comment on the major grant/SSF management risks and issues, if any, including those attached to the CCM Invitation Letter. Describe how you plan to address those risks and monitor progress in the next Phase/Implementation Period.

Progress on Conditions Precedent and special conditions/GF concerns in 1)Pre-assessment Summary UGD-T-MOFPED, Periodic Review December 2013 and 2) Management Letter: 2nd Disbursement in Phase 2-Grant Agreement UDG-T-MOFPED, is summarised in Annex 9.

A. The Programmatic issues that were identified in TB SSF phase 1 and the actions taken are summarized in the table below.

Issues Action taken

Stock-out or expiry of anti-TB medicines due to un-reliable or incomplete consumption data and stock out of laboratory supplies (reagents and slides) at health facility level

To address the risk of stock-out or expiry of anti-TB medicines due to un-

reliable or incomplete consumption data and stock out of laboratory supplies

at the health facility level, a data officer has been recruited with support from

partners and will be based at NMS to analyze health facility reports, collate

data on stock status and write reports that will be shared with the Pharmacy

division of MoH, NTLP and other partners supporting to strengthen the

procurement and supply chain. The Pharmacy division will use this

information and correlate it with morbidity data to compute stock needs and

advise NMS and GF on the future quantities of medicines and laboratory

supplies to procure. Further, in TB SSF phase 2 the MoH will integrate the

ordering and reporting on stock status of TB medicines, laboratory reagents

and related supplies into the web-based ordering system used by the national

HIV/AIDS control program (WAOS). This will ease reporting and ordering

of TB medicines and laboratory supplies and will provide timely information

on stock status to all stakeholders at national and district level. Health

workers at the health facility level will be trained, mentored and supervised

to improve the Logistics Management Information System (LMIS), with

support from TB SSF phase 2.

Partial implementation of activities by SSRs due to limited coverage and capacities

The activities of the SSRs were reviewed, most especially the activity on

coverage of 1010 sub-counties by three SSRs. Due to inadequate funding to

engage the three SSRs (NGOs), the SSRs withdrew from implementing this

activity. In regard to facilitation of sub-county health workers to

identify and supervise community treatment supporters for TB

patients, delivery of funds to the sub-county health workers38 was

difficult to administer because of their wide geographical spread. This

activity was to be undertaken by partner NGOs but as there was no

management cost for the implementing NGOs it never got executed.

Partners are supporting this activity in six out of nine zones (North,

SW, SE, East, West and Kampala). With TB SSF Phase II, the program

will facilitate sub-counties in three underserved regions (NW, NE and

Central) in the first year and subsequently expand to additional

districts as partners’ support phases out (49 in year 1, 80 in year 2 and

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Public health cadre who links the health facilities to the community

69

112 in year 3). The sub-county health workers will deliver medicines in

the communities and identify community treatment supervisors.

Management costs for delivering the facilitation funds to the sub-

county health workers in the districts have been included in the TB

SSF Phase II budget. Through another GF health systems

strengthening grant to MOH Uganda, the MoH is strengthening the

capacity of Village Health teams (VHT) to identify and support

treatment supporters for TB patients. Expanding the coverage of

VHTs and strengthening their capacity to support TB patients will

complement the support provided by sub-county health workers and

improve treatment outcomes while reducing the risk of development

of drug resistant TB. The NTLP will proactively monitor the VHT and

sub-county health workers related activities to ensure that the TB

community activities are effectively implemented.

Limited implementation time and human resource capacity for the prevalence survey

The MoH is partnering with Makerere University School of Public Health

(MUSPH) to conduct the TB prevalence survey. A Memorandum of

Understanding (MoU) was signed between MoH and MUSPH. The MoH fast

tracked procurement of equipment and by end of August 2013, all the

equipment had been delivered to MoH except the Xrays which are expected

in September 2013. Technical assistance was received from WHO-Geneva

and by end of August 2013, preparations for the survey were in final stages

and the study was scheduled to start in October 2013.

Limited human and financial resources for rolling out PMDT and conducting follow up activities

The NTLP received technical assistance from international partners to

complete the PMDT guidelines, the M&E tools and the training materials.

Further, the NTLP received technical assistance from partners on the

architectural and structural requirements that were needed to remodel

Mulago National Referral Hospital MDR-TB Unit. Mulago and Kitgum

hospital MDR-TB Units were remodelled by partners. More staff was

recruited for Mulago, Kitgum and Mbarara hospitals with support from

partners. Staff at NTLP and 09 MDR treatment facilities were trained on

PMDT with support from partners. The 09 MDR treatment facilities are

currently treating and following up MDR patients. Five additional facilities

are being prepared to treat MDR patients.

Risk of diverting funds for social support and transport refund to patients to unintended beneficiaries and delays in procurement for service providers

The NTLP presented to GF secretariat a concept on the Management of living

support (Food and Transport refund) for MDR patients, outlining internal

controls to ensure that intended beneficiaries receive the support. The

concept was approved by the GF on 30 July 2013. (Annex 8)

B. Financial absorption was generally low during the first 12 months of implementation. The cumulative cash outflow after one year of implementation was US$ 4,179,783 against a cumulative budget of US$ 12,788,524. This represented a ratio of cash outflow versus budget of 33%. The cash balance as of 31 December 2012 was US$ 2,069,548. The major factors that contributed to low absorption are discussed in the table below with actions that were taken in phase I TB SSF or will be taken during Phase II TB SSF to improve absorption.

70

Issues Action taken

Procurement of medicines and their associated procurement and supply management costs which comprised 64% of the budget for year 1 delayed because of delayed approval of the procurement and supply management (PSM) plan. This delayed procurement of additional drugs using grant funds.

The country will soon (before end of December 2013) be submitting a GF country profile which covers procurement of commodities related to the three diseases (HIV, Malaria and TB). The program anticipates that the country profile for the year 2014 will be submitted and approved before signing of the Phase II Grant. This will help to reduces delays in procurement.

In addition, the newly recruited PSM local expert at the Focal Coordination Office (FCO) will fast track PSM issues as soon as they arise and thus reduce the delays in making decisions that affect procurement of medicines and other commodities.

Late submission of the progress update and disbursement request report for June 2012, submitted in January 2013. This contributed to delays in disbursement of funds from GF to the PR.

The late submission of PUDR has been recognised by the PR as a weakness and the PR is improving systems to have the reports submitted on time.

Disbursement of monitoring and evaluation (M&E) funds which accounted for 17% of year 1 budget was frozen due to misuse of funds. There were cases of misuse of funds related to trainings, supervision, communication, fuel, perdiem, radio messages and talk shows in another grant managed by MoH. In the interim, MoFPED, MoH, and the Global Fund agreed that the PR engages in reallocating funding meant for such budget items. The process of reprogramming further delayed the disbursement.

MoH has started putting in place measures to address the related weaknesses in accountability of funds. These activities have been reintroduced in phase II TB SSF as they are critically needed to improve program performance. For Phase II TB SSF, the country will identify a non-public sector sub-recipient with adequate internal controls to manage the funds for the risk prone activities.

Part of the M&E funds (US$ 881,858 for year 1) was meant to support the TB prevalence survey. Half of these funds were disbursed to the PR, however, delays in finalizing the protocol of the TB prevalence survey, selection of the survey coordinator and contracting of the School of Public Health to lead the survey, have resulted in zero absorption of the funds in year 1.

Since December 2012, progress was made: an MoU was signed with the School of Public Health, the survey protocol was finalize and teams staff for the survey were recruited. Preparations for the prevalence survey are in the final stages and the field activities are expected to start in October 2013. Once completed, this activity will not affect absorption in Phase II.

Delays by the PR in addressing conditions precedent (CPs) relating to programmatic interventions (MDR-TB, training, M&E etc) contributed to low absorption of funds.

The CPs relating to programmatic interventions have been addressed as explained in Annex9. The program expects smooth implementation of the second phase without further delayed disbursements.

71

5.1.3 Grant Performance Rating

Please answer the following questions if you are submitting the CCM Request for a Phase 2 or RCC Phase 2. If you are submitting the CCM Request for Periodic Review, proceed to section 5.2 ‘Financial Performance’.

Grant Performance Rating for the current Phase (Phase 1/RCC Phase 1)

A1 A2 x B1 B2 C

Please provide a rational and justification for the rating.

Performance Rating

A1 > 100%

A2 100-90%

B1 60-89%

B2 30-59%

C <30%

AVG performance on Top 10 TRAINING Indicators only

0

AVG performance on TOP TEN indicators (including TRAINING)

92%

Number of TOP TEN indicators with B2 or C Rating

1

TOP TEN indicators rating A2

AVG performance ALL indicators 99%

ALL indicators rating A2

Intermediary Result for Quantitative Indicator rating

See Rating highlighted in

the Matrix

Important: The calculated INDICATOR RATING for a grant cannot equal A1 or A2 if one or more

“Top 10 Indicator” or “Top 10 equivalent Indicator” is rated B2 or C (i.e., less than 60% achievement).

Please fill in the Intermediate Result given by the Matrix in the box below, in order to get the final

Quantitative Rating

The rating of 41% of the indicator on laboratory confirmed MDR-TB cases enrolled on second-line

anti-TB treatment, resulted into an overall rating of B1.

Intermediate Quantitative Rating result from the Matrix above

A2

Final Quantitative Rating B1

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5.2 Financial Performance

5.2.1 Financial situation at cut-off date

Cash at cut-off date

Please note that the financial information required for this section is in the Financial template provided

with the CCM Invitation package Renewals_Financial Template_FinancialRequest_Cash-at-cut-off-date –

the CCM must paste a screenshot of the information to this section in the CCM Request template (Word

document) by selecting the relevant cells in Excel and using Paste option in Word to insert as a picture.

Financial Request must be filled out in the Excel file only. Do not edit the table after pasting it here!

5.2.1 Financial Situation at Cut-off date

Cash at Cut-off date

PR SRs Total

a. Disbursed to PR to cut-off date

6,313,869.65 N/A 6,313,869.65

b. Less: Disbursed from PR to SRs -

181,101.92 181101.92 0

c. Less: Expenditure incurred to cut-off date -

5,093,028.17 -5,093,028.17

d. Add: Interest received

- 0

e. Add: Other income - please specify 0

f. Equals: Cash at cut-off date 1039739.56 181101.92 1,22,0841.48

Please include a Liabilities summary at cut-off date with the CCM Request (goods and services received/ordered but not yet paid for) that would need to be part of the budget from the cut-off date forward. It has nothing to do with commitments for activities still to take place. Failure to include them could mean that they will not be included in the funding envelope provided.

AS at cut of date of 30 June 2013, there was no Liabilities pertaining to CCM goods and services.

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5.2.2 Analysis of expenditures versus budget

With reference to the latest available EFR at cut-off date, please summarize the main reasons for any under-spending or over-spending against budget.

Source: MOH EFR Report for Period January to June 2013

Cost Category Budget Expenditure Variance Reason for Variance

Human Resources 381,150 87,475 293,675 The variance relates to funds that were meant for the

MDR coordinator and Data Manager that were not

utilized pending recruitment and actual deployment.

Technical Assistance 104,100 - 104,100 The Technical Assistance relates to training of the

Prevalence Survey Team on the use of X-ray

machines. The X-ray Machines have not yet been

procured due to internal delays relating to systemic

issues.

Training 493,702 - 493,702 The variance is attributed to non-disbursement of

training funds due to delayed fulfilment of a Condition

Precedent related to the development of a training

data base.

Health Products and

Health Equipment

741,289 483,313 257,976 The under spending relates to non-procurement of

personal protective wear for management of MDR TB

and Second Line Drugs Delivery boxes.

Medicines and

Pharmaceutical

Products

6,386,168 3,313,356 3,072,812 .The expenditure variance of US$ 3,072,812.44

relates procurement of First and second line drugs

planned under the 3rd & 4th quarter of the first year.

Procurement and

Supply Management

Costs

1,881,235 407,156 1,474,080 The budget variance relates to the PSM Costs

associated with the medicines not yet procured.

These products were procured through GDF/GIZ.

Infrastructure and

Other Equipment

368,433 310,161 58,272 The variance largely relates to procurement of 9

vehicles that were delivered and paid during the

following reporting period.

Communication

Materials

425,761 19,856 405,905 The other variance is attributed to non-disbursement

due to freeze on activities under this category.

Monitoring and

Evaluation

3,702,587 451,033 3,251,554 The variance largely relates to non-disbursement of

Funds for activities such as Prevalence Survey,

Annual program review with the implementing

partners/stakeholders and Support Supervision at all

levels.

Living Support to

Clients/Target

Population

247,975 - 247,975 No disbursement made under this category

Planning and

Administration

146,064 10,299 135,766 The variance largely relates to non-disbursement of

funds for activities such as co-ordination meetings

and office sundries by GF.

Overheads 38,406 10,381 28,025 The variance relates to Rent for Uganda Stop TB

Partnership and insurance 3 vehicles that were

delivered.

Other 84,867 - 84,867 The variance relates to un disbursed funds meant for

procurement of laboratory services for MDR -TB

patients.

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At the time the time of the proposal development, the expenditure accounted for about 34% of the

Cumulative budget as at end of June 2013. The underperformance was largely related to:

non- disbursement for activities relating to training, M&E and Communication materials, due to delayed fulfilment of the Conditions precedent,

procurements and related PSM costs for supplies and commodities whose procurement process was underway, and

delays in finalizing of the protocols for management of the adherence enablers for MDR TB patients.

Please comment on whether the overall % expenditure versus budget variance at the cut-off date is in line with the average % achievement against all indicators in the performance framework. If not, please explain the reasons.

The overall % expenditure versus budget variance at the cut-off date is not in line with the average %

achievement against all indicators in the performance framework. The average % achievement against

all indicators in the performance framework for the semester ending 30 June 2013 was 99%, which is

much higher than the 34% expenditure versus budget variance at the cut-off date for the following

reasons:

Following the freeze of funds for training, supervision and other M&E related activities, the

NTLP mobilized funds from in-country partners to support some of the activities that should

have been supported by GF. Partners helped to narrow the gap although the funds provided by

them were still not adequate to cover all the needs.

A number of partners are supporting various TB control interventions in various parts of the

country which has helped to improve overall program performance.

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SECTION 6: CCM REQUEST FOR RENEWAL (PR 1)39 6.1 Programmatic Proposal 6.1.1 Program Objectives, SDAs, Indicators and Targets

Please provide a Performance Framework for the next Phase/Implementation Period and comment on whether indicators

and targets are aligned with the national program strategy, plans and systems.

In view of the challenges encountered during implementation of TB SSF Phase I, NTLP undertook a

detailed and in-depth review of the activities of TB SSF Phase I. In this context, each activity of the TB

SSF Phase I and of R-10 Phase II were viewed in light of the country needs, TB Strategic Plan and

preliminary findings of the Joint Review of TB Program. For Phase II, some activities in Phase I were

retained, some discontinued and some new activities were included. Further, each activity for Phase

II was also assessed as to the level of impact. Details of this comparative analysis along with rationale

and necessary justification is in Annex 10.

Phase 2 TB SSF will be implemented under the following objectives and related SDAs.

Objective 1: To expand and consolidate high-quality DOTS

SDA 1.1: Procurement and supply chain management (PSM) 1.1.1 Procure quality first line anti-TB drugs (FLDs) 1.1.2 Storage and distribution of anti-TB drugs to districts 1.1.3 Procure LMIS forms 1.1.4 Integrate ordering of TB medicines, laboratory reagents and related supplies the into a web-based system (Hospitals and HC IVs) 1.1.5 Train health workers in the lower health facilities on web-based ordering. 1.1.6 Supervise health workers in the lower health facilities SDA 1.2: High quality DOTS 1.2.1 Facilitate Sub county health workers (49 districts in year 1, 80 in year 2 and 112 in year 3) 1.2.2 Procure 20 Xpert MTB/RIF machines 1.2.3 Build capacity of health workers at regional and district hospitals to diagnose TB in children 1.2.4 Procure Laboratory reagents for ZN smears. Objective 2: To strengthen TB/HIV collaboration SDA 2.1: TB/HIV

2.1.1 Hold two workshops to develop implementation guidelines for the integrated TB-HIV model. 2.1.2 Print 3000 copies of the implementation guidelines for the integrated TB-HIV model.

Objective 3: To strengthen Program Management of MDR-TB (PMDT) SDA 3.1: MDR-TB 3.1.1 Procure second line drugs (SLDs) for programmatic management of MDR-TB patients 3.1.2 Provide adherence enablers to MDR-TB patients to enhance treatment completion 3.1.3 Provide incentives to 70 Health workers in 14 PMDT treatment centers 3.1.4 Support TB Specimen Referral for Routine Surveillance ((TSRS) of Drug resistant TB 3.1.5 Procure laboratory services for managing MDR-TB patients 3.1.6 PMDT supervision to MDR treatment centers and follow up sites 3.1.7 Train health workers in follow up facilities 3.1.8 Procure Technical Assistance (Green Light Committee)

3.1.9 Support salaries for two laboratory scientists for the NTRL

Objective 4: To strengthen _TB control in Uganda Prisons Services SDA 4.1 High Risk Groups

4.1.1 Strengthen on-entry screening for all new inmates in thirty five (35) prison units 4.1.2 Conduct annual mass screening of inmates in thirty five (35) prison units. 4.1.3 Support transportation of sputum specimens from prison units without laboratories. 4.1.4 Procure Xray films.

39

Please fill out the section separately for each PR.

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Objective 5: To strengthen partnerships to scale up TB control interventions SDA 5.1: Coordination 5.1.1 Support salaries of Uganda Stop TB Partnership (USTP) Staff 5.1.2 Procure supplies for USTP office 5.1.3 Facilitate USTP monthly and quarterly meetings 5.1.4 Rent office for USTP 5.1.5 Support coordination and advocacy activities of the USTP secretariat 5.1.6 Mapping exercise for partners including grass root organizations SDA 5.2: ACSM 5.2.1 Implement a TB Advocacy and awareness week (one week prior to World TB day) 5.2.2 Hold a 5-day TB exhibition week 5.2.3 Commemorate World TB day 5.2.4 Support two orientation meetings on TB, TB/HIV and MDR for health activists per year. 5.2.5 Identify and train 5 successfully treated MDR patients for each of the 14 MDR treatment sites to identify, support adherence and follow up MDR patients. 5.2.6 Facilitate successfully treated MDR patients that will support MDR patients to adhere to treatment. 5.2.7 Build capacity of grass root civil society organizations on TB education. 5.2.8 Facilitate grass root civil society organizations to carry out Community TB education and social mobilization. SDA 5.3: PPM 5.3.1 To conduct a national situational analysis on PPM 5.3.2 Adapt the WHO PPM policy guidelines 5.3.3 Develop implementation guidelines for PPM 5.3.4 Print 5000 policy and implementation guidelines. 5.3.5 Support advocacy meetings for professional bodies on PPM 5.3.6 Disseminate guidelines on PPM country wide. 5.3.7 Train Private health workers on TB, TB/HIV and MDR TB. Objective 6: To strengthen program capacity to plan, implement, monitor and evaluate TB control SDA 6.1: Human resources 6.1.1 Continue to support an M& E specialist and a Program Officer 6.1.2 Support staff salaries for the Data Manager and the MDRTB Focal Person 6.1.3 Program Management staff to attend International Conferences SDA 6.2 M&E 6.2.1 Hold supervision visits at all levels 6.2.2 Hold program management and planning meetings at various levels 6.2.3 Data base and back-up system for at NTLP central unit. 6.2.4 Print 3000 copies of Standard Operating Procedures (SOPs) on data management. 6.2.5 Develop the next strategic plan (July 2015-June 2020)

The performance framework with indicators and targets has been revised and is one of the documents

submitted with this proposal (Annex 11). All indicators that were used to monitor Phase 1 TB SSF

have been maintained for monitoring of Phase 2 TB SSF except for one indicator on “number of

districts/reporting units reporting no stock outs” which has been modified to “ number of Hospitals

and HC IVs reporting no stock outs.” The indicators and targets for the Phase 2 TB SSF grant

reporting are aligned to the existing national reporting systems in the country.

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Based on the identified gaps and challenges under section 5.1.1 “Programmatic Achievements” please

summarize the key M&E systems strengthening activities, including any planned operations research or

evaluations to be undertaken during the next Phase/Implementation Period. Does the CCM propose

reallocation of resources to support the above stated M&E strengthening initiatives? If yes, comment on

the budgetary and programmatic implications, if any, on the overall request.

The M&E systems strengthening activities that will be undertaken during the next phase are;

Integrating TB reporting into the District Health Information System (DHIS-2)).

The M &E unit at the NTLP central unit will be strengthened with capacity to store, retrieve,

back up, analyse and share program data.

Data quality audits for health facilities will be conducted every six months to verify data

completeness and consistency. Data quality assessments will also be applied to MDR

management.

The standard operating procedures on data quality management will be printed and

disseminated to all health facilities.

The activities above will be financed within the resource envelope availed to the country from GF

for TB control activities.

6.1.2 Pharmaceutical and Health Product Management (if applicable)

Please complete this section only if procurement of Pharmaceutical and Health Products is planned in the next Phase/Implementation Period. Otherwise, continue to section 6.2 “Financial Proposal”.

Based on the key risks and challenges in the PHPM area in the current Phase/Implementation Period as identified under

section 5.1.2 “Grant/SSF Management”, please summarize the measures and/or mechanisms that have been put in place or

are proposed in the PSM plan (or the Country Profile if this is already in place) for the next Phase/Implementation Period.

Please include an assessment of the risk of treatment interruptions at the health facilities in the next Phase/Implementation

Period and a list of the possible underlying causes related to PHPM activities that may have a negative impact on the

continuous availability/access to key health products (such as stock outs, diversion and theft of health products).

During phase 1 TB SSF, there were a number of challenges that affected availability, access and use of

anti-TB medicines. During phase 2 TB SSF, the challenges will be addressed as follows:

a) The system to collect logistics data for programmatic and procurement decision making is

inadequate. The Procurement and Supply Management Review completed in February 2013

indicated that: There are no established minimum and maximum stock levels for TB medicines at

health facilities; Commodity stock cards are not systematically updated and information contained

therein is not necessarily linked to the Requisition and Issue Vouchers; Records of receipts or

issues of products from or to facilities other than NMS are not routinely entered in the stock cards;

The Logistics Management Information System (LMIS) tools were not uniform across all health

facilities. This situation could cause data availability and quality problems at health facility and

national levels. In addition, false high or low months of stock of TB medicines have been observed

in the central level stock status reports. This was largely caused by the use of issues data from

NMS as proxy for consumption data and may impact on the procurement decision making

process.

During phase 2, the Ministry of Health will strengthen LMIS for TB medicines to capture

consumption data and facility level stock status. This will be done through building onto the

current HIV/AIDS web based ordering system to cater for TB; training Health workers involved in

ordering of TB drugs on how to use the system; adapting and rolling out the mentorship model for

essential medicines as a continuous improvement strategy to strengthen SCM for TB drugs and

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pharmacovigillance especially for new treatment regimens like RH and MDR TB regimens with

focus on parts of the country that are currently not covered by partners. Data managers to handle

facility based data and coordinate the sharing of LMIS data between NMS and NTLP will be

stationed at NMS.

b) A significant overstock of MDR – TB medicines was recorded during phase 1 of implementation

period. The overstock was a result of a couple of factors some of which are: Poor coordination

between NTLP and NMS resulted in the procurement of MDR-TB medicines for patients not yet

enrolled on treatment and LMIS data was not systematically shared between the two entities since

the transfer of the TB products management function to the NMS.

The situation was corrected by loaning out excess medicines at risk of expiry to other countries

currently in need of the same commodities. To prevent recurrence, six months staggered

shipments have been agreed in principle between GDF and NTLP. For all orders placed, annual

quantities needed will be broken down into two deliveries to allow for continued revisions of

national forecasts and align them with actual progress. Phase 2 procurement plan is premised on

detailed analysis of patient needs and anticipated program scale up to minimize forecasting errors.

To further strengthen quantification for MDR TB medicines, the NTLP will adopt a new

quantification tool and procure TA from GDF to train key technical officers at the MoH in the use

of the tool. This will be done in partnership with in-country partners.

c) Sub-optimal storage conditions of health products procured for the TB grant at central and

peripheral health facilities. During phase 1, special note was made of health products stored in

conditions well below minimum standards. This was observed during a tour of Mulago national

referral hospital. Such a situation could compromise the quality of the health products stored at

facility level.

The MOH is committed to improving warehousing conditions for medicines and medical supplies

at all levels of Health care. A national assessment of warehousing conditions was conducted and

improvements have started. In country partners have recently funded a country wide initiative for

supply and installation of shelves. During phase 2, improvements will continue in this direction.

d) Improving coordination with NMS to monitor delivery of TB medicines by the Global Drug Facility

and ensure complementarities of procurement against resources from the Government of Uganda

and the Global Fund. During phase 1, challenges arose partly because NMS was not the primary

consignee for all documentation relating to PSM shipments. As a result documentation would

delay at MoH leading to demurrage accumulation; Delivery terms were CIF (Entebbe-air, or

Kampala – sea) and as a result the Permanent Secretary MoH had to appoint clearing agents to

deliver these shipments to NMS while the Pharmacy Division MoH had to clear the shipments

with NDA. The many players created a coordination challenge.

During phase 2, the primary consignee has been changed from Permanent Secretary MoH to

General Manager NMS for both documentation related to shipments and actual delivery of

commodities. This will ensure that a smooth coordination of shipments is achieved. In line with

this arrangement, the terms of delivery have been changed to DAP – NMS Entebbe implying that

NMS is the sole player interfacing with GDF and this will help reduce the coordination challenges.

Under this arrangement GDF or its agent is responsible for in country clearance and delivery of

shipments to NMS. MOH Pharmacy Division will support GDF in applying for clearance by NDA.

The Pharmacy Division in liaison with PM-NTLP will play the role of oversight and monitoring to

ensure that this arrangement is fully functional.

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To ensure complementarities of procurement against resources from the Government of Uganda

and the Global Fund, a single national quantification and supply plan has been developed

indicating commodities to be received from each source while eliminating duplications.

e) Increasing consumption of the medicines at risk of expiry (where they are under-consumed);

proactively monitoring stock levels of medicines to minimize the risk of expiry; and continually

adjusting future estimate and forecasts; During phase 2, we shall coordinate implementing

partners involved in TB management at district level to include Supply Chain Management and

monitoring to correlate information received through web based ordering system. This will be

done during the USTP quarterly meetings.

f) During phase 1, random sampling and testing of health products was carried out by the National

Drug Authority (NDA) but results were not shared with the Global Fund as required by the Quality

Assurance Policy. During phase 2, MOH will ensure that testing results are timely shared with the

Global Fund.

6.2 Financial Proposal

6.2.1 Resources available to finance the grant/SSF after cut-off date

Please note that the financial information required for this section is in the Financial template provided with the CCM Invitation package Renewals_Financial Template_FinancialRequest_Resources-available – the CCM must paste a screenshot of the information to this section in the CCM Request template (Word document) by selecting the relevant cells in Excel and using Paste option in Word to insert as a picture. Financial Request must be filled out in the Excel file only. Do not edit the table after pasting it here!

Please note that TRP Clarified Amount must take into account Global Fund Board mandated 90% adjustment

6.2.1 Resources available to finance the grant/SSF after cut-off date Year 3 Year 4 Year 5 Total

Year 3 Year 4 Year 5 Total

a. TRP clarified amount allocated to PR

4,567,015

4,803,070

4,995,459 14365544

b. Any Board mandated adjustments

(456,702)

(480,307)

(499,546) -1436555

c. Adjustment +/(-) for (borrowing) and/or

staggered commitments not yet committed

(1,343,082)

d. Adjusted TRP clarified amount 2,767,231 4,322,763 4,495,913 11,585,907

e. CCM reallocations +/(-) (implementation

arrangements) 0

f. Adjusted TRP clarified amount after

CCM reallocations 2,767,231 4,322,763 4,495,913 11,585,907

g. + Undisbursed amount at cut-off date 11,202,841.4

h. + Cash at cut-off date 1,220,841.48

i. =Total Resources available (after cut-

off date for the next Phase/Implementation

Period) 24,009,589.88

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6.2.2 Summary funding request from cut-off date to end of next Phase/Implementation

Period

Please note that the financial information required for this section is in the Financial template provided with the CCM Invitation package Renewals_Financial Template_FinancialRequest_FundingRequest – the CCM must paste a screenshot of the information to this section in the CCM Request template (Word document) by selecting the relevant cells in Excel and using Paste option in Word to insert as a picture. Financial Request must be filled out in the Excel file only. Do not edit the table after pasting it here!

6.2.2 Summary funding request from cut-off date to end of next Phase/Implementation Period

2013/14 Year 3 Year 4 Year 5 Total

a. Total Budget required (after cut-off date for the next Phase/Implementation Period)

8,555,365 4,883,482 5,848,649 3,407,991 22,695,487.03

b. - Undisbursed amount at cut-off date

11,202,841.4

c. - Cash at cut-off date 1,220,841.48

d. = Incremental amount requested 10,271,804.15

e. % of adjusted TRP clarified amount (cannot exceed 100% of adjusted TRP clarified amount)

89%

6.2.3 CCM Budget Request for the next Phase/Implementation Period

Please explain how lessons learned from the current Phase/Implementation Period have been factored into this funding

request (e.g. budget reallocations, under-spending leading to more realistic budget estimates, reflection of price changes).

The country response against TB has been structured in a way that has brought on board the

participation and involvement of wide range of stakeholders. These have included GoU agencies; the

Local governments; the Development partners, Civil society organizations; Private practitioners.

Through this approach several lessons have been learned some of which have been incorporated into

this proposal. These included:

a) Increasing service coverage through participation of local governments and Civil society

organization.

Program implementation during Phase 1 scaled up to lower level health facilities through the

decentralized approach. This involved the use of many actors such as the local government structures

(DTLS, Sub county health workers, and community based organizations) to carry out community

education and increase on case finding of the TB patients. Phase 2 of the grant intends to maintain

and strengthen such partnerships by ensuring education materials, guidelines and funding is availed

to such activities. Supervisions have been proposed to be conducted down to the community level. A

non public sector sub-recipient will be identified to improve accountability of funds for risk prone

activities. It is also envisaged that the non-public sector SR will also improve absorption capacity.

.

b) Joint planning and review meeting.

Sessions of joint planning and review meetings did not only help improve the local partnerships, but

also the aspect of program ownership. Various stake holders support interventions in the TB strategic

plan, which are within their mandates and this has minimized program overlaps and duplications of

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activities among the implementers. Phase 2 intends to augment the use of joint planning and review

sessions to strengthen this collaborative approach. The program intends to conduct mapping of local

partners as one way of identifying and building new partnerships for TB control and also conduct a

situation analysis of the private health practitioners to assess their current involvement in the TB

response. This will guide the program design and implementation of interventions at the community

level and within the private health sector.

c) Sessions of budgeting improves ownership and equity:

With the zoning and rationalization that was speared headed by the Ministry of Health, partners have

also been involved in rationing of the financial resources. The establishment of the USTP secretariat,

whose mandate among others is to mobilize resources for the TB response, was a step forward in

harnessing and aligning the support received from partners to the strategic plan priorities.

The USTP secretariat will be strengthened by supporting a finance officer and strengthening its

capacity in financial and grants management. This will go a long way in improving its capacity to

mobilize additional resources for the TB response.

d) Improvements in M&E and program reporting

Program reporting was weak during Phase 1 implementation. Lack of timely and accurate data and

reports hampers quality decisions for the program.

Phase 2 intends to strengthen the M&E systems at the central NTLP unit and at the various levels of

the health system. M&E systems for reporting on program data and stock out of medicines at the

health facility level will be strengthened.

The above lessons have played a role in influencing the budget reallocations. The need to involve new

partners especially from the private sector resulted into the introduction of a service delivery area

(SDA 5.3- PPM) that is designed to ensure that the Private Health Providers contribute to case finding

and treatment success rate.

The need for accurate and timely reporting influenced the budget reallocation towards the setting up

of the M&E database and the Web based logistics Management system (focusing on the Procurement

and Supply Chain management).

Budget provisions for Joint planning, program reviews and supervisions have been maintained. These

will ensure that program interventions are constantly reviewed and assessed for quality and timely

implementation.

Does the budget request reflect the average programmatic performance in the current

Phase/Implementation Period? If not, please provide an explanation.

No, the budget request does not reflect the average programmatic performance in the current

phase/implementation period due to the following reasons:

The phase 2 budget funding has a ceiling of USD $ 11.585 million. The average programmatic

performance for the semester ending 30 June 2013 is 89% resulting into USD $ 10.31M that the

country would be eligible for in Phase II TB SSF. Of the 10.31M, 65% is for procurement and

management costs of anti-TB medicines, laboratory reagents and equipment (Xpert machines) leaving

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only 35% for programmatic interventions. Although the country appreciates that it is only eligible to

access 89% of the ceiling, the remaining funds (less procurements) are inadequate to address the

critical gaps identified by the Program review and those identified by MOH/NTLP and GF during

Phase I implementation. For this reason, the country has applied for 100% of the Adjusted TRP

approved budget for Phase II TB SSF and 100% of the balance of the Phase 1 undisbursed sum

amounting to US $ 2.647M, resulting into a total budget of US$ 14,140,122.

6.3 Compliance with Focus of Proposal Requirement

This question is not applicable for Low Income Countries.

Describe whether the focus of proposal requirement has been met per the threshold based on the income classification for

the country.

Not applicable

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Supporting Information (to be submitted with the CCM Request)

Annexes Annex 1 CCM Oversight Plan Annex 2 Conflict of Interest (COI) Policy Annex 3 A summary of the preparation process for TB SSF Renewal Request Annex 4 The Minutes of the CCM Resource Mobilization Committee Meeting Annex 5 The Minutes of the CCM Board Meeting Annex 6 Fund flow mechanism for GF TB SSF Grant Annex 7 Joint External Review of the National TB Programme in the Republic of Uganda Annex 8 A concept paper on internal controls to manage food and transport refund for

MDR patients. Annex 9 Progress on Conditions Precedents and GF concerns Annex 10 Comparative Analysis of Activities in Round 10 and TB SSF phase 2 Annex 11 Performance Framework for Phase II, TB SSF Annex 12 NTLP Strategic Plan 2012/13-2014/15 Annex 13 M&E Plan for the NTLP Strategic Plan Annex 14 National Drug Resistance Survey-Uganda Annex 15 Assessment of HIV/STI/TB and Drug Abuse among Prisoners in Uganda,2009 Annex 16 Procurement and Supply Management (PSM) Plan Annex 17 Renewals Financial template (Financial Gap Analysis and Counterpart Financing

CCM Summary Budget Request, Financial Request, CCM analysis of the request versus original budget

Annex 18 Detailed budget Annex 19 Workplan