Regional Health Integration to Enhance Services in East Central Uganda Activity (RHITES-EC)

The Challenge

The East Central (EC) region of Uganda, home to 4.4 million people, faces unique challenges due to its waterside geography: seven of the 12 EC districts are bordered by water, which contributes to inequitable access to health services in part because this impedes reaching health facilities.

This inequity also is increased by: low educational levels, especially among girls; pockets of mobile, marginalized, and migrant populations; high levels of unemployment, especially among youth; and limited youth-friendly services despite the fact that the majority of people in this region are younger than 25 years old.

Furthermore, redistricting in Uganda over the last decade has resulted in a near doubling of the number of districts in the country, with many newly created and often more rural districts lacking basic infrastructure and having a poorer resource base. Of the more than 530 government and private not-for-profit health care facilities in the EC region, 70% are at the Health Center II (HCII) level, compared to 59% nationally. This reflects greater dependence on lower-level health care facilities, where infrastructure, resources, and services are fewer than at higher-level facilities.

Consequently, the burden of key health issues – HIV, HIV/TB coinfections, malaria, and the availability and access to RMNCAH, FP, nutrition, and laboratory services – varies greatly among districts.

Overview

USAID’s RHITES-EC activity supported the Uganda Ministry of Health to improve regional health outcomes by increasing the use of high-quality health care services within 12 districts in EC Uganda, which has a population of approximately 4.4 million. The coverage region has more than 500 healthcare facilities that deliver a range of services, with 130 facilities offering HIV treatment (ART) services, and Jinja Regional Referral Hospital as the only tertiary-level facility.

The activity worked to:

• Increase demand, access, availability, and quality of health services;
• Expand the availability of resources for public sector health services;
• Strengthen systems for management, information, and health service delivery; and
• Increase the adoption of healthy behaviors and practices in households and communities.

URC and its partners shared the vision that these goals are achievable through an integrated service delivery approach that prioritizes gender and youth-friendly services, local capacity development for sustainability, quality improvement (QI), collaboration, learning and adaptation, and improved district stewardship.

Achievements

RHITES-EC is building district capacity to manage and deliver quality health services at both facility and community levels. The activity has made significant progress on its goals and, in many cases, has met or exceeded them as detailed below.

HIV/TB Service Delivery: The activity has surpassed annual targets for HIV case finding, treatment initiation, retention in care and viral load testing coverage and suppression for people living with HIV in East Central Uganda. This is bringing Uganda closer to achieving control of the HIV epidemic, partly due to its successes with index client testing as well as strong client and peer support programs that help link clients to care on the same day as diagnosis. RHITES-EC has supported national efforts to decrease HIV/TB coinfection by successfully rolling out TB preventative therapy to eligible patients.

• As a result of activity interventions, the number of people living with HIV (PLHIV) in the EC region receiving ART and active in care has doubled during the past five years, from 42,554 by December 2016 to 84,106 by September 2021.
• The Uganda Population HIV Impact Assessment 2016-2017 estimated the HIV viral load suppression among HIV-positive adults to be 48.8% in the EC region – the lowest in Uganda – compared to a national average of 59.6% at activity baseline in 2016. By September 2021, viral load suppression for PLHIV in care for the EC region improved to 95%, according to the Data for Accountability, Transparency, and Impact Monitoring (DATIM) system.
• RHITES-EC also reduced the mother-to-child HIV transmission rates from 8.8% at the end of the activity’s first year in September 2017 to 2.6% by September 2021, below the national target of 5%. The activity also provided voluntary medical male circumcision services to more than 224,000 males, increasing the circumcision coverage for the EC region to greater than 80%.
• Similarly, TB diagnostic and treatment units have been scaled up, from 102 in October 2016 to 130 by September 2021.
• Key TB service indicators have improved: The TB case notification rate has more than doubled, from 52 cases/100,000 (October–December 2016) to 112 cases/100,000 (July–September 2021). Overall, 22,756 new and relapsing TB cases have been notified during the last five years.
• The proportion of children among notified TB cases has increased from 3% (October–December 2016) to 13.3% (July–September 2021). The treatment success rate has been maintained above 80%, 87.5% by September 2021 up from 55% by the end of the first year of implementation (October 2016–September 2017).
• By October 2021, the activity had seamlessly and successfully transitioned HIV/TB service delivery to USAID’s Local Partner Health Services- East Central Uganda (USAID LPHS EC) USAID Government to Government Jinja Regional Referral Hospital (USAID G2G-Jinja RRH) and USAID Local Service Delivery Activity (USAID LSDA). USAID RHITES EC continues to sustain quality service delivery through above site technical support to USAID LPHS-EC and the districts in the region to achieve the 95-95-95 HIV epidemic control goals.

Malaria: By helping health facilities to implement test and treat policies, the proportion of malaria cases treated for malaria based on positive malaria results increased from 60% at the start of the activity in October 2016 to 97% five years later. The activity also helped decrease the number of patients being wrongly treated for malaria and taking artemisinin-based combination therapy from 70% to 2% in the activity’s first five years (October 2016 to September 2021), significantly reducing this waste from inappropriate use. In October 2021, USAID RHITES-EC successfully transitioned malaria prevention and treatment service delivery to the districts who are now supported by the USAID’s PMI Malaria Reduction Activity.

Maternal and Child Health: RHITES-EC has improved maternal and newborn survival through QI methods, supportive supervision, and clinical mentorships and trainings. The activity has increased community engagement with village health teams to strengthen linkages between facilities and communities, and renovation and remodeling of health infrastructure. As a result of these interventions, significant improvements have been seen. For example:

• RHITES-EC led the design and development of the national basic emergency obstetric and newborn care (BEmONC) training curriculum for Uganda.
• From the fiscal years 2017 to 2022, more than 1.5 million pregnant women attended at least one antenatal care visit at activity-supported MNCH sites. By September 2022, skilled personnel conducted 66.6% of deliveries.
• The national institutional maternal mortality ratio in 2016 was 386 deaths per 100,000 live births. For the EC region, the rate declined to 81 deaths per 100,000 live births in 2022, partly due to improvements in the proportion of maternal deaths reviewed from 13.2% at baseline in October 2016 to 100% (114/114) in 2022.
• Similarly, the institutional neonatal mortality rate has significantly dropped, from 16/1,000 nationally in 2016 to 5.4/1,000 in the EC region in 2022.
• Measles vaccination coverage – meaning final vaccine to completing a vaccine schedule for an infant – has improved from 60.9% in year one to 93.1% six years later.
• The activity renovated six maternity wards, four laboratories, and one maternity theater to improve access to services.
• The activity supported the Ministry of Health to pilot the training of Community Health Extension Workers (CHEWS), which promote seeking antenatal care and having births at health facilities, ensuring pregnant women receive quality care and safer deliveries.

Nutrition: Results have been achieved through implementation of nutrition assessment, counseling, and support (NACS) through quality improvement methods, supportive supervision, clinical mentorships and trainings, increased community engagement with village health teams to strengthen linkages between facilities and communities, and procurement and distribution of essential nutrition equipment and job aids.

Thanks to these interventions, nutrition assessment for children 0-23 months seen at outpatient departments improved in the activity’s first four years from 7.2% to 63.4%, exceeding a target of 45%. At the same time, the burden of acute malnutrition at the facility level amongst children under five years decreased significantly over the past six years from 5.3% at baseline in 2016 to 2.8% by September 2022, compared with a target of 3.5%. NACS in HIV clinics has been sustained above the annual target of 90% during the past six years.

And RHITES-EC’s use of QI methods with implementation science (from 2019-2020) resulted in a doubling of access to iron-folic acid supplements among pregnant women attending antenatal care clinics in intervention districts compared to control districts.

Supply Chain: RHITES-EC worked to strengthen supply chain and logistics management to ensure improved availability and access to essential medicines and health supplies. Key achievements include:

• Improved stock management of essential medicines: As a result of Supervision, Performance Assessment, and Recognition Strategy (SPARS) supply chain capacity-building activities, SPARS scores increased from 44% (11/25) in December 2017 to 75% (18.7/25) by September 2021.
• Improved availability of uninterrupted supply of HIV care commodities: Through timely ordering at 141 ART accredited sites, which increased from 90% in 2016 to 100% in 2021.
• Improved availability of essential medicines and supplies: Stockouts of insecticide-treated nets at health facilities decreased from 60% in 2016 to 20% in September 2021.

Water/Sanitation/Hygiene (WASH): The activity has supported facility- and community-level WASH improvement initiatives through capacity-building activities. All high-volume facilities and the 34 PEPFAR Health Center IIs have been trained in infection prevention and control. A total of 780 outdoor handwashing facilities and assorted facility WASH information, education, and communication materials were distributed to all high-volume facilities and the PEPFAR HC IIs within the region.

Through targeted home-to-home WASH improvement campaigns (guided by community diarrheal data) and aligned social behavior change activities, the percentage of individuals who wash their hands with soap after visiting the latrine at a hand washing station has improved from 60.5% to 80.6%.

And reporting on community indicators – such as safe latrine coverage and hand washing facilities – in the national Health Management Information System has improved over the first five years of RHITES-EC implementation from 27.8% by end of December 2016 to a record-high of 82% by September 2021.

COVID-19 Prevention and Treatment: Provided technical and logistical support to local government for COVID-19 vaccination, with the first dose vaccination coverage amongst adults increasing from 8% in October 2021 to 93% by September 2022, including 73% for full vaccination coverage.