None provided.

Table 3.3.03: Program Planning Overview Program Area: Medical Transmission/Blood Safety Budget Code: HMBL Program Area Code: 03 Total Planned Funding for Program Area: $ 4,650,000.00

Program Area Context:

The Blood Safety Program under the Uganda Blood Transfusion Service (UBTS) helps prevent medical transmission HIV/AIDS by ensuring adequate quantities of safe blood and blood products for all Ugandans. UBTS is a semi autonomous institution of the Ministry of Health (MoH). Currently, about 100,000 patients are transfused annually in hospitals countrywide. Of those, nearly half are pediatric due to severe anemia resulting from malaria, a quarter are obstetric, and the rest are medical and surgical.

USG supports a comprehensive approach to blood safety to support national priorities and meet the needs of the Ugandan people. Key goals of the program are the 1) retention of low-risk, voluntary, non-remunerated repeat blood donors; 2) care referrals of HIV positive donors; 3) blood collection, testing, storage and distribution; 3) staff training; 4) quality assurance; and 5) monitoring and evaluation. In addition, adequate and appropriate infrastructure, transport, supplies and equipment must be made available to support program goals.

As blood transfusion needs are expected to grow by 20 percent annually to reach 400,000 units of blood in FY09, maintaining adequate quantities of safe blood and blood products becomes increasingly important. Community mobilization and education for donor recruitment is jointly implemented by the UBTS and the Uganda Red Cross Society (URCS), an indigenous charitable not-for-profit organization. These institutions have jointly built a countrywide network to access communities in schools and workplaces. Access to and communication with individuals and communities have greatly improved because additional staff were recruited and adequate transport secured for the field activities. Recruitment and retention of blood donors was enhanced through increased use of radio and newspaper advertisements, mobile phone text messages, and scheduled visits by counselors.

HIV sero-prevalence among voluntary blood donors has steadily declined from 2.1 percent in FY04 to 1.67 percent in FY05 to less than 1.5 percent in FY06. The success in lowering HIV prevalence among the donors is attributed to better methods of blood donor selection and counseling, and the increase in voluntary, non-remunerated donors. These methods will be duplicated in subsequent years of the program. Since HIV rates among replacement donors are about twice that of volunteer donors; efforts are in place to phase out replacement donors as repeat donors are maintained. Repeat donors currently represent 55 percent of total donors, and have a lower HIV sero-prevalence rate than new donors. The proportion of repeat donors is targeted to increase by 10 percent during FY06. Retention of voluntary, non-remunerated HIV negative donors is particularly vital for running a successful blood safety program. To encourage repeat donations, 90 percent of blood donors will receive post donation counseling in FY07, and referrals to HIV care services will continue for donors testing HIV positive.

Maintaining high standards for blood collection, testing, storage and distribution is also critical to UBTS's FY07 strategy. UBTS tests all transfusion bloods for HIV, Hepatitis B and C, and Syphilis using effective testing algorithm at the seven regional laboratories: Arua, Fort Portal, Gulu, Kitovu, Mbale, Mbarara and Nakasero Blood Banks. Laboratory equipment for this purpose has been purchased for all the centers. Improvements in the cold chain and distribution of blood have been made recently. In FY06, six blood bank refrigerators and seven deep freezers were purchased for blood storage, and 250 cool boxes were purchased for transportation of blood during collection and distribution to hospitals. While these purchases have helped, 10 refrigerators and freezers need to be purchased in FY07.

Availability of adequate transport is also crucial for running an effective blood safety program. To boost transportation, 11 large vehicles were purchased for UBTS to transport staff and equipment into communities for blood collection in FY06. In addition, nine smaller vehicles were bought to carry out community mobilization of volunteer donors, and one vehicle was purchased to facilitate monitoring and evaluation of the project activities. All vehicles were distributed to Regional Blood Banks according to the needs of each center. Three motorcycles were bought for distribution of blood in urban areas. Two

vehicles were bought for URCS to facilitate mobilization of volunteer blood donors. These efforts have resulted in a 13 percent increase in blood collection from volunteer donors. In FY07, maintenance costs for blood collection and distribution vehicles will have to be met.

Training is also a critical component of UBTS's strategy. In FY06, a total of 737 health workers received training, including blood transfusion staff, blood donor recruitment officers, hospital based blood bank laboratory assistants/technicians and clinical officers from Health Centre IVs. The purpose of the training was to improve skills for procurement of safe and adequate quantities of blood. Two seminars on clinical interface were held for senior doctors at the Mulago referral Hospital. CDC provided technical assistance for strengthening the Management Information Systems for the program. Reporting forms have been revised to enable the program to generate reports for all vital activities on daily, weekly and monthly basis. Also, program personnel were trained to use Personal Digital Assistants (PDAs), and 10 computers and fifteen PDAs were purchased. Computerization of laboratory equipment is now in progress. In FY 07, the program plans to train an additional 475 persons in blood safety.

In FY07, the USG will continue to support the Blood Safety program to consolidate achievements of the past years and bridge gaps in service delivery. The main challenge for the program lies in maintaining the operations so far attained including the constant supply of blood bags, screening reagents and waste disposal management. Fortunately, the UBTS has been granted a reasonable degree of autonomy by government, which has recently enabled it to expedite all operations, including procurement of vital items. Increase in total blood collection has been modest, and occasional stock-out of blood for transfusion is still reported in some hospitals and Health Center IVs. Inadequate infrastructure and space at all the 7 regional blood banks and national referral laboratory at UBTS headquarters is another big challenge to the expansion of the program operations and meeting the increasing demand for safe blood in the country. Most of the current regional blood banks operate in small 2 room spaces some of which are loaned to the program by the regional hospital laboratories. This constraint can only be addressed by construction of buildings to house the blood banks' activities, some of which is currently ongoing; the construction of the two regional blood banks, Mbale in eastern Uganda and Mbarara, in southwestern Uganda, which are expected to be completed by December 2006. The laboratories at these facilities will receive power backup generators. In FY 07, construction of a regional blood bank in Gulu, and the national referral laboratory at Nakasero Blood Bank will be carried out. UBTS priorities for FY07 will include quality assurance activities such as the completion of related manuals, introduction and refinement of processes, and training and supervision of staff.

Program Area Target: Number of service outlets carrying out blood safety activities 230 Number of individuals trained in blood safety 1,575

Table 3.3.03:

None provided.

Table 3.3.06: Program Planning Overview Program Area: Palliative Care: Basic Health Care and Support Budget Code: HBHC Program Area Code: 06 Total Planned Funding for Program Area: $ 24,669,565.00

Program Area Context:

Over 800,000 people are living with HIV (PHAs) and in need of palliative care. Although current data collection and reporting systems make it difficult to accurately reflect the total number of PHAs accessing palliative care (PC) services through USG support, the number is currently estimated at 25% of the total population. This number is expected to increase in FY07. In addition to placing a key priority on improving monitoring and reporting systems in FY07, The USG will continue to strengthen the capacity of government and civil society partners to provide comprehensive, quality PC for more clients. USG/Uganda is also prioritizing improved access to critical care and treatment services for children through linkages with counseling and testing (CT), orphans and vulnerable children (OVC) and antiretroviral treatment (ART) services.

PC services comprise prevention and treatment of opportunistic infections (OIs), psychosocial support, home-based care, nutrition, basic preventive care, tuberculosis (TB) Management, pain and symptom control, spiritual care and culturally appropriate end of life care. The USG supports a variety of approaches to improve comprehensive access to palliative care services. These approaches include a family approach, which targets the index client and their family as a means of improving support for the HIV positive client but also to refer other family members for CT and early referral to care and treatment services. The network approach, which serves to improve access for a client and their family to critical prevention, care and treatment services through linkages and referrals, is also is implemented using a number of different models. The different models include intra and inter-facility based referrals as well as developing strong linkages between clinic and community support particularly through faith networks and decentralized delivery systems. Family members, PHA groups, post test clubs and other civil society partners play critical roles in raising community awareness, motivating clients to seek care services and offering intermediate care and adherence support at the grassroots level. As such, families and communities are the cornerstone of the USG strategy. New elements to the strategy include expanding access to symptom and pain management as well as end of life care.

Uganda has pioneered and continues to expand access to the basic care package comprising cotrimoxazole prophylaxis, long lasting insecticide treated bed nets (LLINs), safe water system and prevention with positive interventions, targeting over 65,000 HIV positive clients and their families. Throughout the past 18 months, cotrimoxazole has become a mainstay or OI prevention. The USG is currently employing a variety of models to expand and ensure access of basic care elements to as many PHAs as possible through a variety of public and private delivery channels. The commercial sector is currently expanding delivery for LLINs, condoms and safe water and has established a virtual facility for civil society organizations to access key commodities at subsidized prices. Basic care elements have also been packaged and are being distributed through key partners supporting PHAs.

OI drugs are sourced through the Uganda Essential Drugs Program, with the support of USG and other partners. However, the availability of PC commodities and supplies remains a challenge. Stock-outs, especially for OI drugs, HIV testing kits, and other medical commodities largely obtained through the national supply chain system are common. Over the next year, the USG will work through SCMS to continue to build capacity for logistics management at the central (National Medical Stores—NMS and Joint Medical Stores—JMS), district and facility level. NMS and JMS manage the national public and private supply chain management respectively. Direct procurement of commodities will be considered as needed.

In Uganda, key wrap around services include improved access to family planning, counseling and broader reproductive health services, supplemental feeding, livelihood and economic emancipation, housing, and access to water and sanitation. Over the last two years, the USG has intensified networking with other sectors and partners to facilitate access to these services for PHA. For example, in partnership with Food for Peace, food commodities worth $30 million will provide ongoing support to 60,000 PHAs, OVCs and their families. In FY07, USG will work with Uganda's Ministry of Health (MOH) to develop guidelines for

addressing therapeutic feeding in HIV/AIDS settings. Efforts are also underway to integrate reproductive health in HIV/AIDS care to address the growing need expressed by PHAs, especially those on ART, to make informed reproductive health choices. USG will continue to explore opportunities to link PHA groups and individuals to household economic strengthening initiatives.

USG/Emergency Plan will leverage PMI to complement palliative care resources. For example, our social marketing program will distribute free and subsidized LLINs in addition to other key elements of basic care. Several PMTCT partners will strengthen the delivery of intermittent preventive treatment through ANC and PMTCT programs. Emergency Plan partners will also support home based management of fever.

The MOH has developed several policies and guidelines to support delivery of quality palliative care including the Cotrimoxazole prophylaxis Policy, the Home Based Care Policy, the Essential Drugs Policy, and National Guidelines for Care of PHA. However, implementation of these policies has been constrained by systemic challenges such as human resource shortages, infrastructure and limited dissemination. The USG is currently supporting several initiatives at the national level to improve human resource management including MIS strengthening, a retention and recruitment survey and improved communications between central and district levels.

Standardizing the quality of care and harmonizing interventions across the various USG partners remains a major gap in palliative care. USG is planning a comprehensive assessment of its palliative care activities beginning later this year. The assessment will provide insight into the degree to which components of palliative care are being offered, and how results are measured. This assessment will assist in further understanding and addressing issues of double counting as well as improving the quality of services offered. Standardized approaches and quality indicators that support improved palliative care delivery are expected outcomes. Uganda will also participate in OGAC's centrally funded PC targeted evaluation, which will address issues specific to services offered, costs and short-term outcomes.

Tracking and reporting individual clients receiving palliative care services remains an ongoing challenge. The comprehensive and complex needs of clients as well as the availability of a variety of established palliative care service providers (public, private, facility and community-based) coupled with a system without unique identifiers makes it difficult to effectively track service utilization. Through data quality assessments and semiannual reporting, USG/Uganda currently estimates a 40% duplication in reporting. This information will be further validated through the planned assessment and evaluation.

Program Area Target: Total number of service outlets providing HIV-related palliative care (excluding 835 TB/HIV) Total number of individuals provided with HIV-related palliative care 225,571 (excluding TB/HIV) Total number of individuals trained to provide HIV-related palliative care 14,368 (excluding TB/HIV)

Table 3.3.06:

plus ups: The USG has been supporting a grants mechanism to increase access to comprehensive services for OVC. This mechanism has recently been merged into a multidonor grants mechanism. USAID holds the contract with Deloitte and Touche to manage the funds. Fy07 service delivery resources programmed under the CORE initiative will be reallocated to this mechanism. However, resources are currently insufficient to meet the vast needs of the community. These resources will further supplement planned fy07 activities.

Added February 2008: Deloitte and Touche through the development of the multi-donor funded Civil Society Fund will be providing sub grant services previously supported by the CORE Initative/ CARE in partnership with Ministry of Gender Labour and Social Development. Activities remain the same.

None given.

Table 3.3.15: Program Planning Overview Program Area: Management and Staffing Budget Code: HVMS Program Area Code: 15 Total Planned Funding for Program Area: $ 11,085,060.00

Program Area Context:

The Emergency Plan in Uganda is staffed and managed by an experienced, multi-faceted group of experts and technicians in health and development. The high level technical and program staff from the five USG implementing agencies offer a vast range of expertise, including epidemiologists, behavioral scientists, clinical specialists, virologists, and experts in the areas of prevention and behavior change communication, palliative care, program management, evaluation, informatics and social work.

U.S. government agencies that support the Emergency Plan in Uganda include the State Department, Department of Defense,, Walter Reed, United States Agency for International Development (USAID), Department of Health and Human Services/Centers for Disease Control (CDC), National Institutes of Health (NIH), and Peace Corps. Each agency has at least one representative on the Country Team, and all contribute to Emergency Plan strategic planning process as well as implementation of project activities nationwide. The overall costs for management and staffing for FY07 is 5.6% of total Emergency Plan budget for Uganda. Program interventions are designed to take advantage of the strengths of each organization, and coupled with strong coordination of activities among the implementing agencies, allows the Uganda Emergency Plan program to maximize USG spending and achieve greater reach and long-term effect.

The Emergency Plan Country Team of senior level managers and experts from all relevant U.S. government agencies, supported by input from their respective broader range of expert staff, crafts Emergency Plan strategy, coordinates implementation of activities, determines the annual country budget, and facilitates the annual reporting process. An Emergency Plan Country Coordinator, with an office in the Embassy and reporting directly to the Deputy Chief of Mission, joined the team during FY 06. The Coordinator provides oversight and direction on day-to-day management and activity planning across all agencies, development of the Country Operational Plan, and responds to reporting requirements. The recruitment process has begun to hire one support staff to assist the Country Coordinator.

In order to promote better coordination of activities across all program areas, technical working groups have been established around the various Emergency Plan focus areas - prevention (with a sub-committee on PMTCT, blood safety, and injection safety), care (with a sub-committee on TB/HIV integration), counseling and testing, orphans and vulnerable children, treatment (with a sub-committee on lab), strategic information, and other policy. Each working group has selected a chairperson who leads the discussion and is responsible on reporting the decisions of each group to the Country Coordinator. Each USG implementing partner working in the specific focus area is represented in the working group. The PEPFAR Working Groups liaise directly with national technical groups in the same areas.

The USG implementing agencies work in close collaboration with various Government of Uganda ministries in support of the national goals and objectives. In addition, faith based and other indigenous organizations are important implementing partners in the Emergency Plan. Efforts to coordinate PEPFAR programming with Global Fund grant programs continue.

The FY 07 Plan is requesting a total of 252 full-time (100%) staff to implement the Emergency Plan in Uganda, which includes 16 new positions for FY 07. In addition, Peace Corps is requesting an additional 65 volunteers for FY 06, 30 of which will be Emergency Fund supported. CDC/HHS's staff of 227 works in four major areas: program technical support, laboratory, informatics, and epidemiology/behavioral evaluation. USAID's team of 27 staff manages 27 different Emergency Plan prime activities, implemented through contracts, grants and cooperative agreements, which include policy development, clinical service provision, behavior change communication, and programs in abstinence, faithfulness, condom use, PMTCT, injection safety, palliative care, TB/HIV integration, ART, orphans and vulnerable children, national logistics and laboratory systems, HIV/AIDS programs in conflict areas, strategic information and program coordination. DOD, with a staff of 4, implements ART service delivery, counseling and testing, and prevention for the

Ugandan defense force. Peace Corps' 6 staff and 96 volunteers are working on HIV/AIDS prevention programs.

Full-time (100%) staffing levels proposed for FY 08 will increase by 18 across all USG agencies, and Peace Corps is requesting an additional 161 volunteers, of which 60 are to be funded by the Emergency Fund. As the Country Team has experienced a recent change in the majority of senior-level members - a new Ambassador, Deputy Chief of Mission, CDC Country Director, USAID HIV/AIDS Team Leader, and a relatively new Emergency Plan Country Coordinator - these staffing levels will be revisited prior to next year's COP submission.

Table 3.3.15: