1. Overall goals and objectives The Overall goal is to Support the Government of Uganda to provide and scale-up comprehensive HIV/AIDS care, treatment and prevention services through the integration and strengthening of the District Health Service (DHS). The programme goal will be achieved through three objectives including: 1: To

increase access to family-centred, comprehensive HIV and AIDS prevention, care and treatment services through integration of these services into the (DHS) in 13 districts of the Central Region of Uganda by September 2015. 2: Build human resource capacity for sustainable delivery of comprehensive HIV and AIDS services in 13 districts of Central Region of Uganda by September 2015 and 3: Strengthen DHS planning, administration, Monitoring & Evaluation, logistics and supply chain management mechanisms for effective and efficient delivery of comprehensive HIV/AIDS services in 13 districts of the Central Region of Uganda by September 2015.

2. Target populations and geographic coverage The target population will include People Living with HIV (PLHIV) and their affected families and HIV/AIDS service providers in 13 districts of the Central region of Wakiso, Mukono, Luwero, Nakaseke, Nakasongola, Mityana, Mubende, Mpigi, Masaka, Lyantonde, Kayunga, Ssembabule and Kalangala.

3. Enhancing cost effectiveness and sustainability To improve both efficiency and effectiveness while increasing sustainability of service delivery, Mildmay Uganda will adopt a model that emphasizes technical support in areas with identified capacity gaps, while encouraging ownership and more responsibility of the implementing sites in the day-to-day running of the clinics.

4. Health Systems Strengthening As a strategy for health systems strengthening and sustainability of access to good quality HIV and AIDS care in rural areas DHTs will be mentored in planning, budgeting, resource mobilization, monitoring and supervision of health services. The project will set up local systems to provide performance-based conditional grants to target districts

5. Cross-Cutting Budget Attributions Human Resources for Health: All HC will be supported to implement a functional task shifting model. Tailor-made skills-building will be done for district and HC III & IV key staff, in leadership and HRM to enhance capacity for managing health systems.

a. REDACTED

c1. The capacity of the HC shall be built through coaching and mentoring to provide continuous nutritional assessment and counselling using national Food and Nutrition policies and guidelines

g. Mildmay will work with district and partners in the catchment area to reduce on gender based violence

6. Key issues: Mildmay Uganda will provide technical assistance and collaborate with the targeted districts to link the HCs to existing Child survival program interventions in the central region.

Family planning (FP) services will be integrated within the HCs or HCs will be linked to other HCs providing FP services or family planning projects in the central region of Uganda; the HCs providing FP services will receive FP logistics through the national health system

Malaria cases shall be managed using MOH guidelines. ITN s will be provided through basic care package by PACE.

Safe Motherhood: In partnership with DHS in the central districts Mildmay will link the HCs in the spheres to other implementing partners providing PMTCT and Maternal health services.

TB activities shall be integrated in services provided at the implementing sites. Anti TB drugs will be provided through MOH/ Global fund.

b. Gender Working closely with the district health Office (DHO), Community Development Office and the HCs in the central region, Mildmay will provide technical assistance to ensure that there is gender equity in provision of HIV/AIDS services.

Target populations and coverage of target population or geographic area Mildmay Uganda will support District Health Services (DHS) in 13 districts of the Central region of Uganda (Wakiso, Mukono, Luwero, Nakaseke, Nakasongola, Mityana, Mubende, Mpigi, Masaka, Lyantonde, Kayunga, Sembabule and Kalangala) to effectively deliver comprehensive, sustainable services and scale up access to quality adult HIV and AIDS care and support. Such technical assistance will be carried out in spheres and each sphere will comprise 1 Health Centre (HC) IV/district hospital and 6 other lower level HCs within the same Health Sub District (HSD) (2 HC III & 4 HC II). There will be 18 spheres each with seven HC bringing the number of HC served to a total of 126. Mildmay Uganda main site at Lweza will be part of the HC in Central Uganda and will therefore provide care and support to some of the patients. 74,000 eligible individual within the context of families will be provided with a minimum of two care services, one clinical & one non-clinical. Within the spheres, through the DHS 66,000 HIV-positive individuals will be provided with Cotrimoxazole prophylaxis and all clients will be monitored for adherence. 15,000 eligible HIV-positive clinically malnourished clients disaggregated by (age, sex, pregnant/lactating women & type of nutrition support; therapeutic food, supplementary food, nutrition counselling), will be provided with food &/or nutrition services.

Description of service delivery or other activity carried out Major activities for this program include; Provision of basic care and support, PITC, treatment and prevention of Opportunistic Infections (OIs) including malaria and TB, management of common infections like UTI, RTI and skin infections, pain management and symptom control, functional rehabilitation, nutrition and food security interventions. The program will ensure availability of PEP services for occupational and non- occupational exposure, prevention with positives interventions like partner testing, condom use, contraceptive use.

Integration with other health activities

Mildmay Uganda will promote and support the integration of HIV care into other health services which include cervical and breast cancer screening, PMTCT, mental health, Integrated Management of Acute Malnutrition, waste management, Sexual and Reproductive Health: (family planning, treatment of STIs, adolescent sexual and reproductive health), maternal and child health (MCH). To avoid duplication,

Mildmay Uganda will collaborate with other partners supporting PMTCT, sexual and reproductive health, and door-to-door HCT in the 13 districts.

Relation to the national program Mildmay Uganda will support the functionalisation of the national HMIS data management systems and other national guidelines and policies on TB, ART, PMTCT, counseling and waste management in the spheres. Alignment and adherence to these policies and guidelines will be part of the continuous technical assistance and supervision as well as evaluation of the HC in the spheres.

1. Target populations and coverage of target population or geographic area Mildmay Uganda will support the 13 districts (Wakiso, Mukono, Luwero, Nakaseke, Nakasongola, Mityana, Mubende, Mpigi, Masaka, Lyantonde, Kayunga, Sembabule and Kalangala) within the central region of Uganda to reach 7,500 OVC and their families with care and a comprehensive OVC package as guided by NSPPI. The programme will target at least 420 OVC and their families per 'sphere' 2. Description of service delivery or other activity carried out Mildmay Uganda will address the needs of OVC and their families in eight Core Program Areas: socio- economic security; food security and nutrition; care and support; education; health; child protection; and capacity building to care givers. All the served OVC and their families will receive psychosocial support. The OVC and their families will be provided with at least 3 Core Programme Areas beyond psychosocial/spiritual support. Using the existing CSF structures, Mildmay will support the districts in mapping out OVC service providers in the central region and updating the district OVC service provider directories. The specific activities will include: Updating the district OVC service provider directories; Facilitating the formation of 'circles' of service providers at HC level; Functionalizing submission of regular reports at all levels of DHS.

4. Relation to the national program Mildmay Uganda will support the functionalisation of the national HMIS data management systems, MGLSD MIS and other national guidelines and policies on OVC.

5. Health Systems Strengthening and Human Resources for Health Mildmay Uganda will focus on strengthening the already existing structures to help improve the OVC service delivery by: Working with the districts to functionalise existing data management systems to meet the current national reporting requirements of the HMIS; Working with the district to strengthen linkages

and networks with other public and private sector OVC service providers, following the Mildmay OVC model and other existing models; Strengthening linkages with other implementing partners to increase awareness to the priority needs of the most vulnerable HIV positive children and their households through; • Supporting the districts to strengthen existing linkages and establish new linkages • Supporting the district to strengthen the existing referral systems

Target populations and coverage of target population or geographic area Mildmay Uganda will offer technical assistance to develop the capacity of the District Health Services (DHS) in 13 districts of the Central region of Uganda (Wakiso, Mukono, Luwero, Nakaseke, Nakasongola, Mityana, Mubende, Mpigi, Masaka, Lyantonde, Kayunga, Sembabule and Kalangala) to effectively deliver sustainable services and scale up access to quality adult HIV and AIDS care and support. 36,125 individuals (85% adults) will be maintained on HAART, an additional 3150 (85% adults) individuals initiated on HAART.

Description of service delivery or other activity carried out Mildmay Uganda will offer technical support to Ministry of Health (MOH) facilities within the 13 districts to develop their capacity to provide and scale-up adult ART services according to national guidelines. Follow-up of clients to track clinical outcomes is done through routine reviews at the facility or community clinics during which a number of clinical parameters including weight, CD4, occurrence of Opportunistic Infections (OIs), etc are assessed. The program will implement strategies to promote adherence to ART to minimize the likelihood of developing ARV drug resistance.

Health Systems Strengthening and Human Resources for Health Mildmay Uganda will build human resource capacity for sustainable delivery of ART services in the 13 districts through in-service training, placements, mentoring and coaching.

1. Target populations and coverage of target population or geographic area Provide demographic information on the target population(s) in the area and coverage and scope of planned activities (e.g., percent of population at risk, sub-counties, or health facilities covered). Note that

some projects will have a national-level geographic area.

Mildmay Uganda will offer technical assistance to develop the capacity of the District Health Services (DHS) in 13 districts of the Central region of Uganda (Wakiso, Mukono, Luwero, Nakaseke, Nakasongola, Mityana, Mubende, Mpigi, Masaka, Lyantonde, Kayunga, Sembabule and Kalangala) to effectively deliver sustainable services and scale up access to quality HCT services. In FY11, Mildmay will provide technical support to the HC in the spheres to reach at least 75,000 individuals with HCT, 35,000 of whom will be family members. 80% of all clients attending OPD will receive HCT. Mildmay Uganda will link the HC to HIV/DNA PCR services for at least 80% of HIV exposed infants.

2. Description of service delivery or other activity carried out

Mildmay Uganda has been carrying out HCT at 10 service outlets in 6 districts of Wakiso, Luweero, Mpigi, Mukono, Kamwenge and Mityana. The HCT services are free and open to all. Clients are encouraged to bring all family/household members (Family Approach) for testing. Community HCT is conducted in partnership with Faith Based Organisations (FBO), surrounding community clinics and private companies as requested. Mildmay has been carrying out HBHCT targeting household members of TB patients during TB contact tracing and Home Care for other patients. Mildmay has a facility to do DNA-PCR and supports all its sites for early infant diagnosis. Currently an average of 9,000 HIV antibody tests and 500 DNA-PCR tests are done per quarter.

All HCT services will be delivered using the National HCT guidelines and Mildmay Uganda will provide support supervision to the HC within the spheres for quality assurance and capacity development.

Mildmay will support the districts to strengthen the existing strategies for RCT, VCT and HBCT through; Baseline HC Capacity Assessments to deliver quality HCT services; mentoring and coaching health workers in the HC to offer Provider Initiated Testing & Counselling (PITC) in all units (OPD, inpatient wards, TB clinics, EID for all HIV exposed infants, & HCT) for household members of index clients with effective tracking of repeat testing; technical assistance and support supervision. All clients that test positive will be enrolled for care and support.

In partnership with Uganda Virus Research Institute, Mildmay will work with the districts to establish Quality Assurance mechanisms for HIV counselling and testing at all levels.

1. Target populations and coverage of target population or geographic area Mildmay Uganda will offer technical assistance to develop the capacity of the District Health Services (DHS) in 13 districts of the Central region of Uganda (Wakiso, Mukono, Luwero, Nakaseke, Nakasongola, Mityana, Mubende, Mpigi, Masaka, Lyantonde, Kayunga, Sembabule and Kalangala) to effectively deliver sustainable services and scale up access to quality paediatric HIV and AIDS care and support. Within the spheres, through the DHS 66,000 HIV-positive individuals (15% children) will be provided with Cotrimoxazole prophylaxis and all clients will be monitored for adherence. 15,000 eligible HIV-positive clinically malnourished clients (15% children) will be provided with nutritional services while 74,000 eligible individuals within the context of families will be provided with a minimum of two care services (one clinical & one non-clinical).

2. Description of service delivery or other activity carried out Services offered at Mildmay Uganda will be delivered through a Family Centered Approach with special emphasis for access to children. The program will endeavor to create child friendly clinics at health facilities and also address the special adolescent sexual and reproductive health needs. All children in care will receive basic care and support including: HCT, prevention and treatment of OIs including TB and malaria. Management of other common infections like UTI, RTI and skin infections will be offered in addition to pain and other symptom management, nutrition and food security interventions. Follow-up of clients to track clinical outcomes is done through routine reviews at the facility or community clinics during which a number of clinical parameters including weight, CD4, occurrence of Opportunistic Infections (OIs), etc are assessed according to national and international guidelines.

The capacity of the HC will be built to enable them provide psychosocial support and these in turn will support VHT to address challenges of coping with HIV and adherence to long term treatment for children in the community. Specialized services for mental health, eye care and dental care and functional rehabilitation will also be provided for children.

1. Target populations and coverage of target population or geographic area

Mildmay Uganda will offer technical assistance to develop the capacity of the District Health Services (DHS) in 13 districts of the Central region of Uganda (Wakiso, Mukono, Luwero, Nakaseke, Nakasongola, Mityana, Mubende, Mpigi, Masaka, Lyantonde, Kayunga, Sembabule and Kalangala) to

effectively deliver sustainable services and scale up access to quality paediatric HIV and AIDS treatment. The ART services will target eligible children; 7225 children will be maintained on HAART, an additional 472 children initiated on HAART.

2. Description of service delivery or other activity carried out

Mildmay Uganda will offer technical support to Ministry of Health (MOH) facilities within the 13 districts to develop their capacity to provide and scale-up paediatric ART services according to national guidelines. Mildmay Uganda will provide technical and logistical support to the districts and other service providers in the districts to support the HC in the spheres to integrate Early Infant Diagnosis (EID) into Maternal and Child Health Services (MCH).

Health Systems Strengthening and Human Resources for Health Mildmay Uganda will build human resource capacity for sustainable delivery of paediatric ART services in the 13 districts through in-service training, placements, mentoring and coaching.

The proposed project seeks to build the capacity of 13 districts in the Central region (Wakiso, Mukono, Luwero, Nakaseke, Nakasongola, Mityana, Mubende, Mpigi, Masaka, Lyantonde, Kayunga, Sembabule and Kalangala) to respond effectively to the identified challenges for sustainable service delivery and scale up access to quality care. This project will work with the districts to implement district-specific interventions targeting the six building blocks defined by WHO as critical to Health Systems Strengthening; governance/leadership, health financing, Human Resources, Information and Knowledge, Technology and Infrastructure, Service Delivery. The project will provide performance-based conditional grants to 5 target districts (Mpigi, Luweero, Mukono, Wakiso and Mityana) in the first year to a tune of 61,301 USD. Although only these 5 districts (where Mildmay is currently supporting activities) will receive sub-grants in Year 1, the first project year will largely involve the setting up of effective frameworks for grants management in the other districts. Grants amounts will increase in subsequent years depending on the need, coverage and capacity to manage them and granting will be rolled out to all the target districts. Individual district performance in setting up sustainable systems for continuity of project interventions, including incremental district budgetary allocations to project activities will determine subsequent funds disbursement. From the onset and throughout project life MU staff will continually engage DHTs, Planning/Finance departments and Political staff to detail, document and implement sustainability plans. Project will provide regular feedback

to all stakeholders on implementation of these sustainability plans to ensure a smooth MU exit. The project will initially support the DHO to integrate Inter-Disciplinary Team meetings (IDT) within existing district or HSD meetings quarterly for each sphere targeting, focal persons, committee members and other staff as appropriate. IDT meetings will be hosted on a rotational basis at different HCs within each sphere to encourage regular support supervision from the DHO and higher level facilities to lower level facilities. These meetings will facilitate the leadership role of focal persons, create a forum for inter- facility experiential sharing/learning and provide opportunities to jointly address system challenges, while enhancing accountability of one HC to another. Districts will be assisted to develop and implement locally appropriate in-service training plans that link to other USG and non-USG funded training systems, based on MoH policy. All HCs will be supported to have CMEs within 'spheres' linked to the quarterly district/HSD meetings. The Central Coordination Centre (CCC) at MU in Lweza, will provide specialist support for CMEs as necessary. This will expand knowledge and skills at the lower facility level and allow the burden of care to be spread more evenly over the DHS. Professional growth gained from this intervention will be an incentive for sustainability. To scale-up access to care especially for children - by promoting a family-centred approach - VHTs/PLHIV networks will be identified/strengthened and linked to HC II for logistical and technical support, monitoring and motivation in accordance to MoH guidelines. HC II will provide day-to-day mentoring/supervision but VHTs will also be linked to other established formal training USG or non-USG funded mechanisms. Tailor-made skills-building will be done for district and HC III & IV key staff, in governance/leadership and HRM to enhance capacity for managing health systems. To strengthen active generation and use of information for decision-making, the DHOs, district HMIS focal persons, procurement personnel and HSD in-charges, will be targeted for skills acquisition in areas including reporting using the HMIS,(including feedback), forecasting, quantification and procurement of logistics and EMHS as appropriate.. District and HC supervisory visits, IDT meetings and CMEs will be used to cascade acquired skills to lower level HC and avail HMIS tools as necessary to all HC. HC will be supported to accurately forecast, submit timely drug and supplies requisitions regularly to MoH procurement system and maintain local buffer stock. All clients 'newly' enrolled into care will be registered under MoH system. Using findings from HC capacity assessments, project will engage district political and technical staff and assist them to develop staff retention schemes targeting cadres critically lacking at the different levels in the DHS. Staff retention schemes will include; mechanisms to track/reward performance, equal opportunities for career growth and formal in-service training linked to subsequent bonding as guided by MoH/Public Service policies. Improved functionality of the DHS will be added incentive for staff retention. The project will support districts to identify and take advantage of resources available through MoH and other USG/non-USG-funded partners by strengthening the DHO coordination role. Partners will include PREFA for PMTCT, NULIFE for nutritional support, TBCAP and NTLP for external quality assurance for

TB microscopy and TB drug resistance surveillance, UVRI for quality assurance in HIV diagnosis and Community-based Organizations. In addition to the main laboratory at CCC, MU (with PEPFAR funds) has built laboratory capacity at 5 HC in the target districts. MU will work with MoH to initiate the WHO stepwise Laboratory accreditation for all laboratories attached to supported health facilities. Training of laboratory personnel will be done mainly through placements with established laboratories and support supervision. For capacity building in laboratory management MU will work with Central Public Health Laboratory (CPHL) to link personnel from target districts for training in clinical laboratory management. Mildmay Uganda will work with MoH and CDC to ensure that standards for Good Clinical and Laboratory Practice are clearly defined, documented and operationalised. Through inter-facility and inter-district linkages, the project will also expand access to this enhanced laboratory capacity for HIV disease diagnosis and monitoring.

1. Target populations and coverage of target population or geographic area Mildmay Uganda will offer technical assistance to develop the capacity of the District Health Services (DHS) in 13 districts of the Central region of Uganda (Wakiso, Mukono, Luwero, Nakaseke, Nakasongola, Mityana, Mubende, Mpigi, Masaka, Lyantonde, Kayunga, Sembabule and Kalangala) to effectively deliver laboratory services. The program target to conduct 75000 antibody HIV tests, 4000 DNA PCR tests and 30,000 TB smears in FY 2011.

2. Description of service delivery or other activity carried out

Mildmay Uganda is currently working in all the target districts (except Kayunga) to scale-up access to HIV care either through establishing satellite clinics, supporting community outreaches and/or strengthening linkages. Mildmay Uganda (with PEPFAR funds), has built laboratory capacity at five HC within the central region. In FY 11, Mildmay Uganda will strengthen inter-facility and inter-district linkages to the Mildmay laboratory for HIV disease diagnosis and monitoring. All tests currently carried out at the district or other facilities will continue to be done there while Mildmay will play a technical supporting and quality assurance role. Functional central sample collection/results disbursement networks will be established within the spheres for tests that cannot be done locally e.g. EID. These collecting centres will be linked to Mildmay where the tests will be done through an effective inter-facility courier system.

Mildmay Uganda will provide technical assistance through appropriate training, coaching and mentoring

to DHS to strengthen laboratory supply chain systems management. Mildmay will work to identify other stakeholders to partner with in this effort.

WHO Regional Office for Africa (WHO AFRO) has designed a Stepwise Laboratory Accreditation Scheme aimed at improving laboratory services in Africa. It has a grading system of 1 to 5 stars based on an assessment of the laboratory that uses the 12 elements of Quality Management System Essentials. Laboratories have to make continuous improvements with government help to gain points which add up to a star. Uganda is one of the countries with plans to implement the scheme. Mildmay Uganda will collaborate with MoH to initiate the accreditation for laboratory facilities and offer technical assistance to the facilities especially in the form of placement and support supervision.

Mildmay Uganda will work with MoH and CDC to ensure that standards for Good Clinical and Laboratory Practice are clearly defined and documented. Through its training, support supervision and mentoring activities, Mildmay Uganda will support the operationalisation of these standards in the districts.

The program's focus will be technical assistance mainly in the form of strengthening overall district leadership and coordinating role, aiding facility and district staff to assess current services and supporting them to formulate, implement and monitor solutions. These solutions will be formulated in line with national policies and will link into national logistics and supply management systems. To accomplish all these effectively, Mildmay Uganda will work with the districts to identify and forge linkages with other stakeholders, to ensure sustainability and reduce duplication and wastage.

1. Target populations and coverage of target population or geographic area Mildmay Uganda will procure drugs for an existing pool of Provide ARV for 36,125 individuals currently on HAART and Provide ARV for initiation of an additional 9,000 ART eligible clients in 13 districts of the Central region of Uganda (Wakiso, Mukono, Luwero, Nakaseke, Nakasongola, Mityana, Mubende, Mpigi, Masaka, Lyantonde, Kayunga, Sembabule and Kalangala). The program targets to provide ARV for PMTCT to at least 80% of HIV-infected pregnant women and 80% of the HIV exposed newborns; link 18 spheres to existing national frameworks and other partner organisations for drugs & other logistics management; train 26 district staff (DHO plus procurement focal persons) and 126 HC in-charges on forecasting, quantification, procurement and supply practices for medicines and other health supplies based on the HMIS data.

Description of service delivery or other activity carried out In FY 11 Mildmay Uganda will maintain a 4-month buffer stock of drugs for all existing 36,125 ART clients in the 13 districts to allow time for the district supply and procurement systems to become more effective. Technical support to DHS will be provided to forecast, quantify, procure & maintain buffer stocks of key items (e.g. ARV, TB drugs, septrin) to prevent stock outs.

Relation to the national program Mildmay Uganda will build the capacity of the DHS to procure nationally and internationally approved and cheaper ARV. To avoid stock-outs, Mildmay will support the DHS to forge functional linkages with the NMS. Mildmay will join the DHT for mentorship in planning, budgeting, resource mobilization, monitoring and supervision of health services. HC will be supported to accurately forecast, submit timely ARV drugs and supplies requisitions regularly to MoH procurement system and maintain local buffer stock.

1. Target populations and coverage of target population or geographic area Mildmay Uganda will offer technical assistance to develop the capacity of the District Health Services (DHS) in 13 districts of the Central region of Uganda (Wakiso, Mukono, Luwero, Nakaseke, Nakasongola, Mityana, Mubende, Mpigi, Masaka, Lyantonde, Kayunga, Sembabule and Kalangala) to effectively deliver integrated TB/HIV activities. In FY 2011, the project targets to screen 71070 HIV positive clients for TB and start 3554 on TB treatment.

2. Description of service delivery or other activity carried out The strategies that will be implemented include TB Infection Control and Intensified Case Finding. In TB infection control the measures include isolation of coughing patients and giving them priority in the clinic to reduce long waiting hours; provision of personal protective gear to patients to reduce air contamination from coughing patients; good infrastructural designs of the patient waiting areas and consultation rooms which aid in ensuring good natural air circulation and ventilation. For intensified case finding, districts will be supported to ensure early screening and diagnosis of TB amongst all clients during HCT, clinic visits and home visits (for contact tracing amongst household members of index TB patients); and early initiation of treatment for those diagnosed with TB. TB treatment and follow up using the DOTS strategy will be supported. A field TB focal person working together with the district TB officer will coordinate TB activities in the spheres. Support will be provided for Provider Initiated Counseling and testing in TB clinics and linkage to care and treatment. Directly Observed Treatment Short course for TB/HIV co infected clients will be supported.

3. Integration with other health activities Mildmay Uganda will promote and support the integration of TB/HIV care into other health services.

4. Relation to the national program Programs will be aligned to the national TB and TB/HIV policies and guidelines. All supported laboratories will participate in the National External Quality Assurance for sputum smear microscopy.

5. Health Systems Strengthening and Human Resources for Health Support will be provide to existing district health systems in provision of M&E, supervision, training and logistics for TB/HIV supplies and drugs