Strengthening decentralization for sustainability (SDS) is a USAID funded systems strengthening program aiming at improving local governments leadership and governance role in sustainable decentralized HIV/AIDS service delivery through:. Activities focus in 35 Districts in East, West, and Central Uganda, where its co-located with USAID district based technical assistance partners (DBTAs) like the strengthening tuberculosis and AIDS response (STAR) programs and strengthening the Uganda national response for implementation of services for orphans and other vulnerable children (SUNRISE) operate. SDS provides TA to local governments and service delivery grants. TA is centered on planning and resource mobilization for HIV, M/E, accountability for HIV program performance based on agreed district HIV service targets, enacting ordinances relevant to uptake of HIV services (e.g. delivery in health facilities) and community mobilization. Grants are focused on standardized operational costs for HIV services, district capacity building, and innovative projects across all 35 districts. Grants supplement district budgets for HIV prevention, PMTCT, care and treatment (including recruitment of health workers), M&E and OVC capacity building. Grants support district operational and administrative costs including fuel, communication, district transportation of lab samples to hubs, printing materials, district-led monitoring and mentorship, coordination and planning meetings, waste management, and community mobilization for HIV including outreaches. This is part of the larger aggregate comprehensive HIV support that DBTAs provide to districts. SDS scope strengthens district systems; improves responsiveness and accountability and promotes country ownership and alignment of support.

SDS will award service delivery grants to 35 districts where the STAR E, EC and SW programs operate and these will support districts in weekly transportation of CD4 and DBS samples to reference Labs and hubs where they exist. During FY 2013, SDS will additionally support the recruitment of critical health workers, including medical officers, clinical Officers, midwives, nurses, pharmacists, laboratory and strategic information officer cadre in its districts for both public and PNFP facilities based on the new scale up targets and the current staffing level, in the particular districts. A total of about 420 health workers shall be recruited by this mechanism in about 35 districts and include mainly doctors, nurses, midwives, clinical officers and dispensers. The additional human resources will support the districts to enhance their ability to enroll all the HIV positive clients identified through HTC, medical male circumcision, PMTCT and ensure retention over a long term. Funding for HRH will be managed by SDS with the local governments and in close collaboration with STAR SW, STAR E and STAR EC.

SDS will continue to provide 35 districts with Grants for service delivery support aimed at strengthening:1. coordination of district and sub-county OVC committees,2. support supervision and monitoring at sub county levels,3. OVC-Management information system (MIS),4. Referrals between different OVC service providers identified through the district mapping exercise5. district leaderships role in supporting child protection activities

These performance based grants will improve cross cutting issues that affect delivery of OVC interventions and direct integrated HIV/AIDS services that are necessary for improved health status of HIV infected and affected children and other vulnerable households. The OVC services shall be complimented by health services those are supported through USAID district based programs, the STAR programs. HIV services include EID, PMTCT, pediatric HCT, pediatric HIV care, and treatment including access to ARV drugs, HIV/TB care, psycho-social support and nutrition. SDS will facilitate districts to strengthen their role to coordinate stakeholders including all USAID implementing partners providing OVC services, and include other non-USG donor partners particularly those supporting HIV/AIDS, health, economic strengthening and OVC programs. Coordination meetings will enable the IPs to participate actively in the local government planning and budgeting processes, map out IP interventions and support in the development of district integrated work plans to minimize duplication. OVC activities for funding under performance based grants will be developed with the USAID OVC district based technical assistance program-SUNRISE.

SDS will also facilitate coordination meetings between all (health and HIV/AIDS) USAID implementing partners per district/region, and this will assist USAID partners to harmonize their roles and responsibilities, and identify opportunities for synergies especially in those program areas where services need integration. . SDS will facilitate all the 35 districts to receive Grant B which will focus on capacity building of districts. Key grant B activities include:1. in-service training for social services workforce,2. skills development for community based groups3. community based M &E (CBME).

As a strategy for improving cost efficiency and effectiveness of programs, performance of districts will be measured using performance based indicators and these will provide basis for grant disbursements. Although SDS does not directly implement activities that are specific to targeted service delivery in specific program areas, their activities support in improving the enabling environment necessary for achieving sustained results in HIV/AIDS as they complement efforts by service delivery partners like SUNRISE and STAR programs.

SDS will facilitate district TB supervisors and sub-country health workers to refer sputum samples for TB including suspected cases of MDR TB to regional and national referral Labs. SDS will also support Sub County Health Workers and health assistants follow up of HIV/TB co-infected patients not routinely returning for TB treatment at community level. In order to minimize loss to follow up, SDS grants will facilitate district TB nurses and community health workers to carry out Community Based-Directly observed treatment short course CB-DOTS. Districts will be supported to conduct quarterly integrated support supervision (District Health Teams to Health Sub Districts (HSD); HSD to lower level health facilities); and assisted to conduct TB/HIV coordination meetings both at the health sub-districts and district bi-annual reviews. The technical support for these services will be provided by the STAR programs that are co-located where SDS operates.

SDS will award service delivery grants to 35 districts where the STAR E, EC and SW programs operate and these will support districts in the weekly transportation of CD4 and DBS samples to reference Labs and hubs where they exist. SDS will additionally support the recruitment of critical health workers, including medical officers, clinical Officers, midwives, nurses, pharmacists, laboratory and strategic information officer cadre in its districts for both public and PNFP facilities based on the new scale up targets and the current staffing level. A total of about 420 health workers shall be recruited by this mechanism in 35 districts. This initiative will enhance the ability of lower level facilities to provide quality pediatric care and support services as the MOH scales up option B+. Funding for HRH will be managed by SDS with the local governments particularly in close collaboration with STAR SW, STAR E and STAR EC implementing partners.

In FY 2013, SDS is funded to contribute to SI pivot three Strong/robust basic M&E systems at service delivery points and districts, in over 35 districts. This will be through performance based grants for capacity building. SDS will facilitate districts to take lead to strengthen coordination of all implementing partners (IPs) supporting HIV/AIDS, health and OVC programs. Districts will be provided with a tool for mapping activities of IPs to enhance coordination, efficient planning, and effective use of resources. Coordination meetings will enable the IPs to participate actively in the local government planning and budgeting processes and support in the development of district integrated work plans.

In the past year , SDS conducted district baseline assessments (BA) and the results were disseminated to all districts in FY 2012. Districts have been guided to develop District Management Improvement Plans (DMIPS) that highlight district capacity building needs, priorities and gaps identified in assessments for improved service delivery. Proposed DMIPs interventions will be funded through performance based grants to districts. Grants will focus on capacity building of district leaders/health facility supervisors on financial management, leadership, governance, planning, Monitoring and Evaluation (M&E). Capacity building shall be tailored to address specific district needs identified from assessments to improve service delivery. As a strategy for improving cost efficiency and effectiveness of programs, performance of districts will be measured using performance based indicators and these will provide basis for subsequent grant disbursements. An M&E framework was revised in line with current program changes, and will provide a basis for setting grant performance criteria, evaluating and monitoring performance of districts and the overall program and providing feedback to stakeholders. SDS, and The Uganda Capacity Project and district staff will conduct a needs assessment in districts and support the recruitment and remuneration of key identify SI staff over the next three years, in the most needy districts, with the understanding that these staff will be transitioned to the government pay roll by year three. These staff will contribute to strengthening M&E systems at service delivery points and districts.

SDS, a systems strengthening project focusing at improving local Governments ability to mobilize, manage, and sustain resources for effective and efficient delivery of HIV/AIDS and OVC projects at district level. SDS will provide technical assistance (TA) in areas of coordination, leadership and governance, planning and budgeting, Ffnancial management, human resource management, monitoring and evaluation. SDS will also provide 35 districts with service delivery grants that support:1.district led support supervision and monitoring2.information systems ,3.coordination of key health/HIV stakeholders4.District / local government capacity building for better service deliveryThese performance based grants will improve cross cutting issues affecting delivery of high impact and evidence based HIV/AIDS services.. SDS will strengthen districts to coordinate USAID and donor partners supporting HIV/AIDS., and support IPs participation in local government planning and budgeting processes to facilitate harmonized district planning.Grant activities are developed with district leadership and implementing partners (STARs/SUNRISE projects).. District coordination meetings will assist in identifying synergies across program areas for better integration (PMTCT and MNCH). Last year, SDS conducted district baseline assessments and the results were used to develop district management improvement plans (DMIPS) that highlighted district capacity building needs, priorities and gaps relevant to service delivery. During FY 2013 proposed DMIPs interventions will be funded through Grants, with a focus on capacity building of district leaders/health facility managers on financial management, leadership, governance, planning, Monitoring and Evaluation (M&E).

As a strategy for improving cost efficiency and effectiveness of programs, performance of districts will be measured using performance indicators and these will provide basis for subsequent grant disbursements. An M&E framework was revised in line with current program changes, and will provide the basis for setting grant performance criteria, evaluating and monitoring performance of districts and providing feedback to stakeholders. Although SDS does not directly provide interventions that are specific to targeted service delivery in specific program areas, their activities support in improving enabling environment necessary for achieving the results in integrated HIV service provision as they complement efforts by service delivery partners like SUNRISE and STAR programs.

A new activity for SDS in this FY will entail support of the USG initiative to recruit and second health workers as part of its HRH strengthening support. This will focus in 35 districts where the USAID STAR E, EC and SW programs are operating. Approximately 420 health workers shall be recruited to support the scale up of PMTCT, care and treatment services in both public and private health facilities. SDS will work closely with the district local governments and the STAR programs through the district service commissions to facilitate the recruitment of these critical staff for improved services. At a minimum, each of the supported districts will have at least 12-16 seconded staff to boost human resources needed for quality and comprehensive health services including HIV service delivery. SDS will also support HRH performance reviews in districts of operation.

SDS program will contribute to HTC service delivery through district performance-based grants that increase access to and use of essential HIV counseling and testing services for key populations determined by existing data on HIV prevalence in the districts. SDS, through its district grants, will support the 35 districts to conduct HTC outreaches that focused on selected communities with high HIV prevalence.. SDS will also support health providers in the 35 districts to focus on couple testing campaigns, and outreaches for index client follow-up as identified from the provider initiated counseling and testing data. This will be complementary to targeted outreaches/camps supported by STAR programs for the other key populations (commercial sex workers, fisher folks, uniformed forces, truckers and others ). Clients identified through these testing approaches shall be connected to care and support services by linkage facilitators to ensure support throughout the HIV service and community responses (continuum of response).

Given that there are multiple players in the HIV response and the need for partnership, SDS will provide technical assistance to districts to improve their coordination of all the key players in HTC. This takes into account the important role of the Government of Uganda and USAIDs dedication to partnership with district local governments under stewardship of the Ministry of Health.

Lastly, SDS will support districts with their annual planning process. The results of the performance based grants will be used to hold districts accountable for HTC outputs and allow them to maximize program success by using program results in planning, decision making and resource allocation.

SDS, will work with the district political and technical leadership to promote other prevention services especially condoms. In the 35 districts of operation, SDS in collaboration with the USAID programs STAR E, EC and SW, will identify key district forums to promote the need for uptake and use of condoms among the affected communities. In particular, SDS will use the lot quality assurance survey (LQAS) generated data to guide the districts to know where there are potential hotspots in the districts that require more condom distribution points. SDS will work with the STAR programs and district political leadership to come up with ordinances that encourage hospitality industries to have condoms on a regular basis so as to increase access and facilitate use among those engaging in high risk sex. SDS will also work with the districts to identify influential leaders to be champions and these will promote behavior change among the communities, and support the national campaigns for voluntary medical male circumcision among other prevention.

SDS will provide performance based grants for HIV/AIDS service delivery including PMTCT in 35 districts of operation. The grants will support health workers from the 35 local governments to implement the following PMTCT services: facilitate EID transportation costs for the health workers from PMTCT sites to the labs/hubs; in the event of option B+ roll out, grants will facilitate district led on-site mentorship and supervision costs for district officials to visit each PMTCT site; facilitate PMTCT DQA activity costs for district and health sub-district PMTCT focal persons; and support districts to hold PMTCT quarterly performance reviews. The DBTAs (STAR projects) will provide the technical assistance and oversight for these grant activities and will be working closely with the districts and the ministry of health as they roll out option B+. In a few selected districts, the grants will facilitate monthly PMTCT outreaches by health sub-district PMTCT teams to high volume or hard to reach HCIIs not yet offering PMTCT but close to key population areas. Program support grants will support district leadership (political and technical) to develop ordinances and by-laws promoting delivery of women in facilities and strengthen enacting of these bylaws, in anticipation of national roll up of option B+.Only 55% of the health worker positions are filled against the norms in the districts. Human resources for health is critical for successful scale up of PMTCT services. During this COP, SDS will additionally support the recruitment of critical health workers, including medical officers, clinical Officers, midwives, nurses, pharmacists, laboratory and strategic information officer cadres in its districts for both public and private not for profit (PNFP) facilities based on the new scale up targets and the current staffing level, in the particular districts. A total of about 420 health workers shall be recruited by this mechanism in 35 districts. Funding for human resource for health (HRH) will be managed by SDS with the local governments in close collaboration with STAR SW, STAR E and STAR EC implementing partners.

SDS will provide comprehensive service delivery grants to the 35 local governments where the STARs operate and these will: support quarterly integrated support supervision (District health teams- DHT to Health Sub-district- HSD, and HSD teams to lower level HC IV and IIIs) to especially facilities providing treatment services that is critical for this planning period as option B+ is rolled out to the lower level facilities including H/C IIIs. This district site supervision will be done jointly with the technical assistance partners (STAR SW, E and EC). In addition, SDS will facilitate through the grants the district quality improvement mentorship teams and meetings at lower level facilities that are accredited to offer option B+ and ART. It will support onsite mentorship for ART by district mentors both in the old and newly accredited sites. The grants will also facilitate districts to hold coordination meetings to review program performance and assess progress of care and treatment services. Grants will also support the installation of treatment software at district hospitals for medicines and patient monitoring in selected districts identified by the MoH in collaboration with the STARs and SURE program.SDS will additionally support the recruitment of critical health workers, including medical officers, clinical Officers, midwives, nurses, pharmacists, laboratory and strategic information officers in its districts for both public and PNFP facilities based on the new scale up targets and the current staffing level. A total of about 420 health workers shall be recruited by this mechanism in 35 districts. Funding for HRH will be managed by SDS with the local governments particularly in close collaboration with STAR SW, STAR E and STAR EC implementing partners.

In terms of accountability, SDS will, in collaboration with the district local governments, the STAR programs, and other stakeholders, facilitate a quarterly district performance review meeting to ensure that bottlenecks to ART scale up are addressed. In this forum, districts will also account for funds disbursed through the grants and the outputs.

SDS will support the recruitment of critical health workers, including medical officers, clinical Officers, midwives, nurses, pharmacists, laboratory and strategic information officers for both public and PNFP facilities based on the new scale up targets and the current staffing level, in the particular districts. A total of about 420 health workers shall be recruited by this mechanism in 35 districts. Funding for HRH will be managed by SDS with the local governments particularly in close collaboration with STAR SW, STAR E and STAR EC implementing partners. This initiative will allow PEPFAR Uganda to scale up pediatric care and treatment along with the option B+ rollout.