Uganda Health Activity

Uganda Health Activity is sponsored by USAID/Uganda. USAID/Uganda seeks applications for a cooperative agreement to implement the Uganda Health Activity (UHA).

To: All Interested Organizations Subject: Uganda Health Activity Draft Notice of Funding Opportunity (NOFO) The United States Government, represented by the U.S. Agency for International Development Mission in Uganda (USAID/Uganda), seeks to inform interested organizations of the release of the draft Notice of Funding Opportunity for the planned integrated health funding activity, titled the Uganda Health Activity .

The proposed Uganda Health Activity aims to increase access to and use of quality healthcare services and improve the performance of the health system at subnational levels in priority districts. A draft NOFO is provided as Attachment 1.

Interested organizations are invited to provide comments on the whole NOFO but with special emphasis on Section D – Application and Submission Information, Section E – Application Review Information, and Section F Federal Award Administration Information. The draft NOFO does NOT commit USAID to consider or incorporate any received comments, issue a Notice of Funding Opportunity or make an award on the basis of this draft NOFO.

All response costs incurred in providing feedback to this NOFO are at the respondent’s expense. Please note that responding to this draft NOFO will not give any advantage to or preclude any organization or individual from responding to any Notice of Funding Opportunity (NOFO) that may be subsequently issued. If USAID releases a NOFO, it will be posted on www.

grants. gov . It is the potential applicant’s responsibility to monitor these websites for the release of further information and updates.

Applicants may submit up to three pages of responses or questions in Microsoft Word to this draft NOFO by email to kampalausaidsolicita@usaid. gov no later than the date and time shown below; Issuance Date: April 4, 2022 Response Due Date and Time: April 15, 2022, 5:00 p. m.

Washington, D. C. time (EST)10:00 a.

m. Kampala time Response Email Address: kampalausaidsolicita@usaid. gov Do not submit any applications at this time.

Information received in response to this draft NOFO will become the property of USAID. Therefore, information that cannot be shared should not be sent. Please note that respondents will not receive individualized feedback on their submission.

USAID may revise the draft NOFO based on comments received but is not obligated to do so. Thank you for your interest in USAID programs and we look forward to receiving your feedback on the draft NOFO.

Supervisory Agreement Officer Attachment 1: Draft Notice of Funding Opportunity USAID/Uganda Health Activity Attachment 1 to Cover letter: Draft NOFO USAID/Uganda Health Activity Subject: Draft Notice of Funding Opportunity (NOFO) USAID/Uganda Health Activity Program Title: USAID/Uganda Health Activity (UHA) Federal Assistance Listing Number: 98.

001-- USAID Foreign Assistance for Programs Overseas To all interested Organizations: This is a DRAFT Notice of Funding Opportunity. See the cover letter for feedback submission details. An official Notice of Funding Opportunity will be published with associated due dates at a later time.

The United States Agency for International Development (USAID) Mission in Uganda (USAID/Uganda) is seeking applications for a cooperative agreement from qualified entities to implement the Uganda Health Activity (UHA). This draft funding opportunity is authorized under the Foreign Assistance Act of 1961, as amended.

The resulting award will be subject to 2 CFR 200 – Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, and USAID’s supplement, 2 CFR 700, as well as the additional requirements found in other Sections of this Subject to the availability of funds, USAID intends to provide up to $170 million, to be allocated over the five-year period.

USAID reserves the right to fund any or none of the applications submitted. Eligibility for this award is not restricted. USAID intends to make an award to the applicant(s) who best meet(s) the objectives of this funding opportunity based on the merit review criteria described in this NOFO and subject to a risk assessment.

Eligible parties interested in submitting an application are encouraged to read this NOFO thoroughly to understand the type of program sought, application submission requirements, and selection process. To be eligible for award, the Applicant must provide all information as required in this NOFO and meet eligibility standards in Section C of this NOFO. This funding opportunity is posted on www.

grants. gov , and may be amended. This NOFO and any future amendment can be downloaded from https://www.

grants. gov. Select “Find Grant Opportunities,” then click on “Browse Agencies,” and select the “Agency for International Development” and search for the NOFO. It is the responsibility of the Applicant to regularly check the website to ensure they have the latest information pertaining to this notice of funding opportunity and to ensure that the NOFO has been received from the internet in its entirety.

USAID bears no responsibility for Attachment 1 to Cover letter: Draft NOFO USAID/Uganda Health Activity data errors resulting from transmission or conversion process. If you have difficulty registering on www. grants.

gov or accessing the NOFO, please contact the Grants. gov Helpdesk at 1-800- 518-4726 or via email at support@grants. gov for technical assistance.

Any questions regarding this NOFO must be submitted in writing to KampalaUSAIDSolicita@usaid. gov. Questions sent to any other email address will not be answered. The email transmitting the questions must reference the NOFO number and title on the subject line of the e-mail .

Responses to questions received prior to the deadline will be furnished to all potential Applicants through an amendment to this notice posted on If you decide to submit an application, please note that electronic submission is required. Applications are to be sent as email attachments to KampalaUSAIDSolicita@usaid. gov , to the attention of Agreement Officer, Ms. Andreea Surdu.

Late applications will not be considered for award. Hard copy or fax applications are not authorized for this NOFO and will not be accepted. USAID may not award to an Applicant unless the Applicant has complied with all applicable unique entity identifier and System for Award Management (SAM) requirements detailed in Section D.

The registration process may take many weeks to complete. Therefore, Applicants are encouraged to begin registration early in the process. An Applicant under consideration for an award that has never received funding from USAID may be subject to a pre-award survey to determine financial responsibility, capacity, and ensure the adequacy of financial controls.

Issuance of this notice of funding opportunity does not constitute an award commitment on the part of the United States Government (USG) nor does it commit the USG to pay for any costs incurred in preparation or submission of comments/suggestions or an application. Applications are submitted at the risk of the applicant. All preparation and submission costs are at the applicant’s expense.

In addition, the final award of any resultant grant cannot be made until funds have been fully appropriated, allocated, and committed through internal USAID procedures. While it is anticipated that these procedures will be successfully completed, potential applicants are hereby notified of these requirements and conditions for the award. Thank you for your interest in the USAID/Uganda Health Activity.

USAID/Uganda Attachment 1 to Cover letter: Draft NOFO USAID/Uganda Health Activity Table of Contents ................................................................................................ ............................ 3 SECTION A: PROGRAM DESCRIPTION ................................................................

................... 4 SECTION B: FEDERAL AWARD INFORMATION ................................................................. 42 SECTION C: ELIGIBILITY INFORMATION ...........................................................................

50 SECTION D: APPLICATION AND SUBMISSION INFORMATION ..................................... 52 SECTION E: APPLICATION REVIEW INFORMATION ........................................................ 74 SECTION F: FEDERAL AWARD ADMINISTRATION INFORMATION..............................

78 SECTION G: FEDERAL AWARDING AGENCY CONTACT(S) ............................................ 93 SECTION H: OTHER INFORMATION .....................................................................................

94 ATTACHMENT A: APPLYING LESSONS LEARNED FROM THE REGIONAL HEALTH INTEGRATION TO ENHANCE SERVICES (RHITES) DESK REVIEW TO UGANDA HEALTH ACTIVITY DESIGN ...................................................................................................

96 ATTACHMENT B: PRIORITY PEPFAR DISTRICTS AND CITIES/MUNICIPALITIES FOR IR 3 HSS SUPPORT..................................................................................................................... 99 ATTACHMENT C: BUDGET TEMPLATE - See separate attachment. ..................................

100 ATTACHMENT D: CERTIFICATIONS, ASSURANCES, REPRESENTATIONS, AND OTHER STATEMENTS OF THE RECIPIENT ........................................................................ 100 ATTACHMENT E: PAST PERFORMANCE INFORMATION - See separate attachment. ...

100 ATTACHMENT F: STANDARD PROVISIONS ..................................................................... 100 ATTACHMENT G: USAID/UGANDA LOCAL COMPENSATION PLAN (LCP)- attached separately. ...................................................................................................................................

103 ATTACHMENT H: LDPG REVISED SCHEDULE OF ALLOWANCES (March. 2019) -attached separately. .....................................................................................................................

103 ATTACHMENT I: UGANDA HEALTH ACTIVITY REFERENCES .................................... 104 Attachment 1 to Cover letter: Draft NOFO USAID/Uganda Health Activity SECTION A: PROGRAM DESCRIPTION AGYW Adolescent Girls and Young Women IYCD Integrated Child and Youth Develop.

Activity AMELP Activity Monitoring and Evaluation Plan KCHS Keeping Children Healthy & Safe ANC Antenatal Care LARC Long Acting and Reversible Contraception AOR Agreement Officer’s Representative LMIS Logistics Management Information System ARV Antiretroviral M&E Monitoring and Evaluation CBO Community-Based Organization MCHN Maternal, Child Health, and Nutrition CCA Clean Clinic Approach mCPR Modern Contraceptive Prevalence Rate CDCS Country Development and Cooperation Strategy MEL Monitoring, Evaluation, and Learning CHEW Community Health Extension Worker MIYCAN Maternal, Infant, Young Child, and Adolescent Nutrition CHW Community Health Worker MNCH Maternal, Newborn, and Child Health CLA Collaborating, Learning, and Adapting MOH Ministry of Health COP Chief of Party MPDSR Maternal and Perinatal Death Surveillance and Response CQI Continuous Quality Improvement NDP III National Development Plan III DHO District Health Office NGO Non-Governmental Organization DHMT District Health Management Team NHP III National Health Policy III DO Development Objective NOFO Notice of Funding Opportunity DRM4D Domestic Resource Mobilization for Development PHC Primary Healthcare Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe PMI President’s Malaria Initiative EBF Exclusive Breastfeeding PNC Postnatal Care ECD Early Childhood Development PNFP Private Not-for-Profit EMR Electronic Medical Record PUMRA PMI Uganda Malaria Reduction Activity F&A Finance and Administration QI Quality Improvement FBO Faith-Based Organization RBF Results-Based Financing FP Family Planning RH Reproductive Health FPA Family Planning Activity RHITES Regional Health Integration to Enhance Services G2G Government-to-Government RMNCAH Reproductive, Maternal, Newborn, and Adolescent Health GBV Gender-Based Violence RRH Regional Referral Hospitals GF Global Fund SBC Social and Behavioral Change GOU Government of Uganda SBCA Social and Behavioral Change Activity HC Health Center SCAPP Standards, Compliance, Accreditation, and Patient Protection HCW Healthcare Worker SITES Strategic Information Technical Support HMIS Health Management Information System TA Technical Assistance HRH Human Resources for Health TB Tuberculosis HRIS Human Resource Information System TBD To Be Decided HSS Health Systems Strengthening UDHS Uganda Demographic and Health Survey HUMC Health Unit Management Committee UHA Uganda Health Activity ICARE Improving Care and Resilience for Children and Youth in Eastern Central UHSS Uganda Health Systems Strengthening iCCM Integrated Community Case Management ULA Uganda Learning Activity IEE Initial Environmental Examination UNHLDS Uganda National Health Laboratory & Diagnostics Services IFMS Integrated Financial Management System USAID U.S. Agency for International Development IHSD Integrated Health Service Delivery USG United States Government IP Implementing Partner VHT Village Health Team IPC Infection Prevention and Control WASH Water, Sanitation, and Hygiene IR Intermediate Result Attachment 1 to Cover letter: Draft NOFO USAID/Uganda Health Activity SECTION A: PROGRAM DESCRIPTION USAID/Uganda seeks to award a five-year, approximately $170 million cooperative agreement to improve overall health system resilience and to increase the survival and well-being of vulnerable populations in priority districts.

As an integrated activity across multiple health sectors, UHA will achieve this goal through three intermediate results (IRs): 1) Improved access to and use of quality health services at the community and health facility levels. 2) Enhanced local ownership and leadership for sustainable health outcomes. 3) Strengthened health systems at the regional, district, facility, and community levels.

UHA will focus its activities primarily at the regional level and below, strengthening the quality and availability of maternal, newborn, and child health (MNCH), family planning (FP)/reproductive health (RH), nutrition, and facility-level water, sanitation, and hygiene (WASH) services in a subset of up to 30 focal districts surrounding the seven regional referral hospitals (RRHs) in Gulu, Jinja, Kabale, Lira, Mbale, Mbarara, and Moroto, building on the investments in HIV/AIDS services made by PEPFAR and other USG investments to date.

HIV/AIDS services are a large part of UHA. They feature prominently under IR1 (under quality improvement [QI] efforts) and IRs 2 and 3, where UHA will provide additional district-level health systems strengthening (HSS) technical assistance (TA) in a further 72 districts and cities/municipalities where PEPFAR local implementing partners (IPs) operate.

UHA will provide TA to local IPs to help enhance HIV/AIDS outcomes and their sustainability. UHA marks a strategic shift in USAID’s previous integrated health support. It builds on promising practices identified from recent USAID Regional Health Integration to Enhance Services (RHITES) programming, while incorporating new elements of integration and local ownership.

Community-led and locally owned service delivery is a core element of UHA. The activity includes a greater focus on building the capacity, sustainability, and resilience of local governments and local partner institutions to deliver evidence-based and high quality MNCH, FP/RH, nutrition, facility-level WASH, and HIV/AIDS services at both facility- and community-levels.

This greater focus reflected in part through UHA’s concentration on strengthening the capacity of RRHs to fulfill their technical oversight and health QI mandate in line with Government of Uganda (GOU) objectives and to coach local PEPFAR IPs to more effectively lead epidemic control responses.

Increased coordination and functional collaboration will be critical to success in implementing UHA, given the interlocking nature of USG health investments.

As detailed in Section A5, expected collaboration includes work with 1) Specific PEPFAR local IPs and GOU RRHs in priority sub-regions (leveraging USG government-to-government [G2G] investments); 2) Above-site USAID national health mechanisms; and 3) Allied multi-sectoral development programming, such as food security, livelihoods, resilience, and women’s empowerment activities.

UHA fully aligns with and supports the GOU’s ambitious goals for improved health outcomes and decentralization, as outlined in the new third National Health Policy (NHP III). The activity will also accelerate progress toward three Development Objectives within USAID/Uganda’s Country Development Cooperation Strategy (CDCS) (see Section A3).

Uganda has succeeded in accelerating reductions in maternal, newborn, and child mortality during the past decade, despite resource gaps and health systems stressors. The Ministry of Health (MOH) expanded coverage of high-impact primary health care (PHC) interventions in all regions during this ten-year period.

Nearly all pregnancy and birth-related indicators improved during 2016-2019, including uptake of antenatal care (ANC), facility-based delivery, and post-natal care (PNC). 1 Full immunization coverage > 1 MOH. Endline Review of the Investment Case for RMNCAH Sharpened Plan in Uganda, 2015/16-2019/20 .

June 2020. Attachment 1 to Cover letter: Draft NOFO USAID/Uganda Health Activity also increased from 59 percent to 64 percent. As a result, under-five mortality declined from 90/1,000 live births to 64/1,000 live births from 2011-2016, 2 and institutional maternal mortality appears to be falling.

3 The MOH’s vision for universal health coverage and health sector decentralization has helped enable the progress described above by spurring GOU to commit to increase the availability of high-quality health care at the community-level. The GOU’s new Parish Development Model offers further potential for achieving health and socio-economic transformation among households living in the last mile.

USAID’s accompanying MNCH, FP/RH, nutrition, WASH, HIV, and tuberculosis (TB) health investments— including RHITES and above-site HSS activities—have helped drive concurrent service delivery and systems-focused improvements. Yet despite the momentum, MNCH, FP/RH, and nutrition progress remains far below National Development Plan III (NDP III) 2024/25 targets. Maternal mortality remains very high at 336 deaths/100,000 live births.

4 Neonatal mortality is largely stagnant and accounts for 42 percent of all under-five deaths. Only 31 percent of health centers have basic water services and 12 percent have basic sanitation, inhibiting effective infection prevention and control (IPC) and quality of care outcomes.

5 Nearly half of children under five years and a third of women of reproductive age are anemic, 6 increasing their respective risk for impaired cognitive and social functioning and adverse pregnancy and birth outcomes. Little progress has been made on increasing exclusive breastfeeding and dietary diversity of children. 7 While the modern contraceptive prevalence rate (mCPR) increased from 24.

6 percent to 30. 4 percent among all women between 2015 and 2020, 8 adolescent childbearing has decreased little due to harmful gender and sociocultural norms and economic challenges. The COVID-19 pandemic threatens to reverse progress.

Studies showed sharp declines in MNCH, FP/RH, and nutrition service delivery and uptake and corresponding increases in maternal and under-five morbidity and mortality, likely due to delayed care-seeking behavior. 9 HIV in Uganda is on track to epidemic control in the 90-90-90 cascade.

While there are still areas of improvement needed—particularly in HIV prevention, case finding, and viral load suppression—Uganda has made significant HIV progress and is now considered to be one of six countries globally close to achieving epidemic control. PEPFAR and the GOU are now focused on sustaining this progress.

Health progress remains uneven and fragile across UHA sub-regions, reflecting inequities in access to quality care and largely dysfunctional subnational health systems. Health improvement efforts remain largely fragmented at both district and community level and with different providers working in parallel to the MOH.

Rising internal insecurity, coupled with the continued threat of COVID-19 resurgences, may further strain Uganda’s heavily donor-dependent health system and contribute to backsliding. > 2 UBOS and ICF. Uganda Demographic and Health Survey 2016 .

2018. > 3 Institutional maternal mortality was below 100 per 100,000 health facility deliveries in 2019 according to DHIS2 data, but data on maternal death audits showed higher mortality. > 4 UBOS and ICF.

Uganda Demographic and Health Survey 2016 . 2018. > 5 WHO and UNICEF.

WASH in health care facilities: Global Baseline Report . 2019. > 6 MOH.

Endline Review of the Investment Case for RMNCAH Sharpened Plan in Uganda, 2015/16-2019/20 . June 2020. > 7 UBOS and ICF.

Uganda Demographic and Health Survey 2016 . 2018. > 8 FP2020.

Uganda Core Indicator Summary Sheet: 2019-2020 Annual Progress Report . 2020. > 9 Burt JF, et al.

Indirect effects of COVID-19 on maternal, neonatal, child, SRH services in Kampala . BMJ Global Health. 2021.

Attachment 1 to Cover letter: Draft NOFO USAID/Uganda Health Activity USAID/Uganda is committed to supporting the GOU to successfully operationalize and achieve its transformative vision of a healthy and productive population that contributes to socio-economic growth and national development.

Aligned to the five NHP III priority areas, UHA is designed to help communities and the GOU increase access to evidence-based preventive and curative PHC services. USAID expects that the UHA awardee will incorporate and build upon lessons learned from the past five-plus years of implementation of its suite of five RHITES activities, implemented in Southwest, East, East-Central, North-Lango, and North-Acholi regions.

These activities, which will reach completion in 2023, aim to enhance integrated health services for HIV, malaria, TB, MNCH, FP/RH, and nutrition. The RHITES activities also supported the transition of HIV epidemic control service delivery activities to new local IPs in each region to increase sustainability. USAID/Uganda expects that UHA will successfully transition relevant RHITES activities, while adding new elements.

In July 2021, USAID/Uganda’s Office of Health and HIV commissioned the Uganda Learning Activity (ULA) to conduct an in-depth desk review of the RHITES activities to inform UHA design. The review identified five key barriers and five key facilitators to success, which USAID/Uganda expects the UHA awardee will adopt or scale-up in UHA.

Among the expectations, UHA should: ● Adopt an HSS focus to complement facility-level interventions, including interventions to strengthen supply chain management and coordination at district- and community levels. Improve district- and community-level data quality, collection, and use capacity, including integrating community data within the health management information system (HMIS).

● Strengthen local capacity to design and scale-up the implementation of gender-sensitive and gender-transformative interventions to address underlying health inequities. ● Stimulate community and provider behaviors that encourage health-seeking behaviors. ● Expand subnational leadership and governance interventions at RRHs and district-level.

Increase functional collaboration at community level between UHA and non-health activities (e.g., those working on food security, economic growth, education, or youth). Please see Attachment A for the full list of ten barriers and facilitators identified through the RHITES program review.

Relevant additional bottlenecks to be addressed by UHA include: 1) Challenge: One-size-fits-all TA fails to help districts adapt and deploy health interventions appropriate for their local context. UHA priority sub-regions each feature unique epidemiological, health system, socio-cultural, economic, and environmental characteristics that necessitate customized TA.

Karamoja and Acholi sub-regions, for example, each feature higher stunting rates than their counterparts nationally, indicating need for increased attention to multi-sectoral interventions. Districts require more tailored mentorship based upon their local needs. This will ensure districts can use data more effectively to customize and resource their annual work plans based upon local context.

2) Challenge: Health facilities struggle to operationalize QI and achieve improved quality of care. USAID and GOU programs have succeeded in building health care worker (HCW) skills in MNCH, FP/RH, nutrition, and IPC. Yet prematurity, sepsis, and asphyxia still remain leading causes of maternal and infant death in most regions.

Districts and health facilities require support in scaling-up and institutionalizing HIV QI efforts and expanding them to address quality of care gaps in MNCH, FP/RH, nutrition, and facility-level IPC performance. In addition, many facilities require support in the development of a local QI culture and in operationalizing innovative local quality of care change ideas.

3) Challenge: Priority sub-regions and their surrounding districts vary in their ability to fully plan, coordinate, resource, and sustain PHC interventions. Hands-on clinical skills building alone is insufficient to create lasting improvements in service availability and quality of care. Target sub-regions and districts require high-impact HSS TA to accelerate progress toward and sustain health outcome achievement.

While decentralization reforms are underway via the MOH’s RRH-focused Hub and Spoke Attachment 1 to Cover letter: Draft NOFO USAID/Uganda Health Activity Model, 10 most RRHs and their corresponding districts do not have the planning, data, or domestic financing capacity to lead a PHC response in the absence of partners, impeding progress toward the full health leadership envisaged by the NDP III.

Critical district sustainability barriers include gaps in 1) planning and coordination; 2) supply chain management; 3) data collection, analysis, and use to drive decision-making; 4) health workforce performance and management; and 5) health financing. In addition, many health facilities require remodeling and refurbishment to meet minimum MNCH and facility-WASH infrastructure standards and reinforce quality of care.

4) Challenge: Districts struggle to engage communities effectively in health promotion, service delivery, and oversight. Despite recent robust policies, districts face challenges in delivering health services that are accountable and responsive to client needs. Community participation is frequently absent in district and health facility planning and review processes, weakening accountability and feedback on health service delivery.

Health Unit Management Committees (HUMCs) are promising mechanisms to facilitate community engagement, but they face representation, capacity, and funding limitations. In addition, districts require greater TA in designing, adapting, and scaling social and behavioral change (SBC) interventions that increase uptake of positive health behaviors and drive facility-level care seeking.

5) Challenge: Community PHC service delivery requires scale-up. Community service delivery and self-care interventions offer great promise for increased coverage and promotion of positive health behaviors. Yet community health service delivery challenges are acute, including in the motivation, remuneration, training, and supervision of community volunteers.

Despite a goal of two functioning village health teams (VHTs) per village, many districts fail to reach that threshold. While the President's Malaria Initiative (PMI) has begun scaling-up integrated community case management (iCCM) in 13 high burden districts, coverage is uneven. 11 Those VHTs that do exist must deliver an ever-expanding menu of integrated health services and messages.

To address these issues, the MOH has announced the planned roll out of a Community Health Extension Worker (CHEW) program and has increasingly prioritized community health activities. 6) Challenge: PEPFAR local IPs require tailored technical support to realize their full program management and service delivery functions.

While the RHITES activities are transitioning out of direct service delivery, many recipients local IPs (see Sub-IR 2. 5) possess varied organizational management, technical capacity, and operational gaps that will impede them from achieving and sustaining their targets. PEPFAR local IPs generally work in geographic silos, due in part to the nature of the segmented RHITES awards.

This prevents the sharing of local HIV innovations across geographies and IPs. Harnessing previous learning and the ingenuity, innovations, and persistence of Ugandan HCWs, local partners, and communities will be critical to surmounting the challenges above and creating a more responsive and resilient community health system.

Leading opportunities under UHA include: ● Leveraging the RRH platform to play a critical role in decentralizing health services and providing technical supportive supervision, in alignment with GOU strategy 12 and PEPFAR G2G investments. ● Enhancing functional collaboration between UHA and USAID’s above-site health investments and district-level multi-sectoral programming, including the new Parish Development Model.

● Facilitating active collaboration, learning, and adapting (CLA) among local IPs to ensure best practices are shared across different regions. > 10 USAID-SITES. Reviewing Uganda’s Health System Hub and Spoke Models: September 2018 .

Unpublished manuscript. > 11 MOH/GF/PACE. Implementation of iCCM Study in Uganda .

PowerPoint. Jan. 2021.

> 12 MOH. Comprehensive Supportive Supervision Strategy for the Health Sector, July 2020-June 2025 . 2020.

Attachment 1 to Cover letter: Draft NOFO USAID/Uganda Health Activity ● Leveraging results-based financing (RBF) and Global Fund (GF) funding and domestic resource mobilization efforts to meet infrastructure, human resource, and supply chain gaps, gradually transitioning away from reliance on donor and out-of-pocket funding.

● Scaling successful COVID-19 adaptations and innovations that enhanced continuity of MNCH, FP/RH, nutrition, facility-level WASH, and HIV services. Inadequate access to and use of quality health care, combined with poor health-seeking behaviors and a sub-optimally performing PHC system, leads to inequitable health and nutrition outcomes.

This compromises Uganda’s ability to scale quality health care and sustainably improve the health of its population. UHA seeks to address these challenges and achieve its activity purpose to improve health system resilience in priority districts and to increase the survival and well-being of vulnerable populations.

USAID’s vision is that the Ugandan government, local partners, and communities achieve and sustain transformative health outcomes for Uganda’s most vulnerable. This is reflected in the UHA theory of change (Figure 1), which articulates a change pathway that will contribute to the achievement of the UHA purpose.

Figure 1: UHA Theory of Change UHA’s three foundational theory of change pillars—increased health access and quality, enhanced local ownership, strengthened local health systems—and their associated interventions will contribute to continual availability of respectful and patient-centered care for women, adolescents, children, and their families at the both facility- and community-levels.

The theory of change relies on several important ● UHA coordinates with and collaborates successfully with national-level health mechanisms and with IPs and RRHs in priority districts to scale-up high impact interventions (see Section A5).

Attachment 1 to Cover letter: Draft NOFO USAID/Uganda Health Activity ● PEPFAR local IPs and RRHs, districts, facilities, and communities demonstrate readiness and commitment to assume ownership and financing of UHA interventions. ● RRHs and district health offices (DHOs) understand and operationalize their roles and accountabilities related to continuous quality improvement (CQI), reporting, governance, and supportive supervision.

● USAID’s technical and financial support enhances the enabling environment for health improvements, including local health governance. ● The GOU maintains its commitment to and investment in HIV, MNCH, FP/RH, nutrition, and facility-level WASH service delivery. ● Uganda’s political, economic, and COVID-19 epidemiologic situation remains stable.

Aligned to the theory of change, the UHA Results Framework (Figure 2) depicts the three foundational IR and sub-IRs required to achieve the UHA purpose. UHA’s IRs and sub-IRs are intended to be mutually reinforcing. Each proposed IR and associated interventions at the regional, district-, facility- and community-levels will contribute to the increased survival and well-being of priority populations and improved health system resilience.

13 For example, TA under IR 3 will support the development of more resilient and responsive local health care systems that are increasingly capable of planning, financing, and implementing high quality and integrated HIV, MNCH, FP/RH, nutrition, and facility WASH/IPC health interventions (supporting IR 1). USAID/Uganda expects continual interplay across IRs and sub-results to inform UHA implementation.

For the purposes of planning and budgeting, USAID/Uganda estimates the following levels of effort across IRs: IR 1 (50%), IR 2 (20%), and IR 3 (30%). Throughout, continuous learning and adaptation will be critical to ensuring UHA activities stay nimble, and pivot appropriately based on local operating context. UHA will support health systems and communities to use available data for decision-making and to drive results and investment.

It will also test and support the scale-up of innovative and impactful MNCH, FP/RH, nutrition, HSS, HIV, and local capacity building interventions as well as peer-to-peer learning, as described in Section A4. Alignment with USAID/Uganda CDCS (2016-2021) USAID’s current CDCS strives to support Uganda in accelerating advancements in inclusive education, health, and economic development.

UHA will support results under each of the CDCS’ three primary development objectives (DOs), strengthening Ugandan-led inclusive and sustainable development throughout. UHA interventions will contribute to following CDCS DOs and IRs: ● DO1: Community and household resilience in select areas and target populations increased (IR 1. 3: Enhanced prevention and treatment of HIV, malaria, and other epidemics).

● DO2: Demographic drivers affected to contribute to long-term trend shift (IR 2. 1: Adoption of healthy reproductive behaviors and practices increased; IR 2. 2: Child well-being improved).

● DO3: Key systems more accountable and responsive to Uganda’s development needs (IR 3. 1: Leadership in development supported; IR 3. 3: Key elements of systems strengthened).

> 13 Please review USAID’s Vision for Health Systems Strengthening 2030 for additional information on guidance on USAID’s objectives and approaches in relation to health system resilience.

Attachment 1 to Cover letter: Draft NOFO USAID/Uganda Health Activity As part of adaptive management, USAID/Uganda expects the UHA awardee will ensure implementation aligns with the forthcoming USAID/Uganda CDCS 2022-2025 upon its anticipated release in June 2022.

Implementation Approach and Geographic Focus UHA will operate primarily at the sub-national level 14 to support achievement of its objectives, providing TA to RRHs and districts to scale-up priority high-impact health interventions and HSS initiatives in priority districts. Specifically, UHA will assist the MOH to operationalize its “Hub and Spoke” model for health systems decentralization.

Under this strategy, RRH, Community Health Departments provide technical supportive supervision to lower-level health facilities (especially to Health Center [HC] IV and general hospitals), serve as hubs for skills transfer, and as referral hubs from lower levels for tertiary and specialized care. UHA will center its service delivery and HSS TA