UNIVERSIDAD DE LA REPÚBLICAFACULTAD DE ENFERMERÍA Factores que inciden en el consumo de psicofármacos en el personal de enfermería de una institución médica del interior del Uruguay Br. Alvarez, Catalina Br. Lapido, Soledad Br. Lorduguin, Florencia Br. Mantuani, Flavia M Prof. Agda. Esp. Lic. Enf. Garay, Margarita Prof. Agdo. Mg. Lic. Enf. Díaz, Álvaro
LINK UP UGANDA END OF PROJECT
Community Health Alliance Uganda (CHAU)
Postel Building, Plot 67, Clement Hill Road,
P.O. Box 10207, Kampala, Uganda
Mobile: +256 (0) 752-790 594/078-2-439037
With profound gratitude we acknowledge all the staff of Community Health Alliance Uganda
(CHAU) under the leadership of Mr. Bharam Namanya for the keen interest in this evaluation that they exhibited. From the Inception Phase to final completion of this Evaluation, CHAU staff particularly Dr. David Bitira and Dr. Rodgers Ampwera did not relent in providing all the information the Consultant needed, guidance and feedback. We are extremely grateful to all CHAU's Implementing Partners (IPs) for their active participation in this Evaluation. To all the Young People (YP) who participated in this study, we owe you immense gratitude. Finally, but not least, with gratitude we recognise and acknowledge our Research Assistants who collected data. List of Acronyms and Abbreviations
Community Health Alliance Uganda Continuous Medical Education Civil Society Organisation District Health Officer Focus Group Discussions Female Sex Workers Gender-Based Violence HIV Counselling and Testing Health Sector Strategic Investment Plan Information, Education and Communication Implementing Partners Key Infromant Interview Monitoring and Evaluation Most at Risk Population Initiative Ministry of Health MarieStopes International Uganda Men who have Sex with Men National Strategic Plan Sexual and Reproductive Health and Rights Sexually Transmitted Infections Terms of Reference Uganda AIDS Commission Table of Contents
List of Tables and Figures
List of Figures
In May 2016, Community Health Alliance Uganda (CHAU) commissioned an End of
Project Evaluation to assess the extent to which the three and half year (2013-2016) Link
UP Project achieved its goal and objectives. CHAU working with over 190 service delivery
points including public and private health facilities across 12 districts of central and eastern
Uganda (Kampala, Mukono, Wakiso, Luwero, Nakasongola, Kayunga, Jinja, Iganga, Kamuli, Mayuge, Namutumba, and Bugiri implemented a Project targeting young people (YP) 10— 24 years affected by HIV. The Project sought to achieve better sexual and reproductive health and rights (SRHR) for young people and strengthen the capacity of service providers to deliver quality integrated SRHR/HIV services and information. The targeted key population included YP living with HIV; Young people involved in sex work, young people in transport (truckers, boda bodas/motorcycle riders); fisher folks, slum dwellers, teenage mothers, young men who sex with men (MSM); and other vulnerable young people. This End of Project Evaluation drawing from qualitative and quantitative data collected from six out of the 12 districts confirmed the limitations of integration of HIV with SRHR prior to Project implementation. Upon completion of the Project, most gaps in reaching young people with customized HIV and SRHR services and information had been bridged. Health workers' capacity and skills to provide youth friendly integrated SRHR/HIV services and health facilities were either built or enhanced by the Project. The occasional suffered stock-outs of SRH/HIV commodities and products to a larger measure were addressed during the period of Project implementation. Several young people including FSWs, MSM, fisher folk, truckers and boda boda cyclists that often found it difficult to seek SRHR/HIV services from health facilities freely sought the services as a result of empowerment by the Project and easy access to services. The Evaluation results revealed increased adoption of safer sexual practices to avoid HIV infection such as using condoms among young people, maintaining faithfulness among those with partners, using contraceptives/family planning methods (condoms, injectables and oral contraceptives) by sexually active YP to avoid getting pregnant or transmit HIV to their partners. A high level of self-efficacy on use of contraceptives, correct and consistent use of condoms to prevent HIV/STI transmission, getting tested for HIV and resisting peer pressure was equally high. Confidence among YP to seek condoms, HIV testing and STI treatment services from health facilities increased. Establishment of youth friendly corners by the Project in participating health facilities, as well as youth friendly services in facilities where corners were non-existent increasingly brought HIV/SRHR services closer to young people. The Project's effectiveness can further be seen in the capacity of partner NGOs/CSOs to create monitoring and reporting systems to aid the documentation and response to cases of human rights abuses against young people especially among FSWs and YPLHIV. Inputs procured by the Project were largely well utilized to achieve the desired outputs and outcomes. Work plans and budgets for activities were jointly developed by CHAU, MSIU and the implementing partners, although their execution was sometimes not undertaken according to plan. Delays in release of Project funds most notably in the first quarter of 2015 affected the originally planned logical flow of events and activities. Despite these challenges, the Project registered noticeable achievements especially on quantifiable targets. The Project reached 297,439 and 98,597 young people affected by HIV with integrated SRHR/HIV services of targeted 290,000 and of 30,000 in community and facility based settings respectively; mentored and supported 548 service providers to provide integrated SRHR/HIV services to young people; and reached 3,060 young people with friendly and appropriate services. It is worth noting that efforts were made by the Project to initiate engagements with stakeholders at international, national and lower levels; Global Fund, UNFPA, UNAIDS, MoH, UAC, District technical and political actors, as well as international and national level NGOs promoting the rights of young key populations. Engaging deeply with district and lower level partners at health facilities promises sustainability of Project activities. Thus, the Project's implementation approach through existing infrastructure, local partners/ personnel e.g., peers of KPs is likely to ensure some level of continuity. After Project closure some peer educators (PEs) have continued to disseminate information even though their activities tend to be limited to peers within their localities due to phased out facilitation, among other, challenges. In some areas e,g., Iganga and Bugiri, PEs were linked to other new projects in the areas. The established collaboration with the district technical staff such as health workers and political offices represents a potential for sustainability of Project activities. The involvement of district leaders particularly the District Health Office (DHO), adopting a multi-faceted approach involving both community and facility based approaches and use of edutainment in the mobilization of the target community; all ensure some level of continuity. The achievements, notwithstanding, the Project suffered some constraints and limitations apart from the occasional delays in release of project funds to IPs. These included inadequate stock and sometimes stock-out of HIV test kits, condoms, contraceptives and STI drugs at health centers, retention of PEs, heavy workload, occasional transfers of trained health workers in public health facilities, stigma and discrimination especially among young people living with HIV/AIDS, inadequate space for youth corners at facilities and incompatible syrEx computer software.
The following are recommendations for future Programming:
M&E and Cordination:
1. District Local Governments with support from CHAU need to continue building capacity in M&E for implementing partners (IPs). 2. Institutionalise regular review meetings between Local governments and IPs.
Advocacy and partnership
1. Future interventions need to scale-up advocacy interventions that focus on equitable access to services among vulnerable young people 2. Policies, laws and customs that limit the power and autonomy of vulnerable groups need 3. Sensitise political, religious, cultural and other district leadership on the vulnerabilities of key populations and particularly those in the age bracket of young people. 4. Scale-up engagement with cultural and religious institutions to address structural drivers of HIV and SRHR among young people.
Institutional Capacity Building
1. Strengthen institutional and technical capacity of IPs to deliver quality and inclusive HIV/ AIDS and SRHR services. 2. Strengthen systems and technical capacities of community-based and young people organizations to access and manage resources. 3. Develop a clear Exit Plan to enable IPs be better positioned for the transition.
Behavioural Change Communication
1. Develop Social Behavior Change Communication Strategy for SRHR for KPs 2. Integrate youth empowerment interventions entailing life skills and livelihood skills with SRHR and HIV/AIDS interventions. 1.0 INTRODUCTION AND METHODOLOGY
Background to the LINK UP Uganda Project
Community Health Alliance Uganda (CHAU) is a non-governmental organisation (NGO) registered in Uganda but with affiliation to the International HIV/AIDS Alliance (IHAA). CHAU is a leading technical and organizational capacity building organization in Uganda. It mainly focuses on community and partner systems strengthening, technical, organizational and leadership development; as well as advocacy for enhanced health rights and improved access to and utilization of integrated sexual and reproductive health and rights (SRHR) and HIV services. CHAU also promotes strengthening of partnerships, linkages and coordination of providers in provision of health services. Currently, it operates in about 20 districts of the country. For three years; 2013 to 2015, CHAU implemented the LINK UP Uganda Project, which got a no-cost extension up to June 2016. LINK UP was a three (3) year (2013-2015) Netherlands Government (BUZA) funded Project that aimed to achieve better SRHR for young people 10-24 years affected by HIV. The Project intended to empower young people affected by HIV so that they take up integrated SRHR/HIV services; strengthen capacity of service providers in delivery of quality integrated SRHR/HIV services to the young people; and improve the environment for SRHR/HIV service implementation in the country. The Project was implemented in 13 of the 112 districts1 of Uganda by a consortium of five partners with CHAU as the prime. Other partners include Marie Stopes International Uganda (MSIU), Population Council (PC), ATHENA, Stop AIDS Now (SAN) and GYCA. Link Up project interventions mainly focused on key populations including young people living with HIV; female sex workers, truckers and boda bodas; fisher folks, slum dwellers, teenage mothers, men who sex with men (MSM); and other vulnerable young people in the program districts. These are reached with a package of integrated SRHR/HIV services. The package comprises of SRHR services like gender and sexuality and sexual counselling and education, violence prevention and post violence counselling; family planning counselling and services; psychosexual counselling and harm reduction; post abortion care and services; and self-examination for breast cancer. HIV related services provided on the other hand include psychosocial and positive living support counselling; opportunistic infection treatment; ART treatment and adherence support; palliative care; STI diagnosis and syndromic management; cervical cancer screening and livelihood support. The project also distributed condoms, lubricants and IEC materials and strengthened referral and linkage mechanisms for SRHR and HIV services for young people. HCT, family planning and STI services constitute a minimum package offered to a client. By the end of Link Up project implementation in Uganda, it was envisaged that young people would be better informed and able to make healthier choices regarding their sexuality; more people have access to anti-retroviral drugs, contraceptives and other commodities required for good sexual and reproductive health; public and private health facilities provide better sexual and reproductive healthcare services which more and more people use; and a greater respect for the sexual and reproductive rights of people to whom these rights are denied.
Goal and Outcomes of the LINK UP Project
The overall goal of the LINK UP Project was to contribute to reduced unintended pregnancies, HIV transmission and HIV-related maternal mortality amongst young people affected by HIV 10-24 years. The Project outcomes were: 1 Nakasongola, Luweero, Kampala, Mukono, Wakiso, Kayunga, Buikwe, Jinja, Iganga, Mayuge, Kamuli, Namutumba, Bugiri 1. Young people are better informed and are thus able to make healthier choices regarding their 2. A growing number of people have access to anti-retroviral drugs, contraceptives and other commodities required for good sexual and reproductive health 3. Public and private clinics provide better sexual and reproductive healthcare services, which more and more people are using 4. Greater respect for the sexual and reproductive rights of people to whom these rights are Objectives of the Evaluation
The main purpose of the evaluation was to assess the extent to which the Link Up project achieved its goal, objectives and results, document best practices, lessons and recommendations to inform integrated SRHR and HIV program improvement, scale-up and sustainability; and replication of similar projects. The specific objectives for the evaluation included: 1. To assess the effectiveness of the strategies, model, approaches and interventions implemented by the project to achieve its outcomes and outputs 2. Identify and document gaps and challenges that affected project implementation; and how they could have been resolved 3. To assess level of engagement; and opportunities and challenges of partnerships with MoH, UAC, Local Governments, implementing partners; and other SRHR and HIV project implementing NGOs as well as community engagement in service delivery 4. To determine Link Up project impact on target population and policy environment; and achievements obtained; and identify good practices and lessons learned 5. Identify and document any un-intended outcomes of the Link Up project and benefits to the individual beneficiaries and communities in the project area. Approach and Methodology
Evaluation of this LINK UP Project was two-pronged utilizing mixed methods. Assessment of project effectiveness relied heavily on review of project reports while impact assessment utilized a cross-sectional Evaluation design. In the latter, both qualitative and quantitative methods of data collection were adopted. Quantitative methods were used to generate data on the impact of the Project on the target population while qualitative methods were employed to unravel and complement available data on the project relevance, effectiveness, efficiency and sustainability. Both purposive and non-purposive sample selection techniques were utilized in this evaluation.
1.4.2 Study area and population
Data for the impact assessment was collected from six (6) districts, namely Kampala, Nakasongola, Mukono, Kamuli, Iganga and Namutumba where the Project was implemented. Within the six (6) districts, participants were drawn from communities and sites that had participated/benefited from project activities undertaken between 2013 and 20162. These included slum communities, fishing landing sites, boda boda stages, parks/stages for trucks, bars, lodges and brothels, tuk-tuk sites, health facilities and drop-in-centres. 2 The project timeframe was 2013-2015; but it received a no-cost extension for six (6) months up to June 2016. The primary population for the impact assessment was female sex workers (FSW), fisher folk, boda boda cyclists, truck drivers, HIV+, MSM, slum dwellers and other vulnerable young people. Other participants included Peer Educators (PEs), Health Workers (HWs), Project Staff of Implementing Partners as well as district technical and political officers, and law enforcement officers.
1.4.3 Sample size and distribution
A total of 1,130 young people 10-24 years were considered appropriate to provide data for impact
assessment. This number was calculated using the Cochran (1963:75) sampling formula assuming maximum variability at p=0.5 from a population of 275,000 young people reached with SRHR/HIV information and services. Confidence level was set at 95% (standard normal deviation at 1.96), precision level at 3% and deff at 1.06 to cater for the different stages of sampling participants. The Population Proportionate to Size (PPS) approach was used to distribute the sample between the community and facility settings. A sample of 280 young KPs were allocated to health facilities while 850 were allocated to the community/home based settings. The 280 facility based sample comprised mostly HIV+ young people and other young people who sought for SRH/HIV services from project participating health facilities at the time of the assessment. The 850 community/home based sample comprised 210 FSW, 100 fisher folk, 280 boda boda cyclists, 60 MSM, 90 truck drivers and 110 slum dwellers and other vulnerable youth. Available figures (targets for three groups) and Sudman3 (1976)'s principle of sample distribution was used to administratively distribute the sample among the six (6) sub-populations of young KPs in the community/home based setting. The PPS approach was used to distribute the sub-samples amongst the six (6) selected districts.
1.4.4 Sample characteristics
A total of 1,0944 young people drawn from urban, peri-urban and rural areas were covered in this impact assessment. The sample had slightly more male (53.3%) respondents than female (45.2%) and transgender (1.3%). More than half (70.3%) were unmarried and in the age ranges of 20-24 years (58%), although 28.3% of them reported being in a relationship. The biggest sample was drawn from Kampala (49.5%) where most implementing partners operated. See Table 1.
Table 1: Characteristics young people sampled for the impact assessment
Sex of respondent
3 Sudman, Seymour. 1976. Applied Sampling. New York: Academic Press. 4 The dully completed interviews are less than the sample by 36. The shortfall was due to inability to get 20 MSM from Mukono and 16 HIV+ from sampled facilities within Kampala. Respondents
Single and never married Unmarried, but in a relationship Married/Cohabiting Widowed/separated Main occupation/source of income
Public transport Clerical /office work Bar/Restaurant attendant Religious affiliation
Currently in school
Highest education level attained
Primary, Not Completed Primary, Completed Tertiary/Vocational In terms of literacy, the sample had a mix of literate and semi-literate; 57.6% had attained secondary education and above while primary complete and not completed combined stood at 38.6%. Very few (3.8%) had no formal education at all.
1.4.5 Other data sources
Qualitative data was collected from nine (9) Project Staff of Implementing Partners, 12 PEs, 12 HWs,
8 district technical and political officials and 6 groups of FSW, HIV+ young people and Triple S Club Members. Implementing Partners covered include MSIU, UYDEL, Family Life Education Program (FLEP), Mildmay Uganda, Naguru Teenage Information and Health Centre, Uganda Network of Young People living with HIV (UNYPA), Uganda Youth Coalition on Adolescents (CYSRA) Uganda and COYAA. At the national level consultations were held with MoH and UAC. The lead implementers – CHAU were also consulted extensively.
Data Collection Methods
Both qualitative and quantitative data collection techniques were used in this evaluation. Qualitative data was collected mostly through in-depth interviews and FGDs while quantitative data was collected using a structured questionnaire. These data sources were complimented with review of project reports; all results/achievements on project targets were extracted from the Project Annual Reports. An extensive review of all accessible project documents was done. Documents reviewed include the Project Proposal, the Results Framework 2013, the Project Operational Plan, the Health Sector Strategic and Investment Plan (HSSIP 2010/11-2014/15) and Annual Reports for 2013, 2014 and 2015. A matrix showing trends and patterns of performance on the various strategies and interventions planned for the three years has been presented under the section on project effectiveness. Qualitative data was collected from HWs, PEs, project focal persons from the implementing partners, DHOs and district political staff from the six (6) sampled districts while data on the impact made by the project was collected from the various sub-populations of project beneficiaries. Project beneficiaries covered in this evaluation included FSWs, MSM, HIV+ young people, fisher folk, boda boda cyclists, truck drivers and slum dwellers. To give a visual feeling of the contribution of the project, a video documentary and photography were incorporated in the methods used to collect data. The video documentary and photographs present some of the key program highlights on how the Link UP Project contributed to changes in the lives of
young people affected by HIV, their families and communities at large.
Data Processing and Analysis
Quantitative Component: All the duly filled questionnaires were checked for completeness, edited
and entered on the computer using EPI-INFO (Version 6.0) Statistical Package. After entry, data was exported to the Statistical Package for the Social Scientist (SPSS Version 12 for Widows) for further analysis. Analysis of the data was done in accordance with the evaluation objectives and indicators. Frequencies, percentages and contingency tables (cross tables) were generated according to thematic areas. Variables such as awareness, self-efficacy, access to SRHR/HIV services and quality of care of SRHR/HIV services received from project participating health facilities were developed to summarize the key measures for impact assessment.
Qualitative Component: With regard to qualitative data, all in-depth interviews and FGDs were
transcribed to form texts. The transcripts were reviewed to delineate aspects directly relevant to the study objectives. Thematic and content analysis was used on all the transcribed data. All the qualitative data was triangulated with quantitative data to answer the evaluation objectives. PROJECT DESCRIPTION, RELEVANCE AND LEVEL OF UTILIZATION
LINK UP Uganda was a 3-year SRHR Project implemented in 12 districts of Central and Eastern Uganda with funding from the Netherlands Government (BUZA). BUZA allocated US$ 10.9 million to cover the various project activities over the 3 years. Principally, the project sought to empower YP aged 10-24 to take up integrated HIV/SRHR services, strengthen capacity of service providers in delivery of quality integrated SRHR/HIV services to YP and improve the environment for SRHR/HIV service implementation in the country. LINK UP had two primary partners, namely CHAU and MSU who worked with nine other NGOs and CBOs in a consortium to implement project activities. Project implementation commenced in the last quarter of 2013 and ended in December 2015. However, due to delays in commencement of project implementation in the first year (2013) not all set targets had been achieved by December 2015. Delays in commencement were attributed to the long and protracted process of selecting implementing partners and project staff at CHAU. CHAU was granted a 6-months' no cost extension running from January to June 2016 to complete implementation. In its quest to achieve better SRHR for YP aged 10-24, the Project mostly worked through PEs and HWs to mobilize YP and provide SRH services respectively. Implementing partner organizations set up a network of PEs who was responsible for identifying hotspots for key populations and mobilizing them for services in form of an outreach. Across the 12 districts, implementing partners had a network of over 4,800 PEs. There were also several health facilities both public and private (i.e. Blue Star Clinics) participating in the project. The health facilities were the source of HWs who provided HIV/SRHR services in the outreaches organized by the project. Overall, implementation of Project activities was mostly done through PEs and HWs under direct supervision of the implementing partners like UYDEL, Mildmay, NTIC, MSU, COYAA, FLEP and MARPI. The advocacy component of the project was entrusted with UNYPA, CYSRA and COYAA. CHAU's role was mostly in form of coordination, capacity building, advocacy and resource mobilization. In terms of coverage of activities, all the 12 districts benefited equally, the only difference was with the category of YP targeted. For instance, whereas some categories of YP like boda boda cyclists, FSW, HIV+ and slum dwellers/vulnerable young people were covered in all the 12 project districts, others like fisher folk, MSM and truckers were targeted in specific districts. The areas of operation for implementing partners were not distinct but clearly marked. For instance, nearly all implementing partners operated in Kampala, but had specific geopolitical areas they covered. With regard to age of YP, the primary target group was 10-24 years but often in the outreaches services were given to even youth above 24 years. Project Relevance
Design of this LINK UP Project denotes relevance; the overall project strategy in Uganda was based on
the findings of the rapid assessments that were carried out in March 2013 as part of the planning process. Results from the assessment revealed that whereas the policy environment was conducive for SRHR, implementation still lagged behind. Specifically, the integration of HIV and SRH had been included in several national policies but implementation was low. A visit to three (3) public health facilities within Kampala confirmed the limitations of integration of HIV with SRH; outreaches were also specific to particular services e.g. HIV counselling and testing or immunization. Capacity to reach out and provide a service to young people was also limited at the time. SRHR information available at the time was not well customized for young people, HWs lacked capacity and skills to provide youth friendly integrated HIV/SRH services and health facilities occasionally suffered stock-outs of SRH/HIV commodities and products. Further, several categories of YP e.g. FSW, MSM, fisher folk, truckers and boda boda cyclists found it difficult to seek for HIV/SRHR services from health facilities. Stigma and discrimination was a key issue among sex workers; they were judged harshly because of the nature of their work, many could not easily go to health facilities to seek for services because of fear, sometimes the health workers were not friendly (KII UYDEL). There is no doubt that this project implemented activities relevant to the needs of YP at the time. Available documentation also shows that all activities implemented are consistent with the overall project goal and objectives. For instance, mobilization and provision of HIV/SRHR services through community outreaches was aimed at reaching out to more YP affected by HIV with integrated HIV/SRHR information and services within their locale. LINK UP also contributed to CHAU's mission of empowering communities to live healthy and productive lives through reduction of the unmet need for SRH products and commodities, as well as dissemination of SRHR, HIV, AIDS and general health information to YP. We have been having a big problem of young mothers in Iganga, girls get pregnant at 14 years, 17 years, their parents reject them, they were stigmatized, but Link UP came in to sensitize them, they have been holding community dialogues, so the project was relevant (DHO's Office, Iganga). There was a general lack of youth friendly services in a number of health facilities in the region, there were no clinic days for SRH for young people, no drop-in-centers for youth who find it difficult to seek for SRH services from health facilities (KII FLEP).
2.1.2 Consistency with the vision and mission of CHAU
Based on discussions held and documents reviewed, LINK UP is consistent with the strategic intents
of CHAU and its partners in the consortium. The design and development of the LINK UP Project was guided by CHAU's Scope of Interventions, namely targeting young people with interventions aimed at addressing SRHR and HIV/AIDS/TB, among others. This Scope of Interventions was upheld even in the new Strategic Plan 2016–2020. Further, the review shows that LINK UP's project activities were in tandem with the Government of Uganda's National policies, plans and strategies such as the Health Sector Strategic and Investment Plan (HSSIP 2010/11-2014/15) and the National HIV/AIDS Strategic Plan (NSP 2011/12—2014/15); from which MSU and other consortium partners draw their mandate. In effort to achieve better SRH for young people affected by HIV, LINK UP interventions contributed to the National HIV/AIDS and SRHR indicators and targets. This is well articulated under Strategic Objective 3 on Care and Treatment, the NSP 2011/12-2014/15 accordingly sought "to integrate sexual and reproductive health (including HIV prevention) into all care and treatment services by 2015". LINK UP also contributed to the NSP's Strategic Objective 1 & 2 on Prevention. Further, the project made contributions to Uganda's HSSIP 2010/11 – 2014/15 health services indicators on percentage of eligible persons receiving ART and contraceptive prevalence rate. Working with the MARPs steering committee of Uganda AIDS Commission to identify gaps and share needs, promote provision of integrated HIV/SRHR services, LINKUP made a contribution to national indicators and also the mandate of MoH (KII, CHAU). LINK UP supported the implementation of health programmes targeting young people which were in-line with the district programmes and work plan…we were concerned about the increase in transmission of HIV, abortions among young people (DHO's Office, Mukono). The project has no doubt contributed to improved health and quality of life of young people affected by HIV in communities in the 12 districts where it was implemented. In this LINK UP Project, CHAU and the members of the consortium visualize a Uganda where no person dies of preventable diseases. In a number of project activities, the Consortium members' mission of empowering communities to live healthy and productive lives is evident.
Level of Utilization of Project Resources
2.3.1 Project inputs and efficiency in utilization
Inputs used to deliver the planned outputs in this LINK UP project included human resource, IEC materials and FP commodities. Records show IEC materials as the largest input that was procured; a total of 163,463 IEC materials were procured and distributed in form of brochures, stickers, wrist bands, T-shirts, notebooks among others. The project also made a-one-off procurement of condoms to address shortage, condoms dispensers and wooden penile models to aid dispensing and demonstration of correct condom use respectively (see Table 2).
Table 2: LINK UP Project inputs procured between 2013 and 2016
Quantity Procured in each year
Peer Educator Bags Wooden penile models Peer Educator manuals Male condoms (branded protector condoms) Condom dispensers Quantity Procured in each year
Source: Project Records All the inputs procured were efficiently utilized to achieve the desired outputs. It was reported that IEC materials particularly the T-shirts, bags, umbrellas, bandannas, water bottles and wrist bands were a constant reminder to the people about SRHR. These IEC material carried messages on SRHR which was widely credited for the increase in knowledge and awareness about SRHR among the target population and the general community people including parents to the young people and community leaders. The materials, particularly T-shirts and bags were also a source of motivation for the PEs; it gave PEs identity and a sense of belonging. Besides edutainment, the high turn up of young people at outreaches was tagged to provision of IEC materials. It was reported that the expectation of receiving T-shits, bags, umbrellas, calendars, wrist bands, pens, books and caps attracted many young people to attend and patiently waited through the events.
2.3.2 Timeliness in release of funds
Timeliness in release of project funds is critical in attainment of planned outputs. CHAU and MSU
jointly developed work plans and budgets for activities with all the implementing partners, however, execution was sometimes not undertaken according to plan. Interaction with staff of the various implementing partners revealed occurrence of delays in release of project funds, but they were quick to add that whenever it happened, they received explanations from CHAU. Sometimes funds would come after 2 months, this would stall activities, cause backlog but we tried to be as flexible as possible in order to achieve the set targets (KII, UNYPA). We often experienced delays in release of funds…we had to reschedule our activities making our work plan congested (KII CYSRA). This delay in release of project funds was most notable in the first quarter of 2015; apparently funds were received at the end of the quarter which affected the originally planned logical flow of events and activities. CHAU staff confirmed occurrence of delays which they attributed to various factors both at international and local levels. It was explained that for instance a delay by the international consortium to release funds directly affected the time when CHAU released the funds to the implementing factors. Secondly, release of project funds was tagged on submission of accountability for previous funds; any delay in submission of accountability would also result into delay in release on funds.
2.2.3 Overall project performance
The LINK UP Project has delivered successfully on its goal. Through the consortium, the project has
made available youth friendly integrated SRHR/HIV services, commodities and information within communities and at health facilities. Several young people, who prior to the project found it difficult to access SRHR services and commodities, freely accessed and utilized the integrated package of HIV/SRHR services and commodities that were made available by the project. Project annual reports and staff of the implementing partners all attest to the impressive performance of the project. The level of effectiveness and degree of efficiency exhibited by the implementers signify a project well implemented. A few challenges were reported like delays in commencement of project activities in 2013 and release of funds but these did not deter the good performance. PROJECT EFFECTIVENESS AND APPROPRIATENESS OF DELIVERY
Effectiveness of Activity Implementation
The effectiveness of this LINK UP project was examined in relation to the stipulated goal and the attendant specific objectives. In this Section, we seek to examine the extent, to which the planned results were achieved. As earlier highlighted, this project had four (4) major outcome expectations, namely that; 1: Young people are better informed and able to make healthier choices; 2: Young people have access to ARVs, contraceptives and other commodities for good SRH; 3: Public and private clinics provide better SRH services; and 4: Implementations results into greater respect for SRHR of people to whom they are denied. Various activities were planned and implemented to realize these outcomes with attendant indicators of success. The sub-sections that follow highlight achievements attained against the target on each outcome area.
3.1.1 Young people are better informed and able to make healthier choices
This project set out to reach 275,000 YP aged 10-24 with integrated HIV/SRHR information and services in a community setting over the 3 years of implementation. Review of project reports shows that despite the delays in year 1 (2013), the project effectively reached out to the target population. By June 20165, the project had reached a cumulative total of 297,439 young people with SRH information, majority of who in the 20-24 age range (i.e. 170,442 compared to 32,312 aged 10-14 and 94,685 aged 15-19). This denotes an achievement of 108% of the target. Disaggregation of data by gender shows slightly more males than females and transgender reached i.e. 153,864, 143,570 and 5 respectively. These YP were reached through 600 community outreaches organized by PEs. The Project used several other modes of reaching out to YP including radio talk shows, radio alerts, Triple S Club fora, dialogue meetings, social media and phone pyramids to reach young people with integrated HIV/SRHR information and services. The project also distributed IEC materials in form of brochures, notebooks, stickers, wrist bands, branded T-shirts among others. At the end of the three years, the project had distributed a total of 179, 984 IEC materials. See Table 3.
Table 3: Project achievements in relation to the targets on YP reached with HIV/SRHR services
Targets for the 3 Years
(2013-June 2016) Outcome Area 1: YP are
275,000 YP aged 10-24 reached with HIV/SRHR services in a better informed and are thus community or home-based setting able to make healthier 4,800 YP trained as role models in protecting and promoting the choices regarding their SRHR of YP 10-24 yrs Community Outreaches conducted for HIV/SRH Home visits for YPLHIV on treatment and others on STI medication or contraceptives Triple S Clubs formed IEC materials produced and distributed Community dialogues with parents & other gatekeepers Source: Project Annual Reports 2013, 2014, 2015 and 2016; Link UP Results Framework 2013 (Revised) 5 The project was granted a 6 months no cost extension which ended in June 2016. Further, the project reached over 80% of its target of role models. A total of 4,044 PEs/role models have been trained and actively engaged in the mobilization, dissemination and provision of integrated HIV/SRHR information and services among their peers. For instance in 2014 alone, PEs in alliance with HWs, reached out to 1,480 YP at landing sites with SRH services. Further, the trained project PEs made a cumulative total of 3,500 visits to young people living with HIV (YPLHIV) in their homes to foster positive living. Overall, the review shows that a lot of effort was made to ensure that by the end of the 3-years of implementation of the LINK UP Project, young people in the 12 districts were better informed about SRH and able to make healthier choices. In all outreaches and the peer led door to door sessions, young people 10-17 year old were given information on growing up, body changes in boys and girls, abstinence from sex as well as personal hygiene during menstruation while the older people (18-24 years) were empowered with information and skills on safer sexual choices to avoid health risks like STI, HIV and unintended pregnancies. The latter category of young people were specifically equipment with information on risks of casual sex, faithfulness, safer sex practices; and correct and consistent use of male and female condoms. This was intended to ensure that young people make healthier choices.
3.1.2 Access to ARVs, contraceptives and other commodities for good SRH
The project achieved its objective of making a contribution to reduction of unmet need for family
planning, HIV testing and STI services among young people 10-24 years. Through implementing partner organizations such as UYDEL, FLEP, Mildmay, MSIU, ICOBI etc, the Project successfully partnered with both public and private health facilities to provide youth friendly and integrated HIV/SRHR services. We had 29 health facilities we were supporting on this Linkup project in Luwero, Nakasongola and Wakiso to deliver services like family planning, HIV counselling and testing, provision of ARVs and referrals (KII, Mildmay). Review of Project reports shows that 191 health facilities both public and private had been enlisted by the project to provide quality youth friendly and integrated HIV/SRHR services. By the end of 2014, a total of 106,253 YP had received safer sex counseling from these facilities. They also provided HIV pre-test counseling to 92,171 people and STI treatment to 23,169 YP. In the same year (2014) 8,383 YP older than 24 years had also received similar services. Further, the project established several condom distribution points both at health facilities and in the hot spots where KPs live. Through the condom distribution points, a total of 81,150 male condoms, 10,711 female condoms were distributed. In addition, the project distributed 1,164 cycles of oral contraceptives to young people (see Table 4).
Table 4: Project achievements in relation to the targets on access to SRH services and commodities
Targets for the 3 Years
(2013-June 2016) Outcome Area 2:
30,000 YP aged 10-24 reached with HIV/SRHR services in a facility-based A growing number 20,000 completed referrals made for YP aged 10-24 to access core HIV/SRH 320 health facilities supported to offer quality HIV/SRHR services to YP contraceptives and Young people corners established at HFs other commodities Condoms distributed Targets for the 3 Years
(2013-June 2016) required for good Cycles of oral contraceptives distributed Source: Project Annual Reports 2013, 2014, 2015 and 2016; Link UP Results Framework 2013 (Revised) Further, results of this review reveal that the project surpassed its target on number of young people to reach with integrated HIV/SRHR services in the facility setting. The project targeted to reach 30,000 YP with integrated HIV/SRHR services in a facility setting over a period of 3 years; by the end of the 3 years, a cumulative total of 98,597 had been reached in the facility setting. More females (56,296) than males (42,300) and transgender (1) received SRHR/HIV services from the health facilities. Further disaggregation revealed that the numbers reached comprised of all sub-categories of young people but in varying proportion i.e. 10-14 (9,382), 15-19 (32,408) and 20-24 (56,807). In terms of risk group, more FSW (10,196) than YPLHIV (5,698) and MSM (270) were served at health facilities. Through outreaches, peer led door to door visits and moonlight clinics, the project made 33,767 referrals to partner health facilities for core HIV services including ARVs, STI treatment, male circumcision and other contraceptives required for good SRH. This denotes an achievement almost 2 times the number initially targeted. In 2014 alone, 378 FSW were referred to partner facilities for STI treatment; 588 boda boda riders for male circumcision and 476 fishermen for HIV testing. Overall, the review shows that tremendous progress has been made with regard to stamping out unmet need. More and more young people were observed each successive year accessing integrated HIV/SRHR services. No doubt the project realized its prospect of a growing number of people having access to ARV drugs, contraceptives and other commodities required for good sexual and reproductive health in project participating health facilities.
3.1.3 Provision of better SRH services by public and private clinics
The Project built the capacity of HWs and PEs that participated in the implementation. The Project
trained nearly three (3) times the HWs originally targeted for the provision of quality integrated youth friendly HIV/SRHR services. By Project end, capacity of 548 HWs had been built through refresher trainings and mentorship. Our health workers acquired skills on how to handle this special group of young people…the quality has improved and uptake of services has gone up (HW Nsinze HC IV, Namutumba). In addition to mentorship/coaching, numerous Continuous Medical Education (CME) sessions were organized for HWs at partner facilities as part of efforts to improve their knowledge and skills in SRHR service provision particularly to young marginalized people. Capacity of HWs was also strengthened through support supervision by CHAU and MSU staff. In 2014 alone, 60 training courses for HWs had been organized and executed.
Table 5: Project achievements in relation to the targets on capacity building for service providers
Targets for the 3 Years
(2013-June 2016) Outcome Area 3: Public and private
200 service providers trained to offer HIV and SRH services clinics provide better sexual and to YP aged 10-24 Project Outcomes
Targets for the 3 Years
(2013-June 2016) reproductive healthcare services, 2,500 YP aged 10-24 supported to participate in youth which more and more people are using friendly programming and planning Source: Project Annual Reports 2013, 2014, 2015 and 2016; Link UP Results Framework 2013 (Revised) Interviews with HWs corroborated these results; HWs confirmed integrating services and creating youth corners to foster a conducive environment for offering youth friendly HIV/SRH services. We have integrated ART care with youth care, we want them to get their treatment in their corner,. consultation, HIV testing and even dispensing of drugs is all done from the youth corner, we do not want the youth to mix (KII, Komamboga HC III, Kampala). LINKUP also sought to assist young people to engage in more meaningful participation in activities and projects targeting the youth. This project specifically targeted to support, encourage and advocate for the participation of young people in youth friendly and appropriate programming and planning at all levels. Results of the review show a more than 100% achievement of the target; 3,060 YP were supported to participate in a series of activities that foster young people friendly and appropriate programming at community, health facility and district levels compared to the targeted 2,500. Important to note, all PEs on the project were young people drawn from the target population. PEs were supported and by 2014, they were actively participating in the sensitization and provision of SRHR/HIV services and commodities, to their peers during youth friendly clinic days. Some young people have also been trained, supported and participated in data collection and entry onto syrEx system. By the time of the evaluation, many young people were participating in district and national level events including World AIDS Day and World Contraception Day.
3.1.4 Greater respect for YP accessing SRHR services
Notable progress has been registered in pursuit of greater respect for SRHR of people to whom these rights are denied. As can be seen in Table 6, nearly 400 decision makers including law enforcement officials across the 12 districts have been sensitized about the rights of young people particularly FSWs, MSM and other vulnerable youth to good health/treatment, safer sex, education, marriage, a family etc. The Project organized 15 community dialogue meetings with law enforcement officials particularly the Police on respect of SRH rights and 22 meeting with decision makers at district level. The project also organized 24 media activities to advocate for greater respect of the SRH rights of young people 10-24 yrs while the YP participated in 139 policy and advocacy events. See Table 6.
Table 6: Project achievements in relation to the targets on Respect for SRHR
Targets for the 3 Years
(2013-June 2016) Outcome Area 4:
6 CSOs use REAct monitoring systems Greater respect for the 50 decision makers/ law enforcement officials sensitized reproductive rights of Community dialogue meetings on respect of SRH rights held people to whom these YP participate in policy and advocacy rights are denied 1 coalition implementing activities adapted from national advocacy strategies for YP 10-24 Contributions to global, national, and local policy that address the rights of YP aged 10-24 Contributions into policy processes by young advocates District level advocacy meetings organized National events attended (e.g. World AIDS Day, African Child, YP Day etc) Project Outcomes
Targets for the 3 Years
(2013-June 2016) Advocacy tools for young people produced Media activities on advocacy organized Young People trained in budget monitoring Source: Project Annual Reports 2013, 2014, 2015 and 2016; Link UP Results Framework 2013 (Revised) To further ensure that rights of young people are respected and violations recorded, the project has supported three (3) CSOs to create monitoring and reporting systems. The CSOs trained to use the REAct monitoring systems include UNYPA, Lady Mermaid Bureau and Crested Crane Lighters. The three CSOs had by end of 2015 documented 37 cases of young people who experienced human rights abuses and made appropriate response to the abuses. The cases documented were mostly among FSWs and YPLHIV. In addition to HIV/SRHR services, the project made considerable gains in the protection and stemming of gender based violence. There are a lot of other things that we intervened in like gender based violence, we could give sex workers help in form of post exposure prophylaxis especially those raped, those beaten by clients or taken to the police we also bailed them out (KII MARPI). LINKUP also spearheaded the process of developing an advocacy strategy; by end of 2014, the strategy had been developed and CYSRA Uganda appointed to lead the coalition implementing activities adapted from national advocacy strategies for YP 10-24. In addition, the project produced 12 advocacy tools for young people 10-24 years, 6 briefing papers, 24 policy documents and organized 6 advocacy training. The training was conducted as a strategy for influencing policies that recognize and respect the SRH rights of young people. Discussions with young KPs living with HIV/AIDS corroborated and highlighted the results from the training on the SRH rights; many participants reported knowing their SRH rights. We learnt a lot about our rights in the outreaches and from health workers…I have right to take my ARVs, a right to information, a right to education…I have a right to confidentiality, a health worker should not shout at me in public instructing me to go for counseling (FGD with HIV+, Naguru Teenage HC). Overall, the review shows that tremendous progress has been made in attaining greater respect for SRHR of people to whom they are denied. In the 3 years of the project, over 300 YP participated in various policy and advocacy events organized at district and national levels.
Factors that Affected Project Effectiveness
3.2.1 Factors that contributed to success of the project
Success of the LINKUP project could be attributed to several factors but key among them was the involvement of district leaders particularly the District Health Office (DHO), adopting a multi-faceted approach involving both community and facility based approaches and use of edutainment in the mobilization of the target community. Involvement of DHOs was a strong pillar in the success of the project; it ensured access to public health facilities, the health workers, prioritization of SRH services and space for provision of integrated youth friendly HIV/SRH services. In all districts, except Namutumba, visited for the evaluation DHOs acknowledged actively participating in the implementation of the project. They participated in training workshops to orient health workers on integration of HIV and SRHR services; they instructed health facilities to designate space for youth corners, guided procurement of drugs for HIV and SRHR services and supported the initiation of clinic days for serving young people with HIV/SRH services. Success of outcome 4 of the project is attributed to positive reception of DHOs. We engaged people like the DHO, the district HIV focal persons, health workers, representatives of young people in the radio talk shows to discuss rights of young people to access SRH/HIV (KII CYSRA). We managed to lobby the district leadership in Bugiri to increase funding for SRH which has been used to set up youth corners at public health centers. At the national level, we caused some changes on the HIV policy to include quality treatment and care for young people (KII CYSRA). Participation of HWs in outreaches sessions was also cited among the key factors for the success of this project. Their participation bridged the accessibility gap that existed especially with key populations like FSW, fisher folk and boda boda cyclists. These categories often find it difficult to seek for HIV/SRH services from health facilities due to fear of being discriminated. Link up came with community outreaches which aimed at taking the SRH services closer to the population that needed it but were fearing to come to the health facilities (DHO's Office, Participation of HWs in outreach activities also made referral of KPs more effective because the persons referred were assured of meeting the same HWs at the facilities which fostered acceptance. Through workshops on provision of integrated youth friendly HIV/SRH services, HWs appreciated the importance of providing services to young people and gained skills in handling young people including KPs like FSW and MSM who are usually sensitive and susceptible to discrimination. It was these skills that ensured that KPs who came in contact with them during outreaches felt comfortable to go for more specialized services at health facilities when referred – it built confidence. Lastly, use of edutainment and radio ensured wider reach of the HIV/SRHR messages. The high numbers of young people that turned up at outreaches were credited to use of edutainment. MSIU's tuktuk van was an attraction to both young and older people. The films showed were both educative and entertaining; after captivating people's attention, HWs and PEs took opportunity to encourage the audience to seek for HIV tests, STI screening and family planning services. This gave the project opportunity to disseminate awareness messages to large numbers of young people including those who would have ordinarily shunned the event. To complement information dissemination at outreach sites, the project paid for radio talk shows. Talk shows were embraced by DHOs, District HIV Focal Persons health workers, representatives of young people to discuss and constantly remind the populace about the rights of young people to access SRH/HIV.
3.2.2 Challenges/constraints to effective project execution
Despite the success, project implementation suffered several challenges which undermined its
potential to deliver expected results within set time. Key among the challenges was the occasional delay in release of project funds to implementing partners, inadequate stock and sometimes stock- out of HIV test kits, condoms, contraceptives and STI drugs at health centers, inadequate IEC materials, retention of PEs, heavy workload and transfer of trained HWs, stigma and discrimination, inadequate space for youth corners at facilities and incompatible syrEx computer software. Delay in release of project funds to implementing partners was cited among the biggest challenges that constrained project implementation. Implementing partners reported that they had to design catch-up plans to enable them accomplish the activities they had planned for the year. Apparently, these delays in release of funds were experienced both in 2014 and 2015. The other major challenge although it lasted a short time was inadequate IEC materials. This was suffered mostly in the first half of 2014; Peer Education was constrained as PEs lacked materials to use while engaging and sensitizing their peers. This was partly attributed to the delay in release of project funds. Stock-out of essential commodities and drugs for SRHR was also a common challenge. The high demand generated by the project inadvertently exerted pressure on available stocks of SRHR commodities and services causing inadequacy and occasional stock-outs. It was reported that most participating health centers (both public and private) often had inadequate stocks of HIV test kits, condoms, oral contraceptives and STI drugs. We have been experiencing some moments of stock-out of medicines like Septrin and Ciprofloxacin (HW Nsinze HC IV, Namutumba). CHAU procured buffer stocks, but because of the high demand, stock-outs could not be entirely eliminated. Stock-outs were also partially attributed to competition for available resources from non-primary target population (youth older than 24 years). Older youth often turned up in outreaches to access SRHR services; the project could not turn them away, although it meant that services were going to the wrong target group. This was a common occurrence throughout the three years of project implementation across all districts. Willingness of HWs to embrace provision of youth friendly SRHR services especially in public health facilities also posed some challenges. LINK UP trained and mentored a selection of HWs at each project participating, although all HWs at the facility were expected to embrace provision of integrated and youth friendly HIV/SRHR services. It was reported that some HWs however exhibited unwillingness to offer extra attention to YP seeking for integrated youth friendly SRHR/HIV services particularly FSW. The project also had to contend with transfer of HWs oriented by the project to facilities outside the project area. The transfers disrupted relationships young people particularly the HIV+ had built; to re-establish relations with new persons took time hence affecting service utilization. Access to core HIV/AIDS services such as ART, psychosocial and drug adherence support was undermined by prevalence of stigma and discrimination. In all districts, PEs reported existence of stigma and discrimination against HIV+ young people. Many young people feared to be identified within their communities as people living with HIV. Fora and events for YPLHIV had, in most cases, to be organized at the district level not within the communities where the YPLHIV live. This hampered effective mobilization and formation of groups of YPLHIV. This also created another problem of long distances to meeting points which constrained regular and active participation of YPLHIV group members. On the project management side, particularly tracking progress in implementation only one challenge was cited i.e. use of the syrEx computer software. It was reported, mostly in 2014 that partners had difficulties using the syrEx monitoring and reporting system. Data entry, validation, cleaning, uploading and aggregation using the syrEx system was a challenge to many implementing partners. This resulted into and contributed to inconsistencies in figures reported especially for 2014. But this problem was in 2015 resolved through provision of hands-on training to all M&E staff of the partner organizations on using the syrEx system. Appropriateness of the Project Delivery Mechanisms
LINK UP adopted the most appropriate delivery mechanisms with potential for sustainability. Given its 4 Outcomes6, use of community people, existing health facilities and local organizations targeting similar categories of people in the implementation, community dialogues, as well as peer led door to door approaches (i.e. home visits) was by far the most appropriate approach. Implementation of the project heavily relied and utilized existing resources within the community (i.e. PEs and local leaders) to identify areas with high concentrations of key populations, which was cost-saving and a measure of promoting sustainability of the activities. The approach helped build local structures of community resource persons and ownership of the Project. Participants in the evaluation acknowledged that involvement of PEs and local leaders in the mobilization, registration and sensitization of YP about the importance of testing for HIV, STI testing and treatment as well as family planning greatly contributed to the success of the project. Using the peer to peer approach meant that information and messages about SRH were delivered by people who shared characteristics and had more chances of being accepted by the target population (KII FLEP). Further, use of the tuk-tuk/film van was also cited as a factor behind the high turn up of YP at outreach sites. Apparently, the film van not only facilitated the delivery of SRHR and HIV edutainment messages to YP but also mobilized communities for the services. The PE model also ensured increased involvement of YP in planning and delivery of integrated HIV/SRHR services to YP 10-24 affected by HIV. Use of existing health facilities and trained HWs added to the community resource. HWs trained to provide youth friendly and integrated HIV/SRHR services regularly participated in service camps and moonlight clinics to reach out to hard-to-reach key populations like FSW, MSM and fisher folk. This approach ensured that hard-to-reach key populations received a comprehensive package of health services at their doorstep. This resource (trained HWs) has remained in the communities where the project was implemented. The use of community dialogue meetings and home visits as avenues for community buy-in and reach-out to YP particularly those living with HIV was paramount. All PEs applauded the meetings and home visits noting that they gave them opportunity to get into the communities and effectively reach out to the target population. Through this strategy, the project greatly enhanced access to SRH information and commodities as well as support to HIV+ young people. During the visits, PEs provided support to the sick and positive living counseling to combat stigma and discrimination as well as adherence to medication. The dialogues on the other hand fostered appreciation of the SRH rights of young people among parents and other gatekeepers in all communities where the project was implemented. CHAU's decision to engage existing local organizations implementing similar activities as the implementing partners assured the project with high proficiency in implementation and 6 Outcome 1: Young people are better informed and able to make healthier choices; 2. Young people have access to ARVs, contraceptives and other commodities for good SRH; 3. Public and private clinics provide better SRH services; 4. Greater respect for SRHR of people to whom they are denied sustainability. Projects by design have a definite period of execution, they come and end, but the needs of the people never end, hence the need for a mechanism for sustainability. Outcome 1 of LINK UP's project denotes behavior change, which is not easy to attain in a short period of time, therefore engaging actors who will continue to work with the target population even beyond the project duration was a good sustainability strategy. In addition, the staff in such organizations brought on- board a wealth of experience in implementing activities targeting hard-to-reach or key populations who have been denied most SRH services and commodities. However, some use delivery mechanisms which constrain meaningful involvement of the target population. A few cases of implementing partners using one peer educator to manage seven different KPs were recorded. In Kavule, Kampala, a PE was working with young mothers, boda boda riders, HIV+, slum dwellers, drug users and MSM. Overall, drawing from a review of Project Reports and interviews held with staff from partner organizations that implemented this LINK UP project, it can be concluded that the project adopted the most appropriate strategy. The project realized and even surpassed most targets, denoting effectiveness of the strategies and approaches employed in project execution. The impact the project has had on the target population also denotes choice of good and appropriate delivery mechanisms. 4.0 PROJECT IMPACT ON YOUNG PEOPLE AND THE SRHR POLICY
Project Impact on Young People's Knowledge and Access to SRHR/HIV Services
Implementation of this Project was meant to increase YP's knowledge about SRHR and therefore their ability to make healthier choices regarding their sexuality. This section presents data on access to SRHR/HIV information as well as sexual behavior of the people that were reached by the project.
4.1.1 Participation in project awareness creation activities
LINKUP had a big reach on the target population. Evaluation results show that over 90% received
information on the various SRHR/HIV issues. Particularly, 96.7% confirmed receiving information on HIV/AIDS, 93.1% on STIs and 91.6% on unwanted pregnancies in the 3 years. More evidence of project reach was observed with numbers that attended SRHR sensitization meetings. More than half (62.9% and 60.1%) admitted attending sensitization meetings on prevention of HIV and STIs respectively. Similarly, 93.8% attended sessions where project staff talked to them about condom use, personal hygiene (83.9%), body changes (72.7%), sex before marriage (68.9%), abortion (71.3%) among others (see Table 7).
Table 7: Young people sensitized on SRHR/HIV between 2013 and 2016
Young people who received SRHR/HIV information in past 3 years Unwanted pregnancies SRH Rights for youth Attendance of sensitization meetings on SRHR in past 3 years Prevention of HIV Prevention of STIs Unwanted pregnancies Places where sensitization took place in past 3 years Boda boda/truck stage Bar/lodge/brothel Community hall/playground Proportion of young people sensitized about the following: Sex before marriage Personal hygiene Sexual gratification Sources where YP learned most about SRHR/HIV in past 3 years HWs at facility/drop-in-centers Outreaches/service camps Peer educators/door-to-door Youth club discussions /social media
Brochures/leaflets The most dominant source of learning about SRHR was radio closely followed by health facilities and outreaches or service camps. Two thirds (35.3%) of the sample reported that they had learned most about SRHR through radio. This corroborates results in the Project Annual Reports on the number of YP reached through talk shows; by the end of 2014 an estimated 25,000 YP had been reached with SRHR information and 70 listeners' calls received during talk shows. Evidence of use of other avenues to disseminate messages on SRHR/HIV was also observed from the results of the Evaluation. About 51% of YP in the sample who participated in outreaches acknowledged receiving IEC materials with messages on SRHR/HIV. The Project branded T-shirts were the commonly cited (29.6%) promotional materials that young people received. Other IEC materials reported received include brochures (24.2%), water bottles and wrist bands (16.3%), calendars and posters (7.7%), umbrellas (4.6%) and bags (4.4%). But the latter were mostly for peer educators. mobilizing, sensitizing and providing SRH services to young people like STI screening, treatment, HIV counseling and testing, drugs and follow-up of young people on drugs to ensure that they are taking their medicine as directed (HW Iganga Islamic HC III,
4.1.2 Knowledge of places with SRHR/HIV services
Awareness creation activities of the project had a big impact on YP's knowledge on service access
points. Evaluation results show that 95% knew where HIV testing services could be found within their communities. Knowledge of places offering other SRHR services such as family planning, oral contraceptives, STI testing, ART was also high (see Table 8).
Table 8: Level of awareness of facilities with integrated HIV/SRHR services
Awareness of facilities with HIV/SRHR services
% 10-15 16-19 20-24 25-28
Awareness of existence of of SRHR/HIV services in the community HIV testing 1033 Awareness of facilities with HIV/SRHR services
% 10-15 16-19 20-24 25-28
Oral contraceptives Post Abortion care Types of existing health facilities reported by YP in their Private for profit Public/Government Staff of implementing partners corroborated the different ways awareness was made to the KPs. Through our trainings, we provided KPs with well-tailored messages on HIV, where to test from, how to prevent infection and how to use a condom (KII, MARPI). Knowledge on SRHR/HIV service points was common and almost evenly distributed among all ages. Results show that, with the exception of the 10-15 age group, all young people (i.e. 16-19 yrs, 20-24 and 25-28) were equally knowledgeable about where SRHR/HIV services such as HIV testing, STI testing and treatment, family planning services including oral contraceptives could be found within their communities. Results in Table 9 further show that several YP confirmed availability of SRHR/HIV services within their communities. Commonly, YP reported existence of facilities with HIV testing and family planning services in their communities. This, knowledge of SRHR/HIV service access points, signifies LINKUP's tremendous effort in making young people better informed about SRHR.
4.1.3 Access to SRHR/HIV services and commodities
LINKUP's aspiration of getting more YP to access SRHR/HIV services and commodities was achieved.
Evaluation results show that a notable proportion of YP received SRHR/HIV services and commodities. For instance, among YP that participated in outreach activities, 89.9% received an SRHR service or commodity. Majority received HIV counseling and testing (88.4%) and condoms (75%). Notable proportions were tested and treated for STIs (30.1% and 19.6%) respectively while 26.9% received referrals to health facilities for further management. Nearly all the referrals were completed (95.2%) and services received ranged from HIV testing (48.6%), treatment for STIs (45.7%), and medical male circumcision to enrollment on ART (16.2%). See Table 9.
Table 9: Young people who received SRHR/HIV services and products
Young people that received SRHR/HIV services or commodities during outreaches SRH services or commodities received by young people during outreaches HIV counseling & testing STI screening/testing Referral to health center Indicator
Oral contraceptives for FP Proportion of young people referred by PE/HWs to health facilities for SRH services Proportion of completed referrals (i.e. received the SRH services) SRH services young people received through the referrals to health facilities N=278 Male circumcision Young people who got health services from facilities nearest to their homes in past 3 years Type of health services YP got from facilities nearest their homes in the past 3 years N=815 STI testing & treatment Other curative services Communities with health facilities offering youth friendly SRHR services SRHR services and commodities reported to be easy to access within sampled communities Post Abortion care Oral contraceptives The findings in the Table corroborate reports in the Project Annual Reports on completed referrals; by the end of 2015, a cumulative total of 33,767 completed referrals had been recorded. The results also compare, though remotely with the Population Council study conducted among YPLHIV in Luwero and Nakasongola; 48% of the YPLHIV confirmed receiving referral slips for HIV/SRHR services. Impact of the LINKUP Project was further evident in the proportion reporting presence of health facilities in their communities offering integrated youth friendly services. Slightly over two-thirds (68.6%) of sampled YP confirmed presence of health facilities within their communities where young people (10-24 yrs) freely accessed SRHR services. This was corroborated by YP found at health facilities at the time of the Evaluation; 41.8% attributed their choice of the health facility on friendly health workers. Others chose the facility either because services were free (41%), had been referred (14.2%) or because of proximity (28%). Among the SRHR services easiest to access included HIV testing, delivery, STI testing and treatment, family planning and oral contraceptives. In the sample,
86.2% affirmed that they had easy access to HIV testing services in their communities. Important to note, the entire sample reported having a health facility within their community. than a half (57.7%) sought for other curative services SRHR (HIV testing treatment - 18.9%, ART – 7.5%); it is facilities offering youth In Kamuli Hospital, every Thursday is Youth Day dedicated to accessing unlimited services to young people especially SRHR/HIV (KI, CAO's Office—Kamuli) Overall, the End of Term Evaluation results and data in the Project Annual Reports are not contradictory i.e., a confirmation of the Project's positive impact on the target population with regard to outcome area one. A big number of young people was reached with SRHR/HIV messages and services as well as accessing anti-retroviral drugs, contraceptives and other commodities particularly condoms required for good SRH.
4.2 Project Impact on Young People's Sexual Behaviour and Self-efficacy
4.2.1 Sexual behaviour and intentions
The Project sought to influence the sexual behavior of young people (10-24 yrs) to make healthier
choices, which was largely achieved as per the Evaluation findings. Evaluation results, for instance, revealed that over 90% of sampled YP were taking measures to avoid infection with STIs. Over 80% reported using condoms to avoid STIs while those who tested for HIV and decided to remain faithful to their partners were 22.8% of the sample. Important to note, 87.9% of the sampled had ever had sex and among them only about 7% were not having regular sex. See Table 10.
Table 10: Health choices of sampled young people
Young people taking measures to avoid infection with STIs Measures young people are taking to avoid infection with STIs N=785 Test partner before sex Test HIV & remain faithful Young people who consider themselves at risk of infection with STIs & HIV Already infected/HIV+ Ever had sexual intercourse Age at which first had sexual intercourse Most recent time sampled young people had sexual intercourse 13-24 months ago 25-36 months ago More than 3 yrs ago Perceived risk of infection with STIs exists but not in alarming proportions. Evaluation results show that nearly half (41.8%) confidently affirmed that they were not at risk of getting STIs at all. In the entire sample, a quarter (25%) feared to be somewhat at risk and 21.6% at big risk if infection with STIs. Staff of implementing partners corroborated these results, noting that the sensitization has triggered a spirit of consciousness to avoid risk even among FSW. The sensitization programmes on condom use, HIV testing and counselling have made even sex workers cautious about their health. they have adopted safer sex practices (KII, MARPI).
4.2.2 Access to FP services
In the communities where the Project was implemented, a notable impact was observed on access to family planning services. Unmet need was reported by only 20.8% of the sample; the majority (79.2%) accessed family planning services when they needed them. At the time of the evaluation 84.8% of YP who were sexually active were using a method of family planning to avoid getting pregnant or their partners pregnant. Majority (76.7%) were using condoms, 19.9% injectables while oral contraceptives (i.e. pills) were being used by only 8.4%. Reports of condom use were made by more males than the female YP in the sample; 82.4% and 68.1% of males and females respectively reported using or their partners using condoms to avoid pregnancy. Comparison across the age sub-groups revealed slightly more condom use among the 10-15 and 16-19 year olds than the 20-24 and 25-28 year old young people. This could be because notable proportions of the latter categories are married people who either use pills or injectables. See Table 11.
Table 11: Access to family planning services and experience with unwanted pregnancies
Disaggregated by age
10-15 16-19 20-24 25-28
Failed to get birth control measure when needed Proportion currently using family planning Birth control measures young people/their partners are currently using N=810 Other natural FP methods Ever got an unwanted pregnancy Age at which got the unwanted pregnancy Proportion currently taking measures to avoid unwanted pregnancies Measures young people are currently taking to prevent unwanted pregnancies N=343 Using oral contraceptives Using condoms 269 Abstaining from sex Prior to Project implementation there was no baseline study undertaken for all the 13 districts that would have been used as basis for assessing the impact upon Project expiry. The findings of this End Term Evaluation cannot, therefore, provide the actual impact due to absence of baseline data to enable comparisons. However, comparison of these results with the baseline done in Nakasongola and Luwero among YPLHIV, reveals, though remotely, an increase in condom use as a contraceptive measure; at baseline, 34% reported using condoms. A decline is, however, observed on oral contraceptives (17%), injectables (49.1%) and implants or IUDs (8.5%). See Figures 1 and 2 based on Nakasongola and Luwero.
Figure 1: Project impact on selected behavior and practices parameters
Had comprehensive knowledge of HIV 1.8 (1.29-2.61)*** Had high level of self-efficacy 1.8 (1.30-2.55)*** Disclosed HIV status Used condom at last sex 1.7 (1.18-2.51)** Seek STI services ( past 6 months) 2.1 (1.46-2.89)*** 2.5 (1.61-4.01)*** Adherence to ART (self-report, past 14 days) Tested for CD4 at least once in the past 12 months 2.4 (1.54-3.61)*** Use of modern FP methods
Figure 2: Baseline and End Term Evaluation comparisons on selected parameters
Disclosed HIV status Had comprehensive For the majority of YP who got unwanted pregnancies, it happened when they were between 16-17 years. Slightly more females (65.3%) than males (57.8%) reported experiencing unwanted pregnancies in this age group. However, among those that got pregnant while aged 18-19, more males (42.2%) than their female counterparts (34.7%) reported to have ever got unwanted pregnancies. Among YP who had ever got unwanted pregnancies, 88.4% were taking measures to avoid falling in that trap again. Various safer sex practices have been adopted to avoid unwanted pregnancies; 78.4% adopted condom use, 20.1% were using oral contraceptives while 7.3% were abstaining from sex. 4.2.3 Level of self-efficacy to use HIV/SRHR services and commodities
The Project had a significant impact on YP's skills and confidence with regard to matters of sexuality. Reported self-efficacy on use of contraceptives, correct and consistent use of condoms to prevent HIV/STI transmission, getting tested for HIV and resisting peer pressure were all found to be high. For instance, 92% were confident to resist pressure from peers to engage in risky sex. Over 80% were confident to refuse sex with someone who does not want to use a condom. In equal measure, 86% were positive; they can convince their partner to use condoms. With regard to access to SRH/HIV services, Evaluation results revealed high self-efficacy levels. Over 80% reported feeling freely to go to a health center for condoms if they needed them. Even bigger proportions were confident to seek for HIV testing and STI treatment services from health facilities even at the detriment of their friends laughing at them (94.1% and 91.9% respectively). See Table 12.
Table 12: Reported skills and self-efficacy with regard to HIV/SRHR services and commodities
Indicators of self-efficacy
I am confident I can resist pressure from peers to engage in risky sex I am confident I can refuse to have sex with someone who does not want to use a condom I am confident I can convince my partner to use condoms I can correctly use contraceptives to avoid unwanted pregnancies I can access contraceptives whenever I need them I can go to a health center for condoms if I wanted them I can go to a health center for an HIV test if I wanted it I am confident I can seek for STI treatment even if my friends would laugh at me It is possible for an HIV+ pregnant woman to give birth to an HIV free baby I can have sex with anyone as long as I am or s/he is wearing a condom If STIs are not treated early and properly they can cause infertility I often feel stigmatized or discriminated because of my HIV status I am often discriminated or victimized because of my sexual orientation I am often harassed by law enforcement officers because of my work I always use a condom with my partner whenever we have sex I always use a condom with partners whose sero-status I don't know to avoid infection with HIV/STIs I am confident I can correctly and consistently use condoms with my partner(s) to prevent infection with STIs Evidence of YP making healthier choices was revealed by the Evaluation; 78.9% of the sample affirmed always using a condom with partners whose sero-status was unknown to them so as to avoid infection with HIV/STIs. Only 18.7% indicated that they did not always use condoms even with people whose sero status they did not know. Results further showed that among YP in relationships, over half (54.9%) always used a condom with their partner(s) whenever they had sex. Confidence to correctly and consistently use condoms to avoid infection with STIs was notably high (76.9%). This implies that only 20.6% had reservations on their ability to correctly and consistently use condoms. This could be attributed to the number of YP reached with information on safer sex in general. In the sample, slightly over half (52.7%) acknowledged that they had been taught by PEs/HWs on to correctly use condoms. In FGDs with FSW, many acknowledged learning how to correctly use a condom. I did not know how to help a man put on a condom, but now I do…we even have health centers that give us condoms; we now have our own condoms, even if a man does not have I provide (FGD with FSW, Makindye, Kampala). Sensitization by PEs and HWs on sexual behavior yielded results. The sensitization was quite effective; 88.2% were stimulated to take action about their sexuality. YP reported various actions/choices regarding their sexuality, for instance 80.2% started using condoms following the sensitization while others either chose to delay sexual debut (7.7%) or opted for oral contraceptives (11.6%). Evaluation results indicate that only 6% did not take any action following the sensitization on sexual behavior.
Project Impact on Quality of HIV/SRHR Services
4.3.1 Reported quality of HIV/SRHR services
Through the refresher trainings, mentorship and CMEs, LINKUP made a strong contribution on the improvement of the quality of HIV/SRHR services provided at health facilities. More than 70% of participants in the Evaluation rated the quality of HIV/SRHR services at facilities where they usually seek care between "Good" and "Average". Very few considered the HIV/SRHR services provided to be of poor quality. For instance, on HIV testing, 74.5% rated the quality as "Good" while 15.2% rated it "Average". Only 3.3% said the facilities where they usually seek care had poor HIV testing services. ART services were also rated highly; 55.7% rated it as "Good", 15.4% as "Average" while only 6% said it was poor. The rest (22.1%) could not rate the quality of ART services because they had not interfaced with it at the facilities where they usually seek care. The rating for quality of family planning services was also notable. See Fig. 3.
Figure 3: Reported quality of HIV/SRHR services in public and private facilities
Key: 1. Family Planning; 2. ANC; 3. Delivery; 4. Postnatal Care; 5. Post Abortion Care; 6. HIV Testing; 7. ART
4.3.2 Access to youth friendly SRHR services
The Project influenced establishment of Youth Corners at project participating health facilities to enable young people access freely SRHR/HIV services. Thirty-two percent (32.1) confirmed presence of a health facility within their communities with a Youth Corner. Presence of youth corners eased access and provision of youth friendly HIV/SRHR services. When LINKUP activities started, only 3 facilities had youth corners, but now additional 16 facilities have set up youth corners. We have been working with 23 facilities, so only 4 did not set up youth corners because of lack of space like Kamuli hospital and Bugiri hospital (KII FLEP). Mukono health centre set up a youth corner facilitated it with drugs and the youth have been separated from adults, so they are able to request for their services without fear (KII Naguru). We have set aside space for a youth corner although we have not yet operationalized it; we have not designated any clinic days yet, partly because young people come individually when in need of our services (HW Iganga Islamic HC III, Iganga). But even where Youth Corners had not been setup, YP reported access to youth friendly services. In the sample, 76.9% confirmed receiving respectful HIV/SRH services. Among them 35.9% revealed that at the facilities where they seek care, they are always free with the health workers and they even easily disclose their sexual history. The rest (41%) also confirmed that sometimes they have such friendly health workers in whom they freely disclose their sexual history. See Table 14.
Table 13: Availability of Youth Corners and friendly HWs
Young people who reported a youth corner at a facility in their community Services young people received from a youth corner in the past 3 years N=347 Health Education Young people who reported having friendly health workers at facilities they seek care Further, assessment revealed that both private and public health facilities were handling KPs in a friendly manner while delivering SRHR services. Over 60% of FSW in the sample were in agreement that HWs in both private and public health facilities handle them in a friendly manner when they seek for STI treatment. HIV+ young people also posted similar ratings; 69.4% and 78.7% concurred that HWs in private and public facilities respectively handle them respectfully (in a friendly manner) when they seek for STI treatment services. It was only Boda boda cyclists who reported getting better care from private facilities than public when seeking for STI treatment (see Figure 4). Figure 4: HWs who handle KPs seeking for STI treatment in a friendly way
friendly HWs were made by KPs with cyclists who reported that HWs handle them in friendly manner when they seek for condoms were 75.9% and 77.3% for public and private health facilities respectively. Private facilities among FSW and HIV+ Public facilities shared similar views
Figure 5: HWs who handle KPs that want condoms in a friendly way
Private facilities Public facilities Interviews with health workers, DHOs and other stakeholders also pointed to evidence of impact on the way HIV/SRH services at health facilities were provided to young KPs. Through this LINK UP project, service providers have been sensitized on how to handle young key population in the health facilities…stigma and discrimination has reduced. We appreciate that we are obliged to provide health services to all in need irrespective of who they are (DHO's Office, Mukono). We changed our service delivery practice of serving adults and adolescents together…after the training on integrating youth friendly SRH services; we designated a different clinic day for young people (HW Busesa HC IV, Iganga). We have seen a lot of attitude change, the health workers are upholding the rights of young KPs, they are using the Youth Charter at the facilities and even uptake of SRHR services has risen (KII CHAI). Drawing from these reports, it can be concluded that service provision evolved at most health facilities that participated in the project. Greater respect for the SRH rights of KPs was evident in the friendly way HWs handle them.
Table 14: Reports of facilities with HWs providing youth friendly SRHR services
Category of KPs Friendly Indifferent Discriminate
Ways HWs in private health facilities handle young people seeking for STI treatment Boda bodas Ways HWs in public health facilities handle young people seeking for STI treatment Boda bodas Ways HWs in private health facilities handle young people seeking for condoms Boda bodas Ways HWs in public health facilities handle young people seeking for condoms Boda bodas
4.3.3 Uptake of HIV/SRHR Services
Project impact on access and uptake of HIV/SRH services among KPs was notable. Many KPs sought
for STI treatment and HIV testing; among KPs that suffered from an STI in the past 3 years, 94% sought for treatment. Slightly more female KPs (96%) than the male (89%) sought for treatment of the STI infection. Proportions that received an HIV test as well as the results in the past year were high, nearly universal; 83% had tested within 1 year preceding the evaluation of which 99% had got their test result. More females than males tested for HIV (see Figure 6). Figure 6: Reported uptake for STI treatment and HIV testing among KPs in the past 1 year
Tested for HIV in past 1 year DHOs interviewed corroborated the reported increase in uptake for HIV/SRH services. Apparently, health center requisitions changed over the 3 years to reflect increased access to SRH services. There are higher quantities of relevant supplies requested for from the National Medical Stores to cater for the youth unlike in the past where it was a general request (DHO's Office, Kamuli). We have recorded a rise in the number of young people receiving SRH services…we started with only 8 youths 2½ years ago but now we have 35 who receive SRH services here (HW Nsinze HC IV, Namutumba). Currently, the uptake of family planning in Mukono is at 45% compared to 23% before implementation of the project started (DHO's Office, Mukono). Systems Strengthening at CHAU
The Project achieved more than it was intended to do; beyond supporting young KPs to achieve better SRHR, it supported the functional set up of CHAU. LINKUP supported hiring of staff, setting up all the human resource systems, finance and governance as well as M&E systems. Particularly in M&E, LINKUP introduced the syrEx program, made it easy to monitor of Project progress made in project implementation excellent. SyrEx eliminates double counting and has several rigorous checks which results into valid data. Further, LINKUP is credited for the transformation of the organization from being a project based to a programme based. Even the staff was transformed to understand and appreciate how KPs are handled. Project Impact on Organizational Development of IPs
The Project had a noticeable impact on the organizational development of the IPs. It helped in building their capacity in human resource, governance, finance and reporting. IPs like COYAA, Nyimbwa, Naguru Teenage and Information Health Centre were supported to set up governance structures; at project start, they lacked Boards which were crucial for oversight supervision and policy guidance. We built the capacity for most of the IPs along the way, whenever we realized a gap; we supported them to fill it. We helped some set up financial systems, like separating accounts for projects, when to return accountability; some even lacked finance officers… (KII, CHAU). Some IPs lacked staff, some were using part time staff who had no contracts, no files, so we supported them to put systems for human resource management; and since 30% of the LINKUP budget were allocated to administration, where we saw personnel gaps, we helped the IP to get staff (KII, CHAU). It was also reported that some implementing partners had no M&E systems prior to joining the consortium. Through LINKUP, these were supported; the project introduced a computer based monitoring system called syrEx to all the IPs, installed it and even trained their M&E staff on how to use it. Capacity of M&E staff was built on report writing; orientation on the LINKUP reporting template was also done. Some IPs had no M&E systems, others had limited skills in report writing; all these were enhanced by the project (KII, CHAU). I was trained in monitoring and evaluation and our 2 finance officers were trained by the project in financial management systems (KII, UNYPA). Implementing partners were in agreement with CHAU staff on the impact the project had on their organizations. They attributed some of the achievements, like funding opportunities, to participation in the LINKUP project. We have benefited a lot….now other organizations are looking for us…LINKUP gave us the exposure and brought more visibility to our work with KPs. We are going to get money from Global Fund, Ministry of Health and the AIDS Control Programme have recognized our role (KII, MARPI). The project has empowered us, at our facility; it trained three people, me, a midwife and an M&E person. I have improved in my counseling skills I now relate easily with young people as though we are peers; the midwife is also doing well…(HW Iganga Islamic HC III, Iganga). The Project is credited by some implementing partners for enabling them to network with other organizations doing related work. We got opportunity to network with other organizations like Mildmay, ICOBI and UYDEL. We also got more exposure, our reputation now in Kayunga is great following the interventions we spearheaded (KII, Naguru).
LINKUP generated higher outcomes that were expected; several un-intended outcomes were registered in the course of implementation. Some of the un-intended outcomes of the project include creation of IGAs, birth of networks of young people living with HIV, formation of a coalition for YP at the national level and building of organizational systems (OD). In Kampala and Luwero, particularly among PEs attached to Naguru Teenage and Information Health Center and HIV+ young people respectively, IGAs were set up. PEs and YP used the money which the project gave them for facilitation of meetings to start IGAs. Piggery, poultry and fish framing projects are among favorite schemes in which groups of young people are engaged. Birth of networks of YPLHIV was also not among the expected outcomes, but it was triggered by the training and mentorship given to YPLHIV to become advocates. YPLHIV realized a need for coordinating their activities and advocacy agenda, so formed a network. At the level of the implementing partners, LINKUP made a big contribution to the organizational development of the IPs. Capacity in human resource, finance and budgeting, reporting and accountability, governance, etc were built which helped some like FLEP to access funding from other donors to continue implementing similar activities targeting YP. LINKUP has enabled some organizations to access funds…like FLEP got funds to continue for another 3 or 4 years doing similar things to what LINKUP was doing, Mildmay also got and Marie stopes…(KII, CHAU Offices). A few negative outcomes were also recorded. For instance, an insatiable demand for HIV/SRH services was created in all project areas of operation. Mobilization activities attracted even older people not targeted by the project which exerted undue pressure on project resources. PROJECT LEVEL OF ENGAGEMENT OF PARTNERS, SUSTAINABILITY,
BEST PRACTICES AND LESSONS LEARNED
Project Level of Engagement of Partners
In order to realize greater respect for the SRHR rights of KPs, by design the project set out to engage various stakeholders at local level, district, national and international levels. This Section highlights project achievements in terms of level of engagement of partners, the lessons learned, best practices which can be used for future replication and the extent to which project outcomes/results are sustainable.
5.1.1 Engagement with policy-makers
Over the 3 years of project implementation, staff of CHAU and the beneficiaries (young KPs)
participated in several engagements with various stakeholders at international, national and lower levels. The stakeholders included Global Fund, UNAIDS, MoH, UAC, the Parliamentary Commission of Health, District technical and political actors, as well as international and national level NGOs promoting the rights of KPs like ICWEA and UGANET. Engagement with stakeholders like Global Fund, UNAIDS, MoH, UAC was mostly achieved through the representation of YP on various committees. CHAU and partners successfully lobbied for the inclusion and representation of young KPs on various policy spaces such as UAC's CCM, the MCH cluster, NAFOPHANU, the UGANET/ICWEA coalition and district-level working groups. By virtue of its position, representatives of KPs from the LINKUP project attended and participated in drafting the MARPs national priority plan under the guidance and leadership of UAC. They also participated in the MARPs technical working group meeting at MoH headquarters and the development of the Global Fund Concept Note. We supported the set-up of the MARPs technical working group which brought together several stakeholders. At the start we met quarterly and a number of frameworks have been developed though not yet finalized. We are also working on the MARPs service package (KII, CHAU). At the district level, LINKUP implementers and beneficiaries participated in meetings of the District AIDS Committee (DAC) and the District Planning Committees. Through these meetings, the respective district leadership was lobbied on inclusion of a budget vote for SRHR for adolescents particularly young KPs. Other engagements participated in over the 3 years of project implementation include organization and celebration of the World AIDS Day and Inter-generation dialogue meetings organised by Reach a Hand Uganda. The meeting which brought together young people, adults, MoH and other stakeholders, debated issues relating to access to SRH and HIV services among the youth.
5.1.2 Advocacy outcomes
LINKUP, through YP trained and mentored to lobby and advocate for their rights at all levels, expected to cause policy and practice changes with regard to HIV/SRHR for KPs. Although the project did not attain high impact policy changes, it made a lot of progress on other fronts. Some of the key areas where the project scored highly were on greater and meaningful involvement of the young KPs in planning and decision making; advocating against bad laws targeting people living with HIV/AIDS and sexual minorities; and changing practices of HWs that provide HIV/SRH services. Advocacy activities enabled young KPs to occupy several policy and planning spaces at international, national and lower levels. Through LINKUP, young KPs got a representative to UNAIDS, UAC and the district AIDS technical and political committees. By end of the project the districts of Namutumba and Bugiri had young people on the DAC and the planning committee. Through UNYPA and CYSRA, the LINKUP trained young KPs successfully lobbied and advocated for changes in laws that hitherto LINKUP inadvertently fostered stigmatization. Prior to LINKUP, the age of consent for HIV testing was 18 years; this meant young people needed consent of their parents or guardians before they could access the service. Young KPs successfully advocated for the lowering of the age of consent for HIV testing to 12 years. Further, the advocacy partners worked hard for the cancellation of the Anti-Homosexuality Bill. They also got MoH to recognize the right of sexual minorities to access health services. A memo to that effect was subsequently sent by MoH to the districts. The other success is embedded in the development and incorporation of the Youth Charter into the Global Fund Concept Note in 2014. The Youth Charter highlights the rights of young KPs with regard to health services. These have been disseminated to all health facilities in the project area. The outcome has been recognition of the special needs of young KPs by Global Fund; it has allocated funds to be given directly to young KPs. Overall, the main advocacy issues were creating an enabling environment for provision of integrated HIV/SRHR services for young people and getting them to occupy policy spaces at the district and national levels. The efforts have paid off; by the time of the evaluation, many health facilities were reported providing integrated youth friendly HIV/SRHR services and designated clinic days for young people. A notable proportion had even set up youth/young people corners at their facilities to ensure that young people access SRHR/HIV services without fearing that community members will see them. We managed to lobby the district leadership in Bugiri to increase funding for SRH which has been used to set up youth corners at public health centers. At the national level, we caused some changes on the HIV policy to include quality treatment and care for young people (KII CYSRA). However, there are some elements of outcome 4 that did not work well. For instance, the Project sought to reduce stigma and discrimination of KPs because of their sexual orientation, HIV status or source of livelihood through advocacy. The laws on sexual orientation have not changed; MSM continue to live in fear of being arrested for their sexual orientation. Similarly, sex work continues to be illegal in Uganda. As a result, KPs particularly MSM and FSW only feel free to interact with HWs they are familiar with i.e. met from outreaches and drop in-centers. Cases of district staff who would not implement decisions agreed upon, though isolated, were recorded particularly in eastern Uganda. This inadvertently constrained effective realization of some elements of outcome 4. Comparison of achievements against planned advocacy outcomes shows notable progress. The success registered over the past 3 years is mostly attributed to the training, orientation and mentorship provided by the project to representatives of young KPs. In addition, the financial facilitation LINKUP has been providing to the young KPs greatly enhanced their capacity to attend meetings regularly and to devote their time to the advocacy issues. Sustainability of Project Activities
A review of project documents and interaction with stakeholders and project beneficiaries points to the existence of in-built pillars of sustainability. The project's choice to implement core activities like information dissemination through the target population was a sign of in-building the sustainability plan in the design. All peer educators who worked on the project were picked from among the KPs and from the areas where the project was implemented. This will remain a big resource in the
The peer educators who we trained as community health workers will always be there even 10 years from now.we got from those communities and we shall leave them there when we leave At the time of the evaluation, several PEs interacted with were still working with the implementing partners and the health facilities where they were attached. Some expressed optimism to continue playing their role of disseminating information but were quick to add that they would limit their activities to young KPs within their locale. At an individual level, there are things I can continue doing like sensitization of people that come to me, I can also continue making referrals but mobilization might be challenging (Peer Educator, Iganga). Amidst the optimism, cases of slowdown of reduced, we used to have weekly meetings but as the project is coming to the end, they have stopped…the last one was in March 2015 (Peer Educator, Iganga). In some areas where implemented, precisely Iganga and Bugiri, the project PEs have already been linked to a new project in the region. Staff of FLEP confirmed that PEs had already been linked to the Obulamu programme implemented by FHI 360. We handed over the peer educators to the Obulamu Programme, they will continue performing their duties at the facilities where they have been attached (KII FLEP). Further, implementation of the project in collaboration with the district technical and political offices provided potential for sustainability. The project planned and utilized existing structures and resources i.e. health workers in public and private health facilities. DHOs, the district HIV focal persons and RDCs in all project districts of intervention were deeply involved in orientation of health workers through CMEs and workshops to appreciate the importance of providing integrated youth friendly HIV/SRHR services. A sense of ownership of project activities was observed. Promises of budgeting and implementing similar activities were made by district staff, and echoed by the Ministry of Health participants. We have designated focal persons for sexual and reproductive health in our health facilities, in the next budget we wnat to fund outreach and moonlight clinic activities. we are lobbying for funds in the next financial year to increase funds for drugs (KII, DHO's Office, KCCA). We are going to work together with CHAU and partners to mobilise communities to sustain the achievements registered by the Project (KII, MOH—Kampala) There was also a lot of optimism that the health facilities engaged in the Project would to a great extent manage to sustain the benefits of the Project even after LINKUP stopped. The health workers who were trained on provision of integrated HIV/SRH services are employees of the facilities, not recruited by the project. Consequently, they are considered a local resource which will remain with the health facilities even after the project. The skills, information and experience the health workers obtained from the project will continue to be used in the provision of youth friendly and integrated HIV/SRHR services. The Project's choice to work with established NGOs as implementing partners also points to existence of in-built pillars of sustainability. By the time of the evaluation several of the IPs had secured funding from other donors to continue implementing similar activities targeting young KPs. On the list is FLEP, MSIU and Mildmay; they used the lessons from the Project to lobby for funds from other donors to continue their work with young KPs. Overall, sustainability is in the people and fostered by availability of political will. We are confident that with unchanged donor priorities, stakeholders in the area will sustain project achievements and the results will be seen for many years (KII, CHAU Staff). Best Practices
Using beneficiaries and organizations with experience to deliver services; the IPs engaged on the Project had vast experience and expertise with KPs. For instance, MARPI had been working with FSW and MSM of all ages, Naguru was working with people living with HIV. Location of IPs in regions: this helped reduce the cost of operation and also ensure easier penetration. The Eastern region had FLEP which was a brain child of Busoga Diocese, Kampala and Mukono were assigned to Naguru, MARPI, ICOBI and UYDEL while Luwero and Nakasongola had UNYPA, COYAA and Nyimbwa. Using standard and internationally recognized monitoring systems: with LINKUP came syrEx which eliminates double counting. Work plans with a cascading model i.e., starting with small targets, then keep increasing over the years. This helps guard against overstretching the capacity of implementing partners at project onset, higher targets are set as more experience is generated. Project worked with technical advisors. The advisors routinely provided oversight guidance to the implementing team. Community entry meetings: enables project buy-in by key decision makers, provides opportunity for focussed planning, lead to avoidance of duplication of services and hence putting resources to utmost use. Assessing the monitoring and reporting capacities of implementing partners – helps in streamlining systems. Double counting eliminated, Continous Medical Education leads to mentorship, skills transfer to other HWs who miss training sessions organized by CHAU Lessons Learned
Various lessons can be learned from implementing this LINKUP project. Key among them is the importance of having Terms of Reference (ToR) for implementing partners, the benefits of working in a consortium; integration yields better results and a need for more time to implement high end projects.
Significance of ToR: Implementing a project through a consortium faces various challenges ranging
from duplication of efforts to underutilization of some actors. Developing and providing each member
of the consortium with ToR is a big step towards success and effective utilization of the resources at the project's disposal. The ToR specifies what each player is expected to do and even provides indicators to measure progress. It also ensures that the individual mandates and persona of the consortium members is not overshadowed by the project.
Working in a consortium: it was observed that multi-stakeholder engagement if done well can be
useful. It is important to engage and involve community gatekeepers in the implementation of the
project – they ensure easy entry, acceptance and ownership of the project. to access groups of young key populations like the FSW. Important to engage expert clients in the home visits for HIV+, they understand the situation and are better placed to provide psychosocial support and counseling.
Importance of integration: integration of HIV services into other SRHR services yields much more
results than when provided separately. The people in need of HIV services are the same that need
SRHR; so providing them together creates synergy and ensures access to a comprehensive service package. Integration of services helped a lot, patients received a variety of services on the same day for example one could come for HIV testing, they receive counselling and at the same time get family planning services (KI, Naguru). Project Time Frame: It was observed that LINKUP was a high end project which was given limited
time to generate sustainable results. The project needed a minimum of five (5) years, for instance,
issues like establishment of youth corners needed much more than setting aside space; sustaining them requires ownership of the concept by the health facility administration and other stakeholders.
Management and Governance Structures: It is important to have sound management and
governance systems. All donors want to work with organizations that have systems in place. At project start nearly all IPs had one or two things missing as far as organizational systems are concerned. All these systems were built and they will remain relevant to these organizations even at the end of LINKUP. 6.0 CONCLUSIONS AND RECOMMENDATIONS
This LINKUP project was implemented to achieve better SRHR for YP aged 10-24. From analysis of the results, review of project documents and interviews with IPs and the beneficiaries, the project largely achieved the objectives it set to realise. During the three years (2013—2015) and the additional no-cost extension half year i.e., to June 2016, the Project attained almost all the quantitative targets set at inception and made a notable impact on the target population. This demonstrated a high degree of effectiveness with which the Project was implemented. The Project successfully mobilized and reached out to young key populations with integrated HIV/SRH services implementing through local partners, peers and other local resource persons and infrastructure.
The design and implementation of Linkup Programme entailed elaborate strategies that ensured
sustainability through: advocacy targeting political, religious and community leaders who are
expected to ensure continuity of the programme interventions; continued engagement of high level
leadership at district level; wider participation of young people in the design and implementation
of linkup interventions led to increased programme ownership.
Linkup also invested in empowering communities to demand for services. The documented lessons
learnt, best practices and success stories will remain key reference points for future HIV/AIDS and
SRHR programmes. Linkup further worked with and through existing structures, hence continuity.
The integration of HIV/AIDS into SRHR will further ensure institutionalization and continuity of
HIV/AIDS response among young people. Technical and institutional capacity strengthening for
implementing partners' structures will ensure continued delivery of quality services. It should be
noted that the Link Up model facilitated realization of efficiency through pooling of resources and
employing a coordinated approach to the HIV/AIDS and SRHR response; thus minimizing
duplication and increasing efficiency and effectiveness. The re-engagement of leadership fosters
ownership and yields strong political will and better results.
Drawing from the findings, the evaluation team has made some recommendations to guide similar support in future. The following could be done in future to improve prospects of sustainability of similar project's outcomes.
M&E and Cordination
3. Improve the Linkup model and theory of change by reorganizing the Linkup qualitative results so that can be directly attributable to CHAU and Linkup. Strengthen and improve CHAU visibility, coordination and functioning. Strengthen CHAU M&E through systematic tracking of performance indicators. Continue building capacity in M&E for IPs. 4. Institutionalise regular review meetings between Local governments and IPs.
Advocacy and partnership
5. Scale up advocacy interventions that focus on equitable access to services, protection against GBV, and change to policies, laws and customs that limit the power and autonomy of vulnerable groups. Target particularly political, religious, cultural and other leaders, as well as district councilors.
6. Scale up engagement of cultural and religious institutions to address structural drivers of the epidemic and SRHR among young people. 7. Strengthen stakeholder engagement through development of partnership strategy and coordination. 8. Develop strategies for engagement of young people, cultural/religions leaders so that they initiate interventions in their communities.
Institutional Capacity Building
4. Strengthen institutional and technical and capacity IPs for delivering quality and inclusive HIV and AIDS and SRHR services. Strengthen systems and technical capacities of Community based and young people organizations to be able to access and handle resources. 5. Maintain the sustainability interventions by working through existing structures and strengthening their capacity; develop a clear and sustainable exit plan when funding projects to enable IPs be better positioned for the transition.
Behavioural Change Communication
3. Develop Social behavior Change Communication Strategy for SRHR for KPs 4. Design deliberate interventions targeting adolescent girls and other youths in secondary schools and higher institutions of learning. 5. Integrate youth empowerment interventions entailing life skills and livelihood skills with SRHR and HIV/AIDS interventions. 6. Develop a strategy for gender integration in SRHR and HIV/AIDS APPENDIX 1: EVALUATION TOOLS
LINK UP UGANDA END OF PROJECT EVALUATION
STRUCTURED QUESTIONNAIRE FOR YOUTH 10-24 YEARS
Hello, my name is I am working with a Consultancy Firm called Socio-Economic Data Center [SEDC]
on behalf of Community Health Alliance Uganda as a Research Assistant. We are conducting an evaluation for
the LINK UP UGANDA Project which has been running in your area since 2013. The purpose of this evaluation is to determine the effect of the project on the knowledge of young people (10-24 yrs) with regard to health issues like HIV/AIDS, family planning and STIs; their attitudes, perception of risk, self-efficacy/confidence and uptake of HIV services, Family planning, testing and treatment of STIs. The interview will take about 20-30 minutes to complete and it is anonymous which means your name and address will not be recorded. If you agree to participate, you have a right not to answer a question that you feel uncomfortable responding to and you are free to stop the interview at any time. Whatever you tell me will be kept confidential and will be combined with responses from over 1,000 other young people drawn from six districts.
INTERVIEWER'S NAME DATE Time started
SECTION 01: IDENTIFIERS
Village (Record the Name)
Location of village (rural, urban, peri-urban)
SECTION 1: BACKGROUND CHARACTERISTICS OF RESPONDENT
How old are you? Interviewer: Write age in completed years
Sex of Respondent: Interviewer: Read out the options
Marital Status – Are you currently ……? Single and Never Married Unmarried, but in relationship Interviewer: Read out the options
Married/ Cohabiting Widowed/Separated Other (specify) _ What is your main occupation or main source of income?
Public transport Question
Clerical /office work Bar/Restaurant attendant What is your religious affiliation? Are currently in school or not? What is the highest level of education attained Primary, Not Completed Primary, Completed Tertiary/Vocational
SECTION 2: KNOWLEDGE AND AWARENESS ABOUT HIV AND SRHR SERVICES AND PRODUCTS
Have you heard or received information about the
following in the past 3 years? Unwanted pregnancies SRH Rights for youth Have you attended any training or a meeting in the past
3 years where you were educated/sensitized about Unwanted pregnancies prevention of the following….? Prevention of HIV Prevention of STIs Interviewer: Read out the options
Where did this training or sensitization meeting take Boda boda stage Taxi/truck stage Multiple responses allowed
Community hall/playground Other (specify) _ Were you provided with any information, education and communication (IEC) materials with messages on
SRHR/HIV at this place [ mention the place] during
or after the sensitization? What IEC materials did you receive at this place [ mention the place] during or after the
Brochures/factsheets Posters/calendars Multiple responses allowed
Water bottles/Wrist bands Were you provided with any services, commodities or products at this place [ mention the place] during or
after the sensitization? Question
What services, commodities or products did you receive HIV counseling & testing at this place [ mention the place] during or after the
Referral to health center Multiple responses allowed
Oral contraceptives for FP Has anyone [e.g. a health worker, peer educator, NGO staff etc.] showed you how to correctly use a condom? Did anybody [e.g. a health worker, peer educator, NGO staff etc.] talk to you about any of the following in the Personal hygiene 1 Interviewer: Read out the options
Sexual gratification 1 Sex before marriage 1 What action(s) did you take after the health worker/ peer educator/ NGO staff talked to you about that sexual Stopped masturbation behavior (insert option mentioned above)? Started using condoms Got contraceptives Multiple responses allowed
Abstained from sex Delayed sexual debut Refused bad touches Other (specify) _ What source of information did you learn most from
about SRHR (i.e. HIV, STIs, pregnancy & rights) in the
Telephone/Social Media Brochures/leaflets Youth Club discussions Circle only 1 response
Educative Film /Tuk Tuk Health workers at facility Outreaches/service camps Peer educators/door-to-door Other (specify) _ Did you feel stimulated to take action like go for an HIV test, STI test or avoid unprotected sex? What action(s) did you take after listening or receiving Took an HIV test information about SRHR (i.e. HIV, STIs, pregnancy & Started using condoms Got FP contraceptives Multiple responses allowed
Abstained from sex Other (specify) _ Have you been referred to a health facility for any SRH services in the past 3 years by a peer educator or health worker from an outreach site or from your area? Did you receive the SRH services for which you had been referred to the health facility? Question
What SRH services did you receive from the health facility where the peer educator or health worker Male circumcision What is the distance to the health center nearest to your What type of health center is nearest to your home? Private for profit Public/Government Does the health center nearest to your home provide the following services? Interviewer: Read out options
Post Abortion care STI testing & treatment Have you sought for any health service from the health center nearest to your home in the past 3 years? What health services did you get in the past 3 years from the health center nearest to your home? Post Abortion care Multiple responses allowed
STI testing & treatment Do you know where you can obtain any of the following SRH/HIV services within your community? Interviewer: Read Out Options
Post Abortion care Oral contraceptives Do young people (10-24 yrs) in your community have easy access to the following SRH/HIV services? Interviewer: Read Out Options
Post Abortion care Oral contraceptives Question
Is there a place or facility within your community where young people (10-24 yrs) like you can obtain SRH services to meet their needs without any fear? Have you heard about the LINK UP Project which
targets young people 10-24 yrs with HIV/SRHR Have you been visited by a peer educator on the LINK UP Project at your home or workplace in the past 3 Are you a member of the Triple S Club [Stay Safe and
Have you accessed or posted any SRHR information on the Triple S Club Face book page?
How many meetings of the Triple S Club have you
attended in the past 1 year? What are the reasons you have not attended any Triple
They are a waste of time S Club meetings in the past 1 year?
Leaders are inactive
SECTION 3: SEXUAL BEHAVIOR AND INTENTIONS OF YOUNG PEOPLE (10-24 YRS)
301 Have you ever had sexual intercourse? 302 How old were you the first time you had sexual 303 When was the most recent time you had sexual 13-24 months ago 25-36 months ago More than 3 yrs ago 304 If not had sex in past 2 years; what are the reasons
Influenced by LINK UP project you have not had sex in the past 2 years? Reducing risk of STIs/HIV To avoid unwanted pregnancy No sexual partner Other (specify) _ 305 Have you ever been abused sexually/molested 306 Given your current life style, do you consider yourself at risk of infection with STIs particularly Already infected 307 Are you doing anything to prevent yourself from contracting STIs particularly HIV? 308 What measures have you taken to prevent yourself from contracting STIs particularly HIV? Test partner before sex Multiple responses allowed
Test HIV & remain faithful Question
309 Have you ever got an unwanted pregnancy or made someone pregnant by accident? 310 How old were you when you got this pregnancy that you did not want? 311 Are you currently taking any measures to ensure that you do not get unwanted pregnancies or make someone pregnant by accident again? 312 What are you doing to ensure that you do not get Using oral contraceptives unwanted pregnancies or make someone pregnant by accident again? Abstaining from sex Multiple responses allowed
Other (specify) _ 313 Are you currently doing anything to prevent yourself or your partner(s) from getting pregnant? 314 What family planning/birth control measures are you currently using to avoid getting pregnant or your partner pregnant? Other natural FP methods 315 For females only: Have you ever needed to use a
birth control measure but failed to get it? 316 At what age do you plan to become sexually active? 317 What measures will you take when you become sexually active to prevent yourself from contracting Test partner before sex STIs particularly HIV? Test HIV & remain faithful Avoid multiple partners Multiple responses allowed
318 What will you do to ensure that you do not get Use oral contraceptives unwanted pregnancies or make someone pregnant Avoid multiple partners Multiple responses allowed
Other (specify) _
SECTION 4: ATTITUDES, PERCEPTIONS AND SKILLS/SELF EFFICACY WITH REGARD TO
Interviewer tell respondent: Now I am going to read for you a number of statements, they
depict other people's beliefs, attitudes and perceptions with regard to SRHR/HIV. Please tell me whether you "agree" or "disagree" with the statement read. There is no correct or wrong answer, they are simply opinions. No. Statements
400 I am confident I can resist pressure from peers to engage in risky sex 401 I can correctly use contraceptives to avoid unwanted pregnancies 402 I can access contraceptives whenever I need them 403 I can go to a health center for condoms if I wanted them 404 I am confident I can convince my partner to use condoms No. Statements
405 I am confident I can correctly and consistently use condoms with my partner(s) to prevent infection with STIs 406 I am confident I can seek for STI treatment even if my friends would 407 I can go to a health center for an HIV test if I wanted it 408 I always use a condom with my partner whenever we have sex 409 I always use a condom with partners whose sero-status I don't know to avoid infection with HIV/STIs 410 It is possible for an HIV+ pregnant woman to give birth to an HIV free 411 I can have sex with anyone as long as I am or s/he is wearing a condom 412 If STIs are not treated early and properly they can cause infertility 413 I often feel stigmatized or discriminated because of my HIV status 414 I am often discriminated or victimized because of my sexual 415 I am often harassed by law enforcement officers because of my work 416 I am confident I can refuse to have sex with someone who does not want to use a condom
SECTION 5: QUALITY OF HIV/SRHR SERVICES AND UPTAKE
What is your assessment of the quality of HIV/SRH services offered at the health center where you usually seek for care? Post Abortion care Interviewer: Read out Options
How well do health workers in Friendly Indiffere private health facilities within your
community treat or handle young Young people with people (10-24 yrs) seeking for STI
Interviewer: Read out
Boda bodas options…. how do they handle……?
How well do health workers in Friendly Indiffere public health facilities within your
community treat or handle young Young people with people (10-24 yrs) seeking for STI
Interviewer: Read out
Boda bodas options…. how do they handle……?
How well do health workers in Friendly Indiffere Question
private health facilities within your
Young people with community treat or handle young people (10-24 yrs) seeking for Boda bodas Interviewer: Read out
options…. how do they handle……?
How well do health workers in Friendly Indiffere public health facilities within your
community treat or handle young Young people with people (10-24 yrs) seeking for Interviewer: Read out
Boda bodas options…. how do they handle……?
Do young people (10-24 yrs) in your community find it easy or easily disclose information regarding their sexual history to service providers at the facility where you seek care? Is there a Youth Corner at the health facility in your community
where you seek care? What health related services have you obtained in the past 3 years Health Education from the Youth Corner at the health facility where you seek care?
Have you suffered from any sexually transmitted infection in the Did you seek treatment from a health center for the STI you suffered in the past 3 years? If Not, what are the reasons you never sought for STI treatment not available treatment from a health facility for the STI you suffered? Didn't take it seriously I didn't know where to go Have you ever tested for HIV? Have you tested for HIV in the past one (1) year? Did you receive your HIV test result? What was the result of your HIV test? SECTION 6: FOR YOUNG PEOPLE 10-24 EXITING HEALTH FACILITIES AFTER GETTING SRHR SERVICES
Interviewer: Ask these questions to only Young people 10-24 yrs sampled at health facilities
Interviewer: Record the type of
Public /Government HC health center visited Private facility – Blue Star Other private for profit clinic NGO/Faith-based facility Other (specify) _ Have you received any of the
following services from this health facility today?
Oral contraceptives Other FP methods Interviewer: Read out Options
Post abortion care HIV counseling & testing STI testing & treatment Counseling on GBV What made you decide to come to I was referred here this health facility for care? Health workers are friendly HC has quality services Multiple responses allowed
It is near my home Services are free Other (specify) _ What is your assessment of the quality of HIV/SRH services you have got from this health center Oral contraceptives Other FP methods Interviewer: Check those
mentioned in 601, read them
Post Abortion care HIV counseling & testing STI testing & treatment How well do health workers in this Friendly Indiffere health facility treat or handle young people (10-24 yrs) seeking for STI
Young people with treatment services?
Interviewer: Read out
options…. how do they handle……?
Boda bodas How well do health workers in this Friendly Indiffere health facility treat or handle young people (10-24 yrs) seeking for Young people with Interviewer: Read out
options…. how do they handle……?
Boda bodas Question
How well do health workers in this Friendly Indiffere health facility treat or handle young people (10-24 yrs) seeking for oral
Young people with Interviewer: Read out
options…. how do they handle……?
Boda bodas Do you find it easy to disclose information regarding your sexual history to service providers at this facility? Is there a Youth Corner at this health facility?
What health related services are provided in the Youth
Health Education Corner at this health facility?
Psychosocial support THANK YOU VERY MUCH FOR YOUR TIME AND FOR SHARING YOUR EXPERIENCES
APPENDIX 2: LIST OF PERSONS MET
1. Mr. Bogere Ali – Iganga Municipal Islamic HC III 2. Isabirye Joseph – Peer Educator, Iganga 3. Sr. Nangobi Phoebe – Busesa HC IV 4. Sr. Namusaabi Ruth – Assistant District Health Officer, Iganga 5. Mr. Bwire Charles – Advocacy Officer, CYSRA 6. Sr. Walujjo Emma – Nsinze HC IV, Namutumba 7. Mr. Okello Benson – Project Officer, FLEP 8. Dr. Kiirya James – District Health Officer, Namutumba 9. Ms. Kyebajja Gorret – Namutumba HC III 10. Sr. Nangobi Eunice – Kamuli General Hospital, Kamuli 11. Mr. Lyagoba Moses – Assistant District Health Officer, Kamuli 12. Sr. Ivumba Aida Ruth – Namasagali HC III 13. Dr. Tumushabe – District Health Officer, Mukono 14. FGD with FSW- Kamuli 15. Mr. Niwagaba Nicolas, UNYPA 16. Ms. Nakayiza Lovinka – UNYPA 17. Dr. Ampwera Rogers – CHAU 18. Dr. Bitira David – CHAU 19. Mr. Otiti Micheal – CHAU 20. Dr. Magina Joseph – LINKUP Project Coordinator, MARPI 21. Ms. Nakasi Jackie – UYDEL 22. Ms. Nabbosa Rebecca – LINKUP Project, Naguru Teenage and Information HC 23. Sr. Ndegeri Dorothy – Midwife, Naguru Teenage and Information HC 24. FGD with HIV+ young people – Naguru, Kampala 25. Mr. Asiimwe Tonny – TukTuk 2, Marie Stopes International Uganda 26. Mr. Lwalira Bernard Dennis – Peer Educator, MSIU 27. Sr. Nabbanja Catherine – In-charge, Komamboga HC III 28. Mr. Isanga Moses – LINKUP Project Officer, Mildmay Uganda 29. FGD with FSW, Space Bar, Makindye Kampala 30. Mr. Kiggundu Paul – DHO's Office, KCCA
Undersökning av spill och läckage vid hantering av antibiotika inom sjukvården Slutrapport AFA-projekt 07-0043 Olle Nygren och Roger Lindahl Gruppen för Arbetsmiljökemi Miljö- och Biogeokemi Kemiska Institutionen Umeå Universitet Projektet, som redovisas i denna rapport, är ett tillämpat projekt med syfte att dels beskriva omfattningen av det spill och läckage av antibiotika, som förekommer vid svenska sjukhus, dels att ta fram exempel och förslag på åtgärder som kan vidtas för att minska omfattningen och spridning detta spill och läckage. En viktig del av detta projekt är därför en återkoppling av resultat till den undersökta och berörda målgruppen. Denna rapport utgör en viktig del av denna återkoppling.