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Situation Analysis for the Trachoma Control Programme,

(F&E Module) (Uganda)

January 2014

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I. Demographic and Disease Information As of 2013, Uganda had a total population of approximately 36 million, 49% of whom are under 15 years of age. The vast majority of the population lives in rural areas (84%); only 16% live in urban areas, defined by the Uganda Bureau of Statistics as gazette administrative centers with a population greater than 1,000. The population is equally split between men and women. With the introduction of universal primary and secondary education, 66% of children between 6 and 9 years old attend school. This increases to 94% of 10 – 14 year olds. The adult literacy rate is 76% for men and 64% for women. In Karamoja and Busoga regions, adult literacy rates are lower, particularly for women as indicated in the table below. Region % of Men Literate % of Women Literate Karamoja 63% 23% Busoga 72% 58% 36 of 112 districts are trachoma endemic. 17 of the endemic districts are located in Busoga (10) and Karamoja (7) Regions. The following data was collected from the 2011 Ministry of Water and Environment Annual Sector Performance Report.

Region District

Access to improved water

(%)

Access to improved sanitation facility (%) TF (%)

Busoga Bugiri 41-65 >70 10.4 Busoga Buyende 41-65 >70 2.3 Busoga Iganga 41-65 60-77 6.9 Busoga Jinja 66-77 >70 10.1 Busoga Kaliro 41-65 >70 6.3 Busoga Kamuli 66-77 >70 5.4 Busoga Luuka 41-65 40-60 20.1 Busoga Mayuge 41-65 40-60 14.9 Busoga Namayingo 19-40 40-60 10.4 Busoga Namutumba 41-65 40-60 20.1 Karamoja Abim 66-77 20-40 65.7 Karamoja Amudat 19-40 <20 57.8 Karamoja Kaabong 19-40 <20 65.7 Karamoja Kotido 41-65 <20 65.7 Karamoja Moroto 19-40 <20 57.1 Karamoja Nakapiripirit 41-65 <20 57.8 Karamoja Napak 41-65 <20 57.1 National (Rural Areas) 64 71 National (Urban Areas) 70 82

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As can be seen, the prevalence of TF is more closely correlated with access to improved sanitation facilities than access to improved water.

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Region District Water

coverage [%] Functionality

[%]

Busoga Bugiri 45 91

Busoga Buyende 42 86

Busoga Iganga 62 87

Busoga Jinja 73 90

Busoga Kaliro 62 95

Busoga Kamuli 67 90

Busoga Luuka 58 93

Busoga Mayuge 42 85

Busoga Namayingo 24 47 Busoga Namutumba 60 83

Karamoja Abim 84 78

Karamoja Amudat 23 83

Karamoja Kaabong 19 84

Karamoja Kotido 42 82

Karamoja Moroto 32 90

Karamoja Nakapiripirit 51 85 Karamoja Napak 49 77

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While the above table does not show the percentage of the population that practices open defecation, it can be assumed that households in Karamoja and parts of Busoga Region are within the poorest 20% of the population. This would indicate that at least 22.7% of the households in these areas are practicing open defecation. All TF, TT and dirty face (DF) data were collected during baseline surveys in 2006/2007 except for the following districts in Busoga Region that had impact assessments in 2013: Buyende, Iganga, Kaliro, Kamuli.

The MDA coverage data is from MDAs conducted between 2007 and 2012.

Note that some districts have split since the baseline surveys were conducted. Split districts have the same TT, TF, DF data until an impact assessment is conducted.

Region District TT (%) TF (%)

Dirty Face (DF* (%)

Program Coverage

(SAFE)

Treatment (Number of yrs >

80% coverage)

Busoga Bugiri 3.8 10.4 41.1 SAE* with limited F 0/4 yrs > 80%

Busoga Buyende 3.3 2.3 * SAE with limited F 1/5 yrs > 80%

Busoga Iganga 4.86 6.9 * SAE with limited F 1/4 yrs > 80%

Busoga Jinja 2.1 10.1 25 SAE with 1/2 yrs > 80%

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*Environ

mental improvement activities are carried out by the Ministry of Water and Environment and WASH partners.

limited F

Busoga Kaliro 3.85 6.3 * SAE with limited F 2/5 yrs > 80%

Busoga Kamuli 2.9 5.4 * SAE with limited F 2/4 yrs > 80%

Busoga Luuka 3.8 20.1 71 SAE with limited F 1/5 yrs > 80%

Busoga Mayuge 3.2 14.9 35.4 SAE with limited F 2/2 yrs>80%

Busoga Namayingo 3.8 10.4 41.1 SAE with limited F 1/5 yrs > 80%

Busoga Namutumba 3.8 20.1 71 SAE with limited F 3/5 yrs > 80%

Karamoja Abim 17.5 65.7 52 SAE with limited F

4/4 yrs > 80%

Karamoja Amudat 17.9 57.8 69.8 SAE with limited F 0/4 yrs > 80%

Karamoja Kaabong 17.5 65.7 52 SAE with limited F 0/4 yrs > 80%

Karamoja Kotido 17.5 65.7 52 SAE with limited F 0/5 yrs > 80%

Karamoja Moroto 14.8 57.1 68.7 SAE with limited F 3/4 yrs > 80%

Karamoja Nakapiripirit 17.9 57.8 69.8 SAE with limited F 0/4 yrs > 80%

Karamoja Napak 14.8 57.1 68.7 SAE with limited F 3/4 yrs > 80%

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Very little research has been done on the knowledge, attitudes, and beliefs that influence face washing and latrine use in Trachoma endemic areas of Uganda. In 2013, JHU·CCP conducted a literature review and behavioral research in Iganga and Moroto districts, looking at face washing and environmental sanitation knowledge, attitudes and practices. Four key findings from the research were:

• Even when latrines were available, many people shunned their use for cultural and normative reasons;

• Even when water was available, people rarely washed their faces; • Most people in both districts feared Trachoma but did not understand the

relationship between Trachoma, face washing, and sanitation; and • The majority of parents felt helpless to protect their children from Trachoma.

Nationally in 2013, 71% of water points had functioning Water and Sanitation Committees linked to the water point and over 80% of these Water and Sanitation Committees had women holding key posts. As of FY 2012/13, all districts had formed District Water and Sanitation Committees and carried out meetings except Moroto and Kotido. In the case of districts with functional committees, progress has been noted in areas of harmonization of approaches and in joint planning and implementation of activities.

The movement and culture of pastoralist populations in Karamoja will need to be considered when developing latrine promotion programs. Additionally, occasional drought in the region causes mass famine which greatly affects the Karamoja population. The program will need to keep these challenges in mind when carrying out F&E activities. There is a very strong system of Elders in Karamoja which should be capitalized on when conducting any outreach activities.

Fishing communities in Busoga Region are extremely hard to reach areas and access to hygiene and sanitation improvements are limited in the coastal areas.

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Region* District Populati

ons per district▲

No. of villages

Population under five years

Population 5-14 years

Total number of primary schools*

Primary school enrolment*

Number of health facilities*

Referral Hospitals

District level

Health centres

Busoga Bugiri 426800 390 85360 123772 208 107751 0 1 44

Busoga Buyende 265100 347 53020 76879 161 72794 0 0 17

Busoga Iganga 499600 445 99920 144884 207 119645 0 1 42

Busoga Jinja 501300 554 100260 145377 164 86556 1 1 66

Busoga Kaliro 216500 485 43300 62785 101 50371 0 0 16

Busoga Kamuli 500800 654 100160 145232 236 130112 0 1 51

Busoga Luuka 260900 233 52180 75661 210 79532 0 0 24

Busoga Mayuge 461200 490 92240 133748 234 125253 0 0 29

Busoga Namayingo 232300 212 46460 67367 113 53955 0 0 22

Busoga Namutumba 218900 230 43780 63481 140 69013 0 0 30

Karamoja Abim 56,500 200 11,300 16,385 46 27205 0 1 10

Karamoja Amudat 113700 94 22740 32973 12 6382 0 0 8

Karamoja Kaabong 395200 256 79040 114608 62 37410 0 1 25

Karamoja Kotido 233300 165 46660 67657 26 17594 0 0 9

Karamoja Moroto 136000 86 27200 39440 30 10964 1 0 43

Karamoja Nakapiripirit 161600 135 32320 46864 43 17595 0 0 19

Karamoja Napak 197700 126 39540 57333 36 16374 0 0 9

*Data is from the NTD Master Plan for Uganda 2013-2017. Population data is from 2011.

Impact Assessments are carried out in trachoma endemic districts after completing 3-5 years of MDA. The impact assessment tool does not measure any changes in knowledge or attitudes, but the tool measures the change in clean faces, proper use of toilets, presence of garbage, and the availability of garbage bins from baseline to impact which could be considered to measure behavioral changes. However, it should be noted that while there is a definition of these indicators they are subjective measurements and difficult to compare the baseline measurement with the impact measurement. Currently, no other performance monitoring plans are in place for the trachoma program. Uganda has a well-developed policy framework stemming from a constitutional provision that every Ugandan has the right to a clean and health environment and that it is the duty of every citizen to create and protect such an environment. The Public Health Act (1964, updated 2000) provisions prevention and suppression of infectious disease, sanitation and housing. The 1999 National Health Policy emphasizes sanitation and hygiene promotion as a key public health intervention. The 2005 National Environmental Health Policy establishes environmental health priorities and provides a framework for the development of services and programs at national and local government levels. The Universal Primary Education Policy emphasizes that all primary schools have health programs. In 2010-2015 The National Development Plan recognizes CLTS as one of the hygiene and sanitation approaches in the country.

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The WASH Sector Performance Framework was developed in 2003 with 10 performance themes for water and sanitation that include: impact, quantity of water, quality of water, access, equity, usage, value for money, affordability, functionality and managerial. It includes both process related and behavioral indicators, including: percentage of water points with actively functioning water and sanitation committees (rural/ WFP)/water supply and sewage boards (urban); percent of people within 1.5 km (rural) and 0.2 km (urban) of an improved water source; percentage of people with access to (and use of) improved and basic latrines/toilets; percentage of people with access to (and use of) hand washing facilities; percentage of water points with actively functioning water and sanitation committees; and percentage of water and sanitation committees/water boards with women holding key positions. In a bid to scale up sanitation and hygiene in Uganda, an agreement was made in 2008 by 3 ministries to clarify institutional responsibilities: Ministry of Water, Land and Environment (MWLE), responsible for provision of public latrines in towns and rural growth centers; works with National Water and Sewage Corporation (NWSC) to provide sewerage disposal; Ministry of Health (MoH) responsible for hygiene promotion at household level; Ministry of Education and Sports (MoES) Department of Primary and Pre-primary Education, responsible for school latrine construction and hygiene education.

II. Trachoma and WASH Coordination Information

The trachoma program is currently under the NTD Program in the Vector Control Division of the MOH. The following diagram outlines the NTD Training, Management and Reporting Flow Chart for the National NTD Program.

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NTD Coordination Team

NTD Coordinator, Schisto/STH Program Manager, Trachoma Program Manager, Onchocerciasis Program Manager, Lymphatic Filariasis Program Manager

Ministries: MOH Health Promotion and Health Education, MOH Environmental Health, Ministry of Education, and Ministry of Water and Environment

NTD Partners: Schistosomiasis Control Initiative, RTI/ENVISION, Sightsavers, The Carter Center, APOC, WHO,

The Uganda Water and Sanitation NGO Network UWASNET members work in different parts of the country implementing Water, Sanitation and Hygiene (WASH) activities in various districts countrywide. UWASNET is structured to reach the grass root members through the Regional Co-ordinators placed in the 10 UWASNET regions namely:

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o Central region coordinated by CIDI o Mid-central region coordinated by Caritas MADDO o South-western region coordinated by ACORD o Rwenzori region coordinated by HEWASA o West-Nile region coordinated by YODEO o Lango-Acholi region coordinated by J.O.Y Drilling Deliverance Church o Mid-eastern region coordinated by UMURDA o Busoga region coordinated by Busoga Trust o Teso & Karamoja region coordinated by SOCADIDO o Karamoja sub-region coordinated by Karamoja Diocesan Development

Services The below map outlines the 10 UWASNET regions

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Trachoma and WASH staff structures

Level NTD Program WASH District NTD Coordinator District Water Officer,

Environmental Health Officer, Water and Sanitation Coordination Committee (includes technical departments, NGOs, and local government representation)

Sub-County NTD Supervisor Health Assistant (in charge of sanitation and school health), Community Development Assistants

Parish NTD Supervisor Parish Chief (under local government)

Community Village Health Teams, Community Medicine Distributor

Community Water and Sanitation Committees, Village Health Teams, LC1

Uganda is part of the Global Alliance for the Elimination of Trachoma by 2020, which has a mandate for eliminating trachoma by 2020. The elimination plan and the means by which to reach their goal (WHO recommended SAFE strategy for elimination of blinding trachoma) is found in the Uganda NTD Master Plan and the Trachoma Action Plan developed and approved by the Ministry of Health.

The NTD Program established a Technical Working Group to provide technical guidance for all NTD activities. The Trachoma Program falls under this group and any changes in the trachoma program will need to be approved by the technical working group before programmatic changes can be implemented.

The Technical Working Group is funded by the MOH and RTI/ENVISION and has the responsibilities for guiding and implementing all WHO recommended guidelines for the trachoma program.

The program will adjust activities to strengthen the program based of preferred practices but the strategy will not change. The ultimate goal is to reduce the prevalence of TF to less than 5% at the sub-district level and to have less than 1/1000 people with trichiasis in the population by 2020. The first set of data was collected during baseline surveys. This data has been collected from 2006 – present. The program started implementing the full SAFE strategy in districts with TF>10% and is conducting surgery activities in these districts. Impact assessments have recently been finalized. Data for 4 of the 12 districts surveyed is currently available. Two of the endemic districts are now below 5% TF and will start post-endemic surveillance activities

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in 2014 per WHO guidelines. Two of the endemic districts are between 5-10% TF and sub-district level mapping is being planned. The impact assessment data for the remaining districts is still being analyzed.

The MOH Health Promotion and Education Division (HPED) reviews and approves all trachoma-related materials produced and distributed in the country. All health education materials used by the MOH and their partners need to be approved by the Division of Health Promotion and Education before use in the districts. Any tools developed need to first be approved by the Program Manager and NTD Coordinator before being given to the Division of Health Promotion and Education for approval. Once approved by the HPED, the Director General gives the final approval. The NTD Secretariat recently developed a communication strategy in which part of the strategy was the review of existing materials and development of a new set of tools. These tools were recently printed and are available at the Vector Control Division for use by the NTD Program and their partners.

The NTD Technical Working Group develops the plans for distributing IEC materials. IEC tools with SAFE messages are disseminated according to the MOH structure: 6 posters/village; district and sub-county trainers receive flipcharts; VHT field guide distributed to CMDs (~1book/2CMDs); Training of trainers manual distributed to district trainers; district-based radio programs are supported in endemic districts according to annual plans. The NTD Secretariat has an advocacy plan with specific objectives (see below). They have invited UNICEF to their meetings but have not presented epidemiological data about Trachoma to WASH stakeholders or discussed integration of Trachoma messages with WASH interventions. To date, the Trachoma Secretariat has not worked with government WASH staff on Trachoma prevention.

The WASH program has guidelines such as The National Sanitation Guidelines, The Improved Sanitation and Hygiene Strategy (ISH), The Kampala Declaration on Sanitation (KDS+10), but they are under review.

The Ministry of Education and Sports has included trachoma in its curriculum for primary school. It is academic and does not include practical application. There are, however, many opportunities for working with primary schools. Health Assistants, based at sub-county level are responsible for implementing the school health program. Many schools have health clubs, and some carry out health parades, where the teachers inspect students and make them wash their faces if they are dirty. This practice, however, has died out in many schools.

Other potential partners in the prevention of trachoma include Wateraid (active in Karamoja), Plan International (active in Busoga), AMREF, UNICEF, and the Child Fund. The best way to involve them in trachoma prevention is through modification of their current tools to include face washing, to engage the WASH organizations in stakeholder meetings, and participating in the Water and Sanitation Coordinating bodies at district level.

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AMREF is conducting a school-based WASH promotion project in a few districts of Uganda that currently does not include face washing, but could incorporate trachoma prevention.

III. Behavior Change Communication (BCC) Tools for Trachoma and WASH The Ministry of Health has communication strategies for many health areas (eg. reproductive health and family planning, HIV/AIDS, malaria, male circumcision). These are available through the MOH website. In addition, the NTD Programme recently developed an NTD Communication Strategy. There is no national communication strategy for the WASH sector, although individual partner organizations may have their own. Sightsavers and JHU.CCP are currently developing a communication strategy for Trachoma prevention.

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Tools that currently exist in country that support Trachoma control (SAFE) and WASH

Organization Type of Material

Quantity Distributed

Description of Tool Quality of Production (H, M, L)

Quality of Messaging (H, M, L)

Culturally appropriate?

Link between materials and communication strategy?

Tools being used as intended?

Electronic copies available?

Appropriate for community mobilization?

Materials available at district/school level for F&E?

MOH NTD Program

Flipchart 2,000

Training tools for Central, District and Sub-County Trainers. Integrated tools with one page on trachoma.

H – large photos, clear text on back of flipchart to guide trainers

L – limited messaging on SAFE, messages are incorrect

Meant to be used nationally

Yes, was developed in line with NTD communication strategy

Yes Yes No No, used for training

MOH NTD Program

Booklet

39,261 (Teachers)

80,460 (CMD)

Field Guide for Supervisors and Teachers in Uganda (2010) – distributed to supervisors, teachers and CMDs

M – too much text and not enough photos

L – mostly text, limited number of photos, too much emphasis on stages of disease and too little on prevention

Meant to be used nationally

Was developed pre-strategy, used for training and in school curriculum

Yes Yes No Yes, with supervisors, teachers and CMDs

MOH NTD Program

Fact Sheet Same as above

Fact sheet for all people involved in NTDs

L – one page laminated print out

L – limited information

Meant to be used nationally

Was developed pre-strategy

Not sure of the value of the tool

Yes No Yes

MOH NTD Program

Poster 35,000

Health Centers, Schools, Communities (market/trading centers) in endemic districts through VHT/CMDs during training

M – photos are clear and large

L – low, message not clear, shows face washing and eye drops

Meant to be used nationally

Yes, was developed in line with communication strategy

Distributing posters now

Yes No Yes

MOH NTD Program

MDA Trainers Manual

2,000

Manual to train CMDs. Has short section on trachoma outlining the disease transmission and the SAFE strategy

M – photos clear but not specific to Uganda

L – too detailed and complicated

Meant to be used nationally

Was developed pre-strategy, used for training

Yes Yes No No, used by trainers

PHAST - Participatory hygiene and sanitation transformation tools (WaterAID)

Pile Sorting Cards

100,000

WASH Partners work with hygiene promoters (VHTs) to carry out promotion activities at the household level

H – large pictures, clear messages

H – messages are clear, encourage discussion

Meant to be used Nationally, could be updated to be culturally specific

Yes, WASH partners develop strategies using PHAST as a tool

Yes Yes Yes Yes, used by teachers and CMDs

PHASE – Participatory

Booklets 76 schools in

Wakiso, An educational programme on

Meant to be used

Yes Yes, used in schools

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Hygiene and Sanitation Education

Kampala, Gulu,

Kitgum, Pader, Agago, Lamwo Districts

Personal Hygiene and Sanitation Targeted at primary school children as change agents Aimed at behaviour change associated with poor personal hygiene & sanitation in schools and at the household level.

nationally could be updated to be culturally specific

CLTS – Community Led Total Sanitation

Training Manual

Facilitators guide for training community change agents

H – good use of illustrations and text boxes to further explain issues

H – Messages are clear. Outline an easy to follow strategy for conducting CLTS activities in a community

Yes, activities are based on community participation to observe challenges and develop an action plan

Yes, with the WASH sector-wide approach

Yes Yes Yes Yes, a version of the tool is developed for school teachers.

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The MOH NTD program IEC materials are managed by the logistic head officer for the ENVISION. This individual tracks the production and dissemination of NTD tools. Water AID distributes IEC materials to their implementing partners who are responsible for managing the distribution of tools. The MOH NTD tools are being distributed but there are challenges. Breakdowns in the supply chain system can cause tools to get stuck at the district or sub-county level. This is usually rectified when supervisors visit the field. However, the training tools get to the end user since they are needed during training. While the majority of the NTD tools are for training and they were focused on NTDs, the PHAST hygiene and sanitation materials were made specifically made for VHTs to conduct health promotion/BCC activities in the communities.

NTD materials are available for duplication through the NTD Secretariat. All NTD tools were developed with consultation from partners. If a program were to develop new BCC tools they would need to follow the MOH approval process: All health promotion materials need to be approved by the NTD Secretariat. After program approval the tools are sent to the Assistant Commissioner of Health Promotion and Education for clearance. Once cleared the Director General has to give the final approval. CLTS is an approach that involves mobilizing communities to completely eliminate open defecation. It does this by focusing on sanitation and hygiene and sanitation behaviour change, in contract with conventional approaches to improved sanitation – typically involving household subsidies for infrastructure which have proven neither scalable nor sustainable. CLTS empowers communities to take collective action to analyse their sanitation and waste situation, and to bring about collective decision making to improve hygiene and sanitation in their communities. The PHAST tool uses participatory methods to help communities improve hygiene behaviors, prevent diarrhoeal diseases, and encourage community management of water and sanitation facilities. It does this by demonstrating the relationship between sanitation and health status, increasing the self-esteem of community members, and empowering the community to plan environmental improvements and to own and operate water and sanitation facilities. This strategy is also known as the Home and Environmental Improvement Campaign. At the community level both structures use the VHTs and community leaders to develop sanitation committees. Additionally, both the CLTS and the PHAST campaigns have school-based campaigns – Child Led Total Sanitation and Child to Child Education. Implementing WASH partners are currently carrying out activities in both the communities and the schools. According to the MOWE Sanitation Coordinator, all of the implementing WASH partners use either CLTS or PHAST or a combination of the two so there is, to a certain extent, standardization of strategies and tools amongst all WASH partners.

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There is an opportunity to work within these existing structures to implement F & E activities. The E component of the SAFE strategy is the focus of the CLTS and PHAST methodology. After discussions with the MOWE, Plan and WaterAID it looks as though there is an opportunity to include face washing messages in the existing program. The current WASH structure uses the MOH structures at the district level to carry out their activities: Health Assistants at the Sub-county (sub-district) level train and supervise activities and VHTs carry out community-based activities. They also work with school teachers and work with schools to establish school health clubs. Additionally, the tools used for CLTS and PHAST are approved by the MOH Health Promotion and Education department so any updates of tools would go through the regular MOH structure (program manager approval then approval of the tools by the Health Promotion department). From our understanding, the MOWE, MOH and Ministry of Education all work together to coordinate the CLTS/PHAST activities. The Uganda Water and Sanitation NGO Network (UAWSNET) is the national umbrella organization for NGOs and Civil Society Organizations in the Water and Environment sector. They have regional coordinators who are responsible for coordinating the activities of the WASH partners in their regions. The regional coordinators for Busoga are Busoga Trust and the Uganda Muslim Rural Development Association and for Karamoja it is the Karamoja Diocese Development Services. UAWSNET works with the MOWE to ensure implementing partners follow the sector-wide approach approved by the MOWE. At the district level there are District Water and Sanitation Coordination Committees. These committees consist of the line ministries, implementing partners and the local government and they are responsible for coordinating WASH activities at the district level. Currently, JHU·CCP and Communication for Development Foundation Uganda (CDFU) are working with the National Trachoma Programme and Sightsavers Uganda to develop a toolkit of materials specifically for trachoma prevention. These materials/tools will be available electronic for production by patners. The table below summarizes the materials that are included in the toolkit.

Organization Type Distribution

JHU·CCP and CDFU- F&E Communication ToolKit (Under production)

Fact sheet For leaders and all people involved in trachoma

Radio design document

A document to guide the district health educator and radio stations on content for radio talk shows and 'community radio' programs on F&E.

Job aid cards For health workers to use when providing take home messages to MDA and TT clients about F&E.

Teachers and students guide

Manual to guide teachers when conducting sessions on trachoma prevention with primary pupils and a guide for the pupils

Poster on transmission

For men and women in trachoma endemic areas

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Poster on prevention For men and women in trachoma endemic areas

Checklist A guide for VHTs and leaders to use during community dialogues.

IV. Advocacy In order to effectively plan advocacy strategies it is important to look closely at both the environment in which advocacy activities will happen and the specific issues and barriers that need to be addressed for face washing and particularly environmental improvement at all levels in the country. This section is not intended to develop the full advocacy plan for the SAFE strategy but rather to provide key background information and to identify current advocacy strategies. The NTD Program has an advocacy plan that focuses on resource mobilization for NTDs. The advocacy goal and work plan flows from the first activity of the implementation approach for the NTD Master Plan: Strengthening government ownership, advocacy, coordination and partnership.

Advocacy Goal: To scale-up an integrated NTD control program for improving the health and socio-economic status of affected Ugandans by 2015. Advocacy Objectives: To reach this goal, advocacy efforts will focus on the following five objectives for the period, 2013 – 2015:

1. To increase central government funding for NTD control from 5% to 15% by 2015

2. To include NTDs in all endemic district annual work plans and to secure allocation of at least 5% of the district Primary Health Care (PHC) funds from the District/Urban Local Government Development Plan to NTD programs by 2015

3. To ensure Village Health Teams (VHT) incentives from all stakeholders are harmonized by December 2013

4. To critically review the suitability of the current MDA implementation vehicle, Child Health Days-plus, by December 2013

5. To develop a policy and guidelines regarding NTD cross-border health issues by 2014

The advocacy objectives mainly focus on the Integrated NTD Program. According to the plan, a NTD Advocacy working group is to be formed and these individuals will be responsible for developing indicators for all aspects of the work: inputs (time, resources, staff); outputs (meetings held, visits made, reports produced); outcomes (press coverage, changes in policy or practice); and the impact of the work. Progress will be discussed and reviewed twice a year to ensure the advocacy activities are on track and to make adjustments as needed.

There is a budget line item for F&E advocacy meetings to be held twice a year in the TAP document but this meeting has not been held, to date.

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The district leadership that includes the District health Officer, Resident District Commissioner, Chief Administrative Officer, LC5 Chairperson, District Education Officers and the District Local Council has been playing the most prominent role in fighting trachoma at the district level and the community leaders, health assistants, teachers, religious leaders and the Village Health Teams at the community level. No political or prominent figure has been specifically involved in trachoma to date. However, there are potential figures such as the First Lady and Minister for Karamoja who and has agreed to champion sanitation and hygiene; Hon. Migereko Daudi, MP for Butembe, Jinja, and Minister for Land who has supported eye care in Jinja; Rev. Wangoola Vasco Dagama, retired eye care specialist in Jinja, BusogaTrust.

There are a number of initiatives competing for funding at all levels. At the district and national levels malaria prevention, child health, HIV prevention and care, and tuberculosis all compete for resources. Other Neglected Tropical Diseases such as Schistosomiasis prevalent in 43 districts, Onchocerciasis endemic in 37 districts, Elephantiasis affecting more than 13 million people in 56 districts, and Jiggers with 6 million people at risk and 2.4 affected also compete for funds and attention from the health sector. Many of these are life threatening and are given priority. The districts are also mandated to take the lead in the supervision, monitoring and planning for the national programs and they must allocate resources for that. At the community level, distribution of medicines to infected individuals with Onchocerciasis, Trachoma, bilharzia and mobilization for national and district programs and at individual levels the WASH program, education and food all compete for funding. Little, if any, is left for promotion of face washing and environmental sanitation.

The primary decision makers influencing water and sanitation are parliamentarians, the Minister of Finance and the Minister of Water and Sanitation, development partners, and corporates. At district level, the Resident District Commissioner, Chief Administrative Officer, LC5 Chairperson, and the District Local Council all make budgetary and policy decisions regarding water and sanitation. At community level, Manyatta heads in Karamoja, religious leaders and LC1 leaders all influence water and sanitation decisions. Communities have the authority to pass local bylaws and enforce them through LC1 courts.

V. Communication Channels Tablets are currently used by the trachoma program to collect impact assessment data. Percentage of men and women age 15-49 who are exposed to specific media on a weekly basis Background characteristic

Sex Reads a newspaper at least once a week

Watches television at least once a week

Listens to the radio at least once a week

Accesses all three media at least once a week

Accesses none of the three media at least once a week

Number

Region East Central Female 11.0 14.4 77.2 4.1 20.1 869

Male 19.7 34.4 88.1 11.8 9.4 236 Karamoja Female 4.8 3.7 28.3 0.6 69.3 289

Male 14.7 16.1 73.7 5.1 23.6 55 Source: Uganda Demographic and Health Survey, 2011

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Mobile phone network coverage map, showing the major mobile phone providers coverage According to statistics from UCC, the number of telephone subscribers had reached 10 million in March 2009 — up from more than 8.7 million in December 2008 — which is about one-third of the country’s population. Of the 10 million subscriptions, 9.8 million are mobile phone subscribers while around 200 000 are fixed-line owners. Currently there are five major mobile phone service providers ranging in size and capability. These include MTN, Airtel, Orange, Uganda Telecom Limited (UTL) and K2. MTN and Airtel are the largest service providers with about 6-8 million customers across and around Uganda. Generally there is relatively good network coverage in Busoga region but coverage in Karamoja is very limited and about half of the region has no network completely. MAPS SHOWING PHONE NETWORK COVERAGE IN UGANDA

Figure 1 MTN phone coverage map Figure 2 Airtel coverage Figure 3 Orange coverage

All districts use town criers at community level, using either static or mobile public address systems. They are used for community mobilization and information. They are owned by either individuals or communities. Film/video halls are very popular and are available in many communities but are affected by limited supply of power. They need generators to run them. In many districts, there are drama groups that can be hired to preform dramas. Radio Stations: In a survey carried out in 2011 only 2 radio stations were functional in Karamoja region and 15 in Busoga region. There is only one TV station in Busoga called R FM and none in Karamoja.

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RADIO BROADCASTING STATIONS

TV stations that broadcast in each trachoma endemic district/region or nationally

There are four TV stations that broadcast nationally: Wavah Broadcasting service (WBS), Nkabi broadcasting Service (NBS), Uganda Broadcasting Corporation (UBC) and Africa Broadcasting Uganda (NTV). Bukedde TV is becoming popular in East central (Busoga) region. None of these stations broadcast in Karamoja, but using satellite TV (DSTV), they can access the national TV stations.

24

TV Broadcasting Stations

Region Company Call sign Station location

Channel Freq Status

Busoga (Jinja, Buyende, Kaliro, Kamuli, Namutumba, Iganda, Bugiri, Mayguew, Buikew, Luuka. Namayingo

Nakabi Broadcasting Services, Ltd. Start DTV Co. Ltd. Africa Broadcasting Uganda Ltd. Wavah Broadcasting Service Uganda Broadcasting Corporation

NBS Star TV NTV WBS TV UBC

Wanyange

38 41/46/48 47 55 58

610 634/674/690 682 746 770

ON NOA ON ON NOA