The single concept note details the applicants request for Global Fund

resources for a disease component for a three-year period. The concept

note should articulate an ambitious, strategically focused and technically
sound investment, informed by the national health strategy and the national
disease strategic plan. It should represent a prioritized, full expression of
demand for resources, and it should be designed and implemented in a way
that maximizes the strategic impact of the investment. The single concept note
for TB and HIV details the CCMs request for countries with high co-infection rates
for the two diseases based on data from the World Health Organization.

TB AND HIV

CONCEPT NOTE
Investing for impact against tuberculosis and HIV
Countries with overlapping high burden of tuberculosis (TB) and HIV must submit a single
concept note that presents each specific program in addition to any integrated and joint
programming for the two diseases.
In requiring that the funding requests be presented together in a single concept note, the Global
Fund aims at maximizing the impact of its investments to make an even greater contribution
towards the vision of a world free of the burden of TB and HIV. Enhanced joint HIV and TB
programming will allow to better target resources, to scale-up services and to increase their
effectiveness and efficiency, quality and sustainability.
All concept notes should articulate an ambitious, strategically focused and technically sound
investment, informed by the national health strategy and the national disease strategic plans
(NSPs).
The concept note for TB and HIV is divided into the following sections:
Section 1: The description of the countrys epidemiological and health systems context including
barriers to access, the national response to date, country processes for reviewing and revising
the response, and plans for further alignment of the NSPs, policies and interventions for both
diseases.
Section 2: Information on the national funding landscape, additionality and sustainability
Section 3: The funding request to the Global Fund, including a programmatic gap analysis,
rationale and description of the funding request, as presented in the modular template.
Section 4: Implementation arrangements and risk assessment.

SUMMARY INFORMATION
IMPORTANT
NOTE: Applicants should refer to the TB and HIV Concept Note Instructions
to complete this template.

Uganda TB and HIV Concept Note

15 October, 2014 1

Applicant Information
Country

UGANDA

Funding Request
Start Date

01 JULY 2015

Funding Request
End Date

31 DEC 2017

Principle Recipient(s)
If the programs are to be managed as separate grants:
Funding Request
End Date for HIV

31 Dec 2017

Funding Request
Start Date for HIV

01 July 2015

Principal Recipient(s)
for HIV

Ministry of Finance Planning and Economic Development (MoFPED)

The AIDS Support Organization (TASO)

Funding Request
Start Date for TB

01 July 2015

Principal Recipient(s)
for TB

Ministry of Finance Planning and Economic Development (MoFPED)

The AIDS Support Organization (TASO)

Funding Request
End Date for TB

31 Dec 2017

FUNDING REQUEST SUMMARY TABLE

A funding request summary table will be automatically generated in the online grant
management platform based on the information presented in the programmatic gap
table and modular templates.

Uganda TB and HIV Concept Note

15 October, 2014 2

SECTION 1: COUNTRY CONTEXT

This section requests information on the country context, including descriptions of the TB
and HIV disease epidemiology and their overlaps, the health systems and community
systems setting, and the human rights situation.
1.1 Country Disease, Health Systems and Community Systems Context
With reference to the latest available epidemiological information for TB and HIV, and in
addition to the portfolio analysis provided by the Global Fund, highlight:
a. The current and evolving epidemiology of the two diseases, including trends and
any significant geographic variations in incidence or prevalence of TB and HIV.
Include information on the prevalence of HIV among TB patients and TB incidence
among people living with HIV/AIDS.
b. Key populations that may have disproportionately low access to prevention,
treatment, care and support services, and the contributing factors to this inequity.
c. Key human rights barriers and gender inequalities that may impede access to
health services.
d. The health systems and community systems context in the country, including any
constraints relevant to effective implementation of the national TB and HIV
programs including joint areas of both programs.
a. Current and evolving epidemiology of HIV and TB in Uganda
HIV Burden
The HIV epidemic in Uganda has been generalized for more than two decades. The 2011 AIDS
Indicator Survey (AIS) revealed an increase in HIV prevalence among adults aged 15-49 years,
from 6.4% in 2004/05 to 7.3% in 2011. This increase is attributed to incident HIV infections and
improved survival due to increased access to HIV care and treatment services including
antiretroviral therapy (ART). The increase in prevalence was noted in several regions with doubling
of prevalence in some regions such as West Nile. It is estimated that by end of 2014, there will be
1,631,828 people living with HIV (PLHIV), increasing to 1,969,778 by 2018 (EPP 2013, page 1).
Figure 1: HIV prevalence by Region 2004/5 and 2011 (AIS 2004/5 and AIS 2011)

Across all regions of the country, women are disproportionately more affected than men with an
overall HIV prevalence of 8.3% among women versus 6.1% among men. Prevalence for both
women and men increases with age and peaks at age 35-39 years for women (12.1%) and at age
40-44 years for men (11.3%). HIV prevalence ranges from 4.1% in Mid-Eastern region to 10.6% in
Central 1 region. Mid-Eastern Uganda, with the highest population coverage of circumcision (53%)
had the lowest HIV prevalence at 4.1% and registered a modest decline from 5.3% in 2004/05
(Figure 1). HIV prevalence was higher among uncircumcised men (6.7%) compared to circumcised
men (4.5%). However, the national coverage for male circumcision remained unchanged (25% in
2004/05 and 26% in 2011). Urban residents are more likely to be infected (8.7%) than their rural
counterparts (7%); this picture is prominent among women with HIV prevalence among urban
Uganda TB and HIV Concept Note

15 October, 2014 3

women estimated at 10.7% compared to 7.7% among rural women while the rates for urban and
rural men are the same (6.1%) (AIDS Indicator Survey 2011, page 101). In the younger age groups
15-24 years, HIV prevalence is estimated at 3.7%; the female HIV prevalence for the age groups
20-24 is two to three fold that of males within the same age category.
HIV sero-discordance among couples remains a major factor in the HIV transmission dynamics in
Uganda. According to the 2011 AIS, 6% of married or cohabiting couples were HIV sero-discordant
(AIDS Indicator Survey 2011, Page 101). Among couples where at least one partner was HIV
infected, 67% are HIV sero-discordant (i.e. in two out of three couples, the partner is uninfected).
The draft 2014 Modes of Transmission (MOT) analysis also shows that transmission in long-term or
stable monogamous relationships due to discordancy remains a key source of new HIV infections.
In 2013 Uganda adopted the WHO 2013 guidelines, which provide for treatment of HIV-positive
partners within sero-discordant relationships irrespective of their CD4 counts. There are also efforts
to encourage couple testing which would help identify sero-discordant relationships, but its uptake
remains low (5% of individuals tested in 2013/2014 tested as couples) (HMIS/DHIS2 July 2013June 2014).
HIV incidence: The country continues to experience a high rate of new HIV infections, at 140,000
at the end of 2013 (UNAIDS 2013 HIV Estimates for Uganda). The number of new HIV infections
was consistently higher than that of individuals initiated on treatment until 2013 when the ratio of
new HIV infections to the net increase in ART was <1 (Uganda HIV Investment Case 2014, page
15). This trend of new infections could be further reduced by full implementation of combination
prevention interventions (especially targeting the sources of new infections) as defined in the HIV
Investment Case. It is envisaged that implementation of the priority scale up plan in Ugandas
Investment Case to attain critical coverage levels of key interventions could avert 2,160,000 new
HIV infections and 570,000 AIDS-related deaths between 2015 and 2025. Integrated adjunctive
interventions such as isoniazid preventive therapy, early detection of TB in HIV infected persons,
and expanding ART coverage to all co-infected persons has obvious implications for the incidence,
prevalence and mortality from the related TB epidemic in the country.
TB incidence, prevalence and mortality
World Health Organization (WHO) estimates of TB mortality, prevalence and incidence rates in
Uganda have declined from 50,492 and 624 per 100,000 population in 1990 to 13, 175 and 179
respectively per 100,000 population in 2012 (Global TB Report 2013 page 159). However, an
accurate estimate of TB prevalence or mortality is not available due to weaknesses in surveillance
and vital registration limiting the certainty of firm conclusions. Accurate data on TB prevalence
should be available in 2017 once the TB Prevalence Survey initiated in 2014 (funded through Phase
I SSF from the Global Fund) is completed and the data analyzed. A recent paper in The Lancet
analyzing the Global Burden of Disease 2013 estimated the annual rate of change (%) in TB
(without HIV) in Uganda for the period 2000-13 to be -1.26 (-1.61 to -0.94) (Murray C et al, 2014,
Table 5; page 1044). The continued rapid population increase in Uganda contributes to the increase
in absolute numbers of TB cases. The Uganda Bureau of Statistics (UBoS) estimates that the
countrys population grew annually at 3.2% during the period 1991 to 2002 (UBOS 2013, page x).
The NTLP coordinated an epidemiological and impact analysis in 2011 with support from a technical
expert (ToR for TB epidemiological analysis page 2-3). Key findings from this analysis, from the
recently concluded Joint External Monitoring Mission (JEMM) and from the process to develop the
National Strategic Plan (NSP) are summarized below to provide an overview of the evolving
epidemiology of Tuberculosis (TB) in Uganda. Trends in incidence, prevalence and mortality (Fig 2)
show wide confidence intervals indicating considerable uncertainty in the estimates. There is
currently no national level vital registration system with standard ICD-10 (10th revision of
the International Statistical Classification of Diseases and Related Health Problems) coding in place
in Uganda. Vital registration data is available at some facilities but coverage is unknown. Only about
30% of children under 5 years old are registered at birth. The proportion of deaths occurring in the
home is also unknown. As such, TB mortality in Uganda is based on WHO estimates. The
estimated annual number of deaths due to AIDs has decreased from 100,000 in 2001 to 62,000 in
2011 (Fig 2) (WHO Global Health Observatory 2011 Web data). These limitations imply that the
underlying causes of AIDs deaths, including the proportion of these who died of TB are not well
known - an estimated 37% of autopsied deaths among PLHIV were attributed to TB (Cox JA et al,
2012, Page 1, 3). TB Treatment outcome in Uganda was previously not disaggregated by HIV
status and therefore the proportion of TB cases that died that were co-infected with HIV is also
unknown. This disaggregation has been recently introduced for the cohort beginning January 2014
and data will be available when treatment outcomes for this and subsequent cohorts are reported.

Uganda TB and HIV Concept Note

15 October, 2014 4

Analysis of notified cases (Fig 3) suggest that after a consistent decline in TB notification rates from
2004 to 2010, there was a slight increase in 2011, followed by another decrease in cases in 2012.
Notification rates based on Ugandan data are slightly higher than WHO rates probably due to using
population denominator data, which is closer to the true population. The population estimates used
in the WHO Global Report are derived from UN, while those used by the National Tuberculosis and
Leprosy Control Program (NTLP) are from the Uganda Bureau of Statistics (UBoS).
Figure 2: Trends in TB incidence, prevalence and mortality; annual deaths due to AIDS (Uganda)

While data show that the TB case notification rates at a national level are decreasing over time, the
percentage change in TB case notification rate shows much variability by year over time. When TB
notification rates were compared from 2008 to 2012 by TB reporting zone (Fig 4), data suggests
that reporting is generally consistent in most zones, with most variability occurring in a few zones,
e.g. North-west, North-east and Kampala.
Besides a slight increase in smear positive cases during 2008-2012, there was very little fluctuation
in the proportion of notified cases that were bacteriologically positive (54-55.9%) and extrapulmonary (11.2 to 11.5%). Kampala and the Northeast are the only two zones that have
consistently notified 15% of all TB as extra-pulmonary, while it is as low as 5% of notified patients in
North and Northwest zones (Uganda TB Strategic plan draft July 2014, page 33). The reasons for
this variation are not clear.
Figure 3: Notification rate (new and recurrent)

Figure 4: TB notification rate by zone

About 50% of Ugandas population is under 15 years. However, children (<15 years) account for
only 3% of all notified smear positive TB cases and ~ 7% of all forms of TB notified (data for this is
not directly available, and is derived from the numbers of category of treatment used for children). It
Uganda TB and HIV Concept Note

15 October, 2014 5

also appears that the proportion of children reported to have smear positive TB out of all smear
positive TB cases decreased over time, but there was a larger decline between 2008 to 2009 before
rising again in 2010. The programs revised recording and reporting formats disaggregate data for
children below 5 years.
The WHO estimates that in 2012 that there were about 1,000 (6601,300) cases of Multi-Drug
Resistant TB (MDR-TB) in Uganda and that about 19% of retreatment patients notified in 2012 were
tested for Drug Sensitive TB (DST); 89 confirmed MDR-TB cases were notified to the NTLP (Global
TB Report 2013Table A4.7, page 175). WHO estimates of MDR are based on a recent national
survey which showed that the proportion of new and retreatment cases that were MDR-TB was
1.4% and 12.1%, respectively (Lukoye D et al, 2013 pages 1, 5). Though there has been a decline
in TB HIV co-infection from 54% in 2011 to 49% in 2013, HIV infection rates remain seven times
higher among TB patients (49%) than in the general population (7.3%). An estimated 1.4 - 7% of
adults and up to 9.5% of children living with HIV had prevalent TB (NTLP: Annual Report
2012/2013, page 15 and 17).
b. Key populations that may have disproportionately low access to prevention, treatment,
care and support services, and the contributing factors to this inequity
Uganda has several Most at Risk Populations (MARPs) that are the leading sources of new HIV
infections (UAC MARPs Review 2014, page 6 and 9) and have challenges accessing HIV and TB
services. The HIV Investment Case 2015-2025 defines several MARPs populations including fishing
communities, Sex workers (SWs) and partners of sex workers, Men who have Sex with Men (MSM),
uniformed services, and truckers. In this application, we use MARPs to include all these groups but
mention specific populations in the description of interventions, as applicable.
The fishing communities around Lake Victoria in the districts of Kalangala, Mukono, Buikwe,
Buvuma, Namayingo, Wakiso, Mayuge, and Kayunga have a very high HIV prevalence, between
20-42% (KMCC Fishing Community Review June 2014, Page 11). The districts/communities around
Lake Kyoga (Amolatar, Apac, Buyende, Dokolo, Kaberamaido, Kayunga, Nakasongola, and Serere)
have twice the national HIV prevalence (14.7%) but lower than that in the Victoria basin. A review of
literature on MARPs conducted by Uganda AIDS Commission (UAC) and UNFPA in 2014
characterized risk behaviors and attempted to estimate sizes of various MARPs from existing
literature in Uganda. Fisher folk featured prominently due to a high HIV sero-prevalence, incidence
and large population size. Major reasons for this high HIV prevalence and incidence in fishing
communities include: a booming sex work industry within fishing communities partly attributed to
high income from fishing and preponderance to alcohol and drug abuse as well as high mobility of
fisher folk, high proportion of individuals with concurrent multiple sexual partnerships, and non-use
of condoms during high risk sex.
The HIV prevalence in fishing communities, from the UAC/UNFPA review, which predominantly
included surveys around Lake Victoria, varied between 23-35% and the population size was
estimated at 2 million; sex workers were estimated at 54,549 with a prevalence of 33% on average;
truckers were estimated at 31,588 with HIV prevalence of 25% to 32%; uniformed personnel were
estimated at 650,000 with HIV prevalence of 10-18%; and MSM were estimated at 10,533 MSM
with HIV prevalence of 13.7%. Because of the wide variation of size estimates for various MARPs
groups, this review and the Investment Case recommended a national MARPs size estimation to
harmonize estimates and guide programming (UAC MARPs Review 2014, page 7). Prevalence of
TB amongst MARPs is not known since this data is not collected routinely. Since a mapping of
these populations is not easily available, it is also challenging to target and prioritize HIV and TB
services for these MARPs. The high mobility of these populations also makes it difficult to provide
HIV and TB services to these communities, and to link and retain those who are HIV infected in care
for both TB and HIV services. Access to various health services is also generally lower within fishing
communities (KMCC Fishing Community Review June 2014, Page 19).
Truckers have historically been associated with high HIV prevalence in Uganda, and the towns and
trading centers along the transport corridor have always had a higher HIV prevalence than
surrounding areas. The Knowledge Management and Communications Capacity building initiative
(KMCC) 2014 Truckers literature review shows very high knowledge of HIV prevention among
truckers, which does not translate into risk reduction; multiple concurrent sexual partnerships with
limited condom use and underlying drivers such as alcohol and drug use with sex work hotspots
along the transport corridor put the truckers at risk of HIV transmission and acquisition. Yet, access
to prevention, care and treatment services along the transport corridors remains limited (KMCC
Truck Drivers Synthesis Report, October 2014, Page 3).

Uganda TB and HIV Concept Note

15 October, 2014 6

Other high risk groups with low access to services

The Priorities for Local AIDS Control Efforts (PLACE) methodology study, which was conducted in
30 districts in 2013-2014, identified several venues that were associated with high-risk sexual
behaviors (acquisition of new partners, multiple partnerships and transactional sex). The most
common high-risk venues included bars, nightclubs, sites for local brew, markets, and trading
centers. Activities at these venues included consuming alcohol, socializing, and dancing, among
others. Across all districts, the HIV prevalence among the patrons and workers in the venues was
about twice the regional prevalence and highest among the female patrons and workers. Yet,
access to HIV prevention information and condoms within these venues were sub-optimal and
condom use was low across all districts, although some districts were worse off than others (PLACE
Report 2014, Pages 9, 13, 21, 23, 37). For example, in Kalangala, a fishing community with high
HIV prevalence, 36% of female workers and 38% of female patrons in these high risk venues never
used condoms in the previous six months while in some districts (e.g. Arua and Dokolo in northern
Uganda and Kabale and Kisoro in western Uganda) >40% of the women and men in these venues
never used condoms. It is also not known what proportions of these populations with higher
prevalence of HIV have access to routine TB screening as this data is also not collected. In this
application, CCM proposes targeted BCC interventions and condom programming for MARPs in
these locations.
Uganda Prisons Service
The Uganda Prisons Service (UPS) has an average population of 35,000 inmates distributed across
~ 233 prisons, with a turnover of over 100,000 annually. The burden of TB is high in UPS with an
estimated prevalence of 654/100,000 population (Uganda Prisons Services Report March 2009,
Page viii). Annual notification of TB from prisons services is about 500 cases of all forms. Efforts to
control TB in UPS are complicated by the high HIV prevalence (11%), high HIV/TB co-morbidity,
prison congestion, poor nutrition and inadequate infrastructure, limited TB awareness and a weak
prison health system. With support from the Government of Uganda, Global Fund (GF) and
partners, the NTLP in collaboration with UPS has implemented a range of TB strategies and
interventions that include: provision of high quality directly observed treatment (DOT) and TB/HIV
collaborative management at 13 TB treatment units (out of 35); strengthened the prisons health
systems through recruitment of health workers and capacity building for TB management and
operational research; engaged NGOs, CSOs and community TB care providers to extend TB care
to prison units; empowered prisoners suffering from TB to support peer education of inmates; and
promoted prison community participation in TB care. Ongoing interventions to increase access to
HIV testing within prisons (supported by CDC) provide platform to integrate TB screening for HIV
infected prisoners.
Urban populations
The rate of urbanization in Uganda, 4.8 percent, is among the highest in the world. While Ugandas
urbanization level is still low, at 12 percent, by 2030 it is projected to reach 30 percent, with an
urban population exceeding 20 million people. In slum areas, the informality of housing overlaps
with informal employment, service provision and legal status. (CIGI May 2013, pages 3,4).
Urbanization rates in Uganda are higher than official estimates if one considers an alternate
measure the Agglomeration Index, which considers density, urban size and proximity to the urban
center. Using this index, Ugandas urbanization moves up to 25 percent using proximity to cities of
50,000 people. (Byamugisha et al, Page 2).
Kampala city alone with a population of about 1.7 million (~5% of national population) accounts for
one of every five TB cases notified to the NTLP. TB treatment outcomes are also among the lowest
in Kampala and speak of the challenges in accessing TB services in this urban setting. HIV
prevalence is high in Kampala at 7.1% (close to the national average of 7.3%). The Global Fund
(GF) has also noted in its most recent Portfolio Analysis the high burden of TB is mainly in the
urban and peri-urban centers, with Kampala accounting for 7,800 cases, Wakiso for 1,300 cases
and other regional towns accounting for between 1,300-1,600 cases each (Pre-Assessment Report
UGD-T-MOFPED Sep 2014, page 3).
c. Key human rights barriers and gender inequalities that may impede access to health
services
Legal context
Some existing Acts (e.g. Penal Code Act on sex work and same sex relationships) make it difficult
to deliver services to key populations (sex workers and MSM). The recently repealed Anti
Homosexuality Act (AHA) also generated a lot of discomfort among the affected populations and
interrupted service delivery (e.g. the suspended national MARPs size estimation study). However,
the health policy environment and guidance on delivery of services for key populations including sex
Uganda TB and HIV Concept Note

15 October, 2014 7

workers and MSM has improved over the last one-two years, with formation of key populations
technical working groups at Uganda AIDS Commission (UAC) and Ministry of Health (MoH), and
development of the MARPs programming Framework by Uganda AIDS Commission (UAC) (UAC
MARPs Framework 2014, Page 8,9). Building on these frameworks, CCM proposes interventions to
improve access to HIV services by all, including minority groups despite the legal environment.
In addition to the legal issues, there is widespread stigma and discrimination against sexual
minorities. A study assessing barriers and opportunities for increasing access to HIV services
among MSM and sex workers, which was conducted in November-December 2013 showed that
these groups experienced stigma from the general population, their families, health providers and
other patients within health facilities. Stigma and discrimination was highlighted as a major barrier to
access to health services (MOH MARPs Report 2014, Pages 7, 8, 33-36).
The HIV Control and Prevention Act has positive elements including establishment of the HIV Trust
Fund. However, criminalization of HIV transmission (AIDS Act 2014 clause 13, 14,18(e) and 41),
which places a burden on HIV infected people may discourage testing, disclosure, uptake of care
and treatment services including TB services, and could fuel stigma and discrimination against
PLHIV.
HIV and TB, Knowledge and Behavior
Data from AIS 2011 indicates that high-risk behaviors remain prevalent in Uganda. Reported
condom use in high-risk encounters is low. Comprehensive knowledge combining several
knowledge measures remains low. In 2011, only 36% of women and 43% of men aged 15-49 had
comprehensive knowledge about HIV/AIDS, with very modest increases from 2004/05 (less than
10% for both men and women). Overall, 19% of the men reported having two or more sexual
partners in the previous year, compared with 3% of the women. Condom use among those
engaging in higher risk sex declined from 47% in 2004/05 to 29% in 2011 among women and from
53% to 38% among men (UAIS 2011 Report, Page 79, 80). This picture was also quite evident in
the PLACE study, which showed low condom use among individuals in high-risk venues (PLACE
Report 2014, pages 9, 13, 21, 23, 37).
A national household survey carried out in 2009/10 by UBOS showed that 17% and 52% of the
urban population seek medical attention from pharmacies/drug shops and private clinics,
respectively. The high TB default rate in urban settings including Kampala could be explained by the
fact that the majority of people in urban settings continue to seek medical attention from Private
Health providers (PHPs) yet the majority of them do not have adequate knowledge on TB and will
therefore not give appropriate counseling and care to TB patients. Knowledge and information about
TB continues to be inadequate at the level of the community limiting demand for TB services,
fuelling stigma and discrimination and contributing to poor and delayed health-seeking behavior.
Gender inequalities
Women and girls are at higher risk of HIV infection and constitute the largest proportion of PLHIV in
Uganda (UAIS 2011 Report, Page 104). Women face barriers in accessing HIV prevention services
due to limited decision-making power, lack of control over finances, and burden of care all of which
limit their economic opportunities. Gender inequality is also a key driver of the HIV epidemic and
negatively impacts on the health seeking behavior. According to the 2011 UDHS, about 39-42% of
married women reported that primarily the husband made decisions about their health care, major
household purchases, and visits to their family or relatives.
According to UNAIDS women who have experienced Intimate Partner Violence (IPV) are 50% more
likely to acquire HIV than women who have not experienced violence (The Gap Report, UNAIDS
2014, Page 136). In- country evidence from the Safe Homes and Respect for Everyone (SHARE)
Project also suggests that young women who have experienced intimate partner violence (IPV) are
at increased risk of HIV infection than women who had not experienced violence (Wagman et al.,
2012). Gender Based Violence (GBV) remains prominent and may also pose additional barriers to
womens access to HIV and other health services. In Uganda, 27% of girls aged 15-24 have
experienced violence, 56% of married women have ever encountered domestic violence during their
marital life, 51% of all women have experienced physical and/or sexual intimate partner violence,
19% had their first sexual encounter against their will, and more than 16% experience violence
during pregnancy (UDHS 2011, page 230-233). This coupled with increasing accepting attitudes of
GBV among communities, high rates of defilement and early marriages and child labor undermine
several health indicators including sexual and reproductive health and HIV service uptake. Evidence
from the Rakai SHARE project and SASA - a project implemented in 6 suburbs of Kampala by
CEDOVIP in-partnership with Raising Voices Uganda, shows that community engagement and
empowerment to address GBV reduces coerced sex by 20%, partner physical violence by 20% and
Uganda TB and HIV Concept Note

15 October, 2014 8

the community incidence of HIV by 36% (Abramsky et al, 2014, page 11-14).
Although there are fewer men than women in the general population (0.95:1), the majority of TB
patients notified to the NTLP are men with the ratio rising from 1.38:1 in 2007 to 1.7:1 in 2013.
Barriers limiting access of women to HIV services could be similar to those limiting access to TB
services for women.
Reproductive, Maternal, Neonatal, Child, and Adolescent Health (RMNCAH) context and
linkages with HIV/TB
There has been a general improvement in the majority of the maternal and child health (MCH)
indicators in Uganda, based on the Uganda Demographic Health Survey (UDHS) 2011, 2006, and
2001 reports. However, the improvements are too slow and below the expected national and
international targets. Under-five mortality rate is 90, down from 137 per 1,000 live births in 2006,
and infant mortality is 54 down from 76 per 1,000 live births. Maternal mortality ratio is 438/100,000,
not significantly different from the adjusted figure of 418 in 2006 but significantly lower than the 524
in 2001. Despite these improvements, the MCH indicators are generally still far below the
Millennium Development Goal (MDG) targets: under five mortality target of 56 per 1,000 and the
infant mortality of 31 per 1,000. Deliveries attended by skilled providers increased from 41% in 2006
to 57% in 2011 but this is far below the MDG target of 90%. The unmet need for family planning
(FP) remains high, at 34% (a small reduction from 38% in 2006). Only 48% of women make four or
more antenatal care (ANC) visits, and the median time for the first ANC visit for pregnant women is
5.1 months of gestation. These poor MCH indicators pose challenges to the scale-up of HIV and TB
interventions among women and children.
d. The health systems and community systems context in the country, including any
constraints relevant to effective implementation of the national TB and HIV programs
including joint areas of both programs
Uganda follows a decentralized system of governance enshrined in the National Constitution (1995)
and Local Government Act (1997). The country has 112 district local governments. Uganda follows
a system of five tiers of local governance linked through political and administrative units (Uganda
TB Strategic Plan draft July14, fig 1; page 10). The Central Government, through line ministries, is
responsible for national affairs and services; formulation of national policies and standards. The
Local government responsibilities include provision of basic social services (including health)
according to national policies and priorities, recruiting and managing human resources, collection
and allocation of taxes and approval of district work plans and budgets.
The National Health System (NHS) is made up of the public and the private sectors. The Public
sector includes the Government of Uganda (GoU) health facilities under the MoH, health services of
the Ministries of Defence, Education, Internal Affairs (Police and Prisons) and Ministry of Local
Government (MoLG). The MoH services are structured into: National Referral Hospitals (NRHs)
which are semi-autonomous; Regional Referral Hospitals (RRHs) which are self-accounting and
under MoH oversight and public general hospitals and Health Centre (HC) IVs, HC IIIs, HC IIs and
Village Health Teams (VHTs, HC Is) which are under the district health system managed by the
Local Governments
The provision of health services in Uganda is decentralized with districts and health sub-districts
(HSDs) playing a key role in the delivery and management of health services at the district level.
The General, Regional and National Referral Hospitals are responsible for providing health services
such as prevention, promotion, curative, maternal, in-patient health services, surgical, blood
transfusion, laboratory and medical imaging services, in-service training and operational research.
In addition, the Regional and National Referral Hospitals provide specialist clinical services. Under
the district health system, the Local Governments (LGs) recruit, deploy, develop and manage
human resources for district health services. In addition, they pass health related by-laws and
monitor the health sector performance in the districts. The Health Sub-Districts (HSDs) are
mandated with planning, organization, budgeting and management of the health services at the
HCIV and health centers within the HSD. The health centers provide basic health services such as
prevention, promotion, curative and rehabilitation health services.
A Hub transport system (National Sample and Results Transport Network) was pioneered in
Uganda by the MoH in 2011 in a phased manner and 19 operational Hubs reaching 616 lower
health facilities had been established by 2012, with the intention to expand to another 53 hubs
serving an additional 1700 health facilities in 2013. In this system, patients samples from lower
level health facilities are transported to central testing points (reference laboratories) for testing.
Test results from the referral laboratories are delivered to referring health facilities through the same
Uganda TB and HIV Concept Note

15 October, 2014 9

system. Local networks at the sub district level are coordinated at health facilities that act as hubs.
These Hubs could either be Regional referral hospitals, District Hospitals or health center IVs. Each
Hub serves 20 to 40 health facilities located in a radius of 40km radius around it. The MoH has also
installed SMS (short messaging services) printers at some of the hubs to directly print results and
thus reduce turnaround time for testing as well as courier costs that would otherwise be incurred to
deliver the results. Each hub has a motorbike and bike rider specifically hired to collect samples and
deliver results from all health facilities in the Hub catchment area. The rider makes regular
scheduled visits visiting 4 to 8 facilities per route on a daily basis and takes different routes each
day. Under this arrangement, he visits each facility in the Hubs catchment area at least once a
week (National Sample Transport Network, page 4-5). Both the AIDS Control Program (ACP) and
the NTLP utilize this hub system to transport samples and results to and from referral laboratories.
The private health sector consists of Private Not for Profit (PNFPs) providers, Private Health
Practitioners (PHPs) and the Traditional and Complementary Medicine Practitioners (TCMPs). The
PNFP and PHP hospitals and health centers are autonomous as granted by their respective legal
proprietors. The PNFP contribute significantly to the health services provided in the country: of all
the hospitals 52% are public, 41% are PNFP and 7% are Private for Profit (PHP) (HSSIP 2010/112014/15, page 6-7). The PHP sector is fast growing and most facilities are concentrated in urban
areas. The GoU subsidizes the PNFP and a few private hospitals as part of Public Private
Partnership. The subsidies cover the minimum package of health services as stipulated in the
National Health Policy and Health Sector Strategic and Investment Plan.
Other than the VHT system (HCI), several other community systems exist and have been used for
various HIV, TB, and other health interventions in Uganda. There are several ongoing community
systems strengthening (CSS) activities including empowering of various community structures and
individuals (volunteers) to support and advocate for adoption of practices that maximize community
response to HIV and TB service delivery. Various community formal and informal networks for key
affected populations also do exist, including networks of PLHIV (family support groups, mentor
mothers and fathers, etc.), networks of MSM, transgender, and sex workers, among others (MOH
MARPs Report 2014, pages 22-23, 44-45). In this application CCM proposes to further strengthen
these community structures for demand creation and service delivery. CCM also proposes to
establish a community recording and reporting system linked to the health system to enable CSOs
and CBOs contribute to TB and HIV case finding and treatment support and adherence.
Whereas a lot of HIV and TB epidemiologic data exists in Uganda, several critical data gaps exist,
which may hamper fully informed investments. Some of the data gaps in relation to HIV investments
include limited evaluation of outcomes and impact of some interventions (e.g. primary prevention
interventions such as behavior change communication) and size estimates for key affected
populations. GOU together with partners, has in the past few months conducted a series of program
reviews, evaluations and special studies including: 1) development of the HIV Investment Case
(2015-2025); 2) Joint External Monitoring Mission for the NTLP (Sep 2013); 3) Development of the
National Strategic Plan for TB 2015-2020; 4) a recently completed mid-term review (MTR) of the
HIV NSP and ongoing development of a new NSP in line with the HIV Investment Case; 5) a
recently completed study assessing barriers and opportunities for accessing HIV services among
sex workers and MSM; 6) an ongoing review of the primary prevention interventions, with support
from the Global Fund; 7) an ongoing TB prevalence survey; 6) on going modes of transmission
analysis; among others. It is anticipated that several of these studies and reviews will be completed
by June 2016 /17 and will inform the implementation of the proposed activities. The HIV primary
prevention review and new NSP are all in advanced stages and will inform the grant making
process. Opportunities for operational research to analyze and study program data to inform policy
and planning also exist; these will be leveraged through this application to build capacity for OR
within programs and implementing partners that translate to published evidence that the program
can use.
Staff recruitment improved in 2012-2013 financial year due to a major recruitment undertaking for
HCIV and HCIII. According to the 2012-2013 Annual Health Sector Review Report (AHSR), the
percentage of approved posts filled by health workers in Public facilities increased from 58% in
2011/12 to 63% in 2012/13. However the staffing at General hospitals and specialized facilities
(national and regional referral hospitals) remained unfilled. The VHT concept is promoted through
training of VHTs of which 75% have been established and only 55% villages have trained VHTs.
The VHTs have also not been fully utilized; in a few instances where they have been engaged their
impact is yet to be realized.
The recent JEMM for TB (NTLP MTR 2013, Page 5-6) identified several constraints in the context of
health and community systems with respect to TB control. These included underfunding and
understaffing at central, regional and district levels; gaps in recording and reporting skills of facility
Uganda TB and HIV Concept Note

15 October, 2014 10

level staff; limitations in M & E and in data management; the discontinuation of the community
based care model so successfully modeled in Uganda due to limited support from the district health
offices; limited scale-up of Programmatic Management of Drug resistant TB (PMDT) in the face of
an emerging epidemic of MDR-TB; poor or no budgetary support to TB control from the district
health office in several districts; limited collaboration and leveraging of the Uganda Stop TB
Partnership despite its expanding network of CSO members; limited or no involvement of the
community in DOT; over-stocking and stock-outs at different facilities due to limitations in
procurement and supply chain management within the National Medical Stores (NMS); low index of
suspicion among health care workers and poorly performing laboratory support systems at the
periphery contributing to suboptimal case notification; limited leverage of the HIV system to
transport sputum samples for testing and centralized external quality assurance (EQA) overloading
the national TB reference laboratory (NTRL); poor coordination between peripheral labs and
treatment facilities compromising treatment initiation for patients with initial loss to follow-up; very
little infection control compromising patients and health workers in facilities; little or no
implementation of contact tracing of children in contact with adults with TB; limited capacity to
suspect and diagnose TB in children and absence of data quality assurance protocols and limited
quality assessments of data contributing to data uncertainties.

1.2 National Disease Strategic Plans

With clear references to the current TB and HIV national disease strategic plan(s) and
supporting documentation (including the name of the annexed documents and specific
page reference), briefly summarize:
a. The key goals, objectives and priority program areas under each of the TB and HIV
programs including those that address joint areas.
b. Implementation to date, including the main outcomes and impact achieved under
the HIV and TB programs. In your response, also include the current
implementation of TB/HIV collaborative activities under the national programs.
c. Limitations to implementation and any lessons learned that will inform future
implementation. In particular, highlight how the inequalities and key constraints and
barriers described in question 1.1 are currently being addressed.
d. The main areas of linkage with the national health strategy, including how
implementation of this strategy impacts the relevant disease outcomes.
e. Country processes for reviewing and revising the national disease strategic plan(s).
Explain the process and timeline for the development of a new plan and describe
how key populations will be meaningfully engaged.
Ugandas HIV Investment Case for 2015-2025 aims at scaling up evidence based HIV
interventions. The Investment Case aims to rapidly scale up selected combination prevention
interventions in the first three years (between 2015-2018) and thereafter sustain the coverage at
these recommended levels, in order to achieve the desired impact (averting 2,160,00 HIV infections
and 570,000 deaths by 2025). The selected interventions include: 1) Anti Retroviral Therapy (ART)
(80% coverage) with treatment irrespective of CD4 count for several MARPs; 2) eMTCT (95%
coverage of ARVs among HIV infected pregnant women); 3) safe male circumcision (SMC) (80%
coverage); 4) access to and use of condoms in high-risk sexual encounters (80%); 5) HIV testing
and counseling (50%); and 6) behavior communication interventions focusing on the most affected
populations including sex workers, MSM, fishing communities, truckers and uniformed personnel as
well as young people in and out of school (Uganda Investment Case 2014, Page 14).The
investment case also emphasizes addressing underlying structural drivers of the HIV epidemic and
integration of HIV with TB and RMNCAH programs as well as enhancements of relevant health and
community systems to ensure effective and efficient programming.
Uganda is also in advanced stages of developing a new National HIV Strategic Plan (NSP) for
2014/15-2019/20. The NSP development started after the 7th Annual Joint AIDS Review (JAR),
which was held September 11th to 12th, 2014. The MTR and JAR as well as the NSP development
are done through multi-stakeholder consultations and efforts.
The National TB and Leprosy Control Program-Strategic Plan (NTLP-SP) 2010/11 2014/15 was
revised (2012) to align it to new evidence and guidance in TB control that was provided by the
Uganda TB and HIV Concept Note

15 October, 2014 11

World Health Organization (WHO), most especially in the area of TB/HIV collaboration and the
need to scale up new diagnostics. In July 2014, the NTLP concluded an exercise to develop a
renewed national strategic plan (NSP) that will take into account the Post-2015 Global TB Strategy,
acknowledge the achievements of the NTLP and the challenges it currently faces and advise the
planning, implementation, monitoring and funding of TB control for the period 2015 to 2020
(Uganda TB Strategic Plan draft July14, Pages 41-42). Specifically, this renewed strategic plan will
also inform the direction and funding request of the NTLP under the New Funding Model of the
Global Fund through a Joint TB HIV Concept Note. This most recent document includes a
monitoring and evaluation plan, operational narrative, budget and a technical assistance
component and is the reference strategic planning document for the NTLP in this Joint application.
a. The key goals, objectives and priority program areas under each of the TB and HIV
programs including those that address joint areas.
Uganda National HIV Strategic Plan (NSP) for 2015/16-2019/20
The draft NSP has four thematic service areas: Prevention, Care and Treatment, Social Support
and protection, and systems strengthening, and is aligned to the Investment Case in terms of the
selected interventions and targets. Similarly, the proposed investments in this application are fully
aligned with the HIV investment case, the TB and HIV NSPs, and address the key challenges
highlighted in the HIV and TB program reviews.
Goal: The goal of this application is to contribute to the following Investment Case goals: a) 77%
reduction in new HIV infections by 2025; (b) reduction of new infections in children from 14,200 to
4,040 between 2014 and 2025; and (c) avoid 570,000 deaths by 2025.
Uganda National Tuberculosis and Leprosy Control Program. Strategic Plan 2015/16
2019/20 (version July 2014)
The Vision guiding the current strategic plan is A Uganda Free of Tuberculosis. The Goal of the
current plan is To reach a reduction of 34% in TB prevalence by 2020 (113/100,000). (Uganda TB
Strategic Plan draft July14, Page 55).
The plan includes four operational (strategic) objectives. Each operational (strategic) objective is
further broken down into comprehensive strategic intervention areas for the national program as
detailed below (Uganda TB Strategic Plan draft July14, Pages 56 to 59):
Objective 1: To detect 85% of estimated TB cases and successfully treat 90% of them by 2020

Increase the capacity of health workers to diagnose TB, especially childhood and clinically
diagnosed TB
Ensure treatment initiation and adherence in all diagnosed TB patients
Improve access to and utilization of quality laboratory network and radiology services for TB
diagnosis
Empower patients, their families and communities in TB care through referral of
presumptive TB patients to diagnostic facilities, supporting treatment adherence and
conducting contract tracing (each patient will lead to activities in the family/community
where the patient comes from)
Strengthen TB care and prevention in congregate settings
Strengthen and expand Public Private Mix in line with national policy framework
Implement an urban TB care and prevention strategy for cities and municipalities
Integrate TB care and prevention services into NCD and MCH services

Objective 2: Provide TB/HIV integration to co-infected patients and enroll >90% of co-infected
patients on ART

Strengthen collaboration and monitoring mechanisms

Scale-up implementation of the one-stop model for co-infected TB patients in ART
accredited facilities
Implement TB/HIV interventions to decrease the burden of HIV among patients with
presumptive and diagnosed TB
Support the provision of ICF and IPT services in HIV care settings
Implement TB infection control practices in all DTUs

Objective 3: To detect 80% of estimated MDR-TB cases and treat successfully 80% of them by
2020

Ensure early detection and improve MDR-TB patient management

Uganda TB and HIV Concept Note

15 October, 2014 12

Expand access and improve MDR-TB treatment (including home based care pilot)
Implement Infection Control practices in MDR-TB facilities including follow up facilities

Objective 4: To strengthen systems for effective management of Tuberculosis & Leprosy services
to meet the NSP targets

Advocate for increased financial resources from domestic sources and ensure maximum
use of available finances
Improve the quality of TB care and ensure patient safety at all levels
Engage communities and stakeholders in TB and leprosy prevention and care
Improve human resource capacity at all levels to effectively deliver TB and leprosy services
To improve availability of quality assured TB and Leprosy medicines, supplies and
equipment for prevention and treatment at all diagnostic and treatment health facilities
To strengthen M&E systems for tracking performance and measuring outcomes/ impacts to
guide decision making
Implement the research agenda through collaboration of NTLP and the Uganda TB
research community
Ensure availability of logistics for NTLP general office operations

b. Implementation to date, including the main outcomes and impact achieved under the HIV
and TB programs. In your response, also include the current implementation of TB/HIV
collaborative activities under the national programs
HIV Program
There is significant progress towards achieving some of the Investment Case and NSP targets
including HIV counseling and testing, expanding ARV coverage within PMTCT as well as ART for
adults (including adolescents) and children (<14 years). However, for some areas e.g. male
circumcision and condom programming, progress has been slower.
Behavior change communication
According to the MTR prevention review, several achievements have been registered in behavior
interventions. Achievements included development of a BCC message book which was distributed
to all districts by UAC; a pastoral letter distributed by the Inter-Religious Council of Uganda (IRCU);
and interventions targeting cultural leaders. UAC also established a message clearing committee
and launched a new campaign Zip-up 256. However, it is estimated that only 1,639,649 individuals
were reached with BCC, representing 7.9% of the targeted number. Also, HIV risk behaviors
persisted. The districts of Kalangala, Bududa and Kyenjojo had the highest proportion of adults
reporting non-marital partners (43.1-53.6% of adults surveyed) while the proportion reporting
condom use at last non-marital sex was lowest in Apac, Atuke, Alebtong, Pallisa, Budaka,
Ntungamo and Kisoro (range: 21.2-37%) (HIV Prevention MTR Report, Sept 17 2014, Page ix).
The KMCC BCC review of 2013 indicates that consistent, targeted messages that are grounded in
the realities of the communities, promoted by multiple sectors and multiple channels such as mass
media and telecommunications are valuable but should be used strategically and targeted to
communities. The review notes that the ABC campaign was previously successful but overlooked
the influence of gender, coercion and socioeconomics of decision-making dynamics and did not
target MARPs such as sex workers and fishermen as well as the risk compensation due to new
technologies like SMC and ART (KMCC BCC Synthesis Report 2013, Pages 7, 8). Inconsistencies
in messages were also cited as a challenge (e.g. mixed messages around use and non-use of
condom). Thus the current BCC models and messages may require adjustments to align with the
current environment.
HIV counseling and testing (HCT)
Scale-up of HCT is a critical element in accessing HIV prevention and care and treatment. Access
to HCT services by the general population increased from 25% of women and 23% of men in 2006
to 66% among women and 45% among men in 2011 (AIS 2011). HIV testing among men increased
four-fold, from 11% in 2004-05 but remains far below the uptake among women. The higher
coverage among females is attributed to HCT opportunities during MCH and PMTCT services. HCT
has expanded over the last three years with expansion of Provider Initiated Testing and Counseling
(PITC), community models, and couples HIV counseling and testing. The Investment Case targets
to test 50% of individuals 15-49 years annually. A total of 5,524,327 adults (15 years and above)
out of an estimated 15,152,308 were tested and received their HIV test results in 2011;
representing 36.4% HCT uptake in 2011. This proportion increased to 58.2% by the end of 2013
(6,982,715 of 12,000,450) (HIV Prevention MTR Report, Sept 17 2014, Page vii). In FY 2013/2014
9.6 million people received HCT from 4,401 sites, including PMTCT sites (HMIS/DHIS 2 July 2013Uganda TB and HIV Concept Note

15 October, 2014 13

June 2014). However, access to testing by some population groups (e.g. men) is still low. Couple
testing is also low; only 5% of testers received couple HCT in 2013/2014. This application includes
activities to strengthen PITC and scale-up community testing for selected high-risk groups including
fisher folk, uniformed personnel truckers, among other groups.
Male circumcision
SMC prevalence was 26% in 2011, according to the AIS. The annual target for the national SMC
program is 1,001,875 circumcisions, to contribute to the previous NSP target of 5 million
circumcisions by 2015. SMC scale-up was initially slow but has significantly increased due to
improved capacity. Training capacity has been built countrywide through recruitment of dedicated
teams for SMC. A mixed model approach has been adopted; using roving teams to conduct SMC
outreaches and camps, in addition to static sites at facilities. A few implementers/sites have
introduced new SMC technologies (Prepex); currently 10 sites use both Prepex and the surgical
method. In 2012/2013, 400,000 out of 1,000,000 targeted circumcisions were done (40%)
compared to 1,023,357 (at 1295 sites) in 2013/2014 (HMIS/DHIS 2 July 2013-June 2014). The
increased number of circumcisions in the past year is a clear indication of the increased demand
and capacity to provide SMC, and the coverage should continue to increase if the momentum and
inputs for SMC are sustained. In this application, CCM requests support to further scale-up SMC
including use of Prepex non-surgical devices.
Condom programing
The MoH is implementing the national Condom Strategy that guides implementation of
comprehensive Condom Programming. The strategy is aimed at increasing demand for male and
female condoms, improving access to and utilization, strengthening the condom supply chain
management, and monitoring and evaluation. Leadership at all levels (MoH Condom Coordination
Unit, District Condom Focal Persons and UAC) has been strengthened to oversee coordination of
strategic condom activities. Both male and female condoms (FC2) are procured and distributed.
The country has recently strengthened capacity for the Condom Post-shipment testing policy, and
this has greatly improved the condom throughput. However, the number of condoms procured
annually has been declining since 2010 and the numbers are significantly below the projected
national need (Figure 5). The supply and commitments for 2014 are less than a half of the projected
need (Condom Strategy 2013, Pages 6, 7). Distribution channels for the condoms also require
enhancement to make condoms more available to high-risk populations. Yet, the alternative
distribution mechanisms (outside health facilities are not well developed) (Condom Strategy 2013,
Page 7). This application includes strategies to enhance community distribution of condoms
especially targeting high-risk and vulnerable populations (sex workers, MSM, fisher folk, truckers
and uniformed personnel), among other groups. Condom distribution at selected hotspots will be
enhanced (informed by PLACE Methodological Study).
Figure 5: Number of condoms procured 2006-2012

PMTCT and EID

Uganda started implementing life-long ART for PMTCT in October 2012. The national PMTCT
program now called the Elimination of Mother-to-Child Transmission (eMTCT) Program supports
the holistic implementation of the four-pronged strategy (primary prevention, prevention of
unintended pregnancy, provision of ARV prophylaxis, care and support). The plan includes the
consolidation of services to increase uptake, male involvement, strengthening of family planning
(FP) services, and improvement of comprehensive care for women living with HIV, their spouses
and their exposed children through early HIV diagnosis and linkages to care. The PMTCT facility
coverage has increased significantly over the past year; from 2,138 in 2013 to 3248 facilities
Uganda TB and HIV Concept Note

15 October, 2014 14

providing PMTCT services by June 2014. The proportion of pregnant women tested for HIV
increased from 30% in 2008 95% in 2014 (HMIS/DHIS 2 July 2013-June 2014). The proportion of
pregnant women living with HIV receiving ARVs increased from 33% in 2007 to 87% in 2014
(HMIS/DHIS 2 July 2013-June 2014). There are several interventions related to community systems
strengthening (e.g. mentor mothers, mentor fathers, family support groups, and VHT among others)
to support mobilization, retention, adherence and psychosocial support. Whereas testing for HIV at
ANC has improved, syphilis testing remains very low. In July 2013-June 2014, 95% of the women
who attended first ANC were tested for HIV while only 6% had a syphilis test, a missed opportunity
for eliminating congenital syphilis alongside eMTCT (HMIS/DHIS 2 July 2013-June 2014)
In 2013, EID facility coverage was 1,696 (76% of the facilities) including 100% of referral hospitals,
100% of district hospitals and 100% of HCIVs, 84% of HCIIIs, and 5.6% of HCIIs. Coverage of EID
testing among infants (first DNA PCR) in 2013 was 60,437 (51%), a steady increase from 7% in
2007. The median age at first PCR has remained fairly stagnant; at 4.2 months in 2011 and 4.8 in
2013 (EID Database; http://www.cphluganda.org/dashboard/new/dashboard/). However, the
percentage of exposed infants who received the first PCR at two months has increased from 45.6%
in 2011 to 59.8% by June 2014, against the NSP target of 50% by 2015. Prevalence of HIV among
those tested was 9% in 2012 and 4.6% in 2013, a significant decline from 19% in 2007. The
prevalence among those that completed the PMTCT cascade was 4% compared to 25% among
those with no PMTCT; however, only 28% had completed the PMTCT cascade. According to the
MTR review, the number of new pediatric infections reduced from 28,000 in 2011 to 8000 by end of
2013 (HIV Prevention MTR Report, Sept 17 2014, Page vii).
ART and pre-ART care
The number of ART facilities increased from 475 in 2011 to 1603 by June 2014; 100% public
hospitals, 91% of HC-IVs (188) are providing ART (87% of the HC IV facilities provide pediatric
ART) services. This has led to a rapid scale-up of the number of individuals on treatment. Pediatric
ART coverage has also increased -- tripled between 2006 and 2013 (Annex 5, pages 17 and 18).
Following the 2013 ART guideline revision, 43% (588,039) eligible adults and children were
receiving treatment by end of 2013 (adults constitute 92% of those on treatment), and 48%
(680,514) by June 2014 (HMIS/DHIS2, July 2013-June 2014). Based on retention data reported by
facilities, 83% of adults and children remain on treatment 12 months after initiation of ART as of
December 2013. Over all, PLHIV are initiating ART earlier: the number of individuals initiating ART
at CD4 <250 reduced from 80% in 2008 to 57% in 2013 and 48.7% by June 2014. Additionally,
100% of HC IV and HC III are performing or linked to CD4 and full blood count for patient
monitoring. The increased number of facilities providing ART and the enhanced coverage for
laboratory monitoring have increased the capacity to enroll and support more individuals on
treatment, and is a crucial step towards the implementation of the WHO 2013 treatment guidelines.
This expanded capacity explains the recent increase in the number of individuals enrolled on
treatment annually.
By June 2014, there were 963,272 PLHIV in care, and of these 79% were receiving cotrimoxazole
prophylaxis while 73% were screened for TB, and 60% accessed the Basic Care package (safe
water system, and cotrimoxazole, mosquito net, condom and education on PHDP) in 2013. The
improvements in HIV care have had an impact on HIV related deaths, which are reported to have
reduced over the years. HIV related deaths reduced from 120,000 in 1998 to 63,000 in 2013
(Uganda HIV Investment Case, Pages 17 and 18).
Services targeting MARPs and vulnerable populations
Over the past few years, Civil Society and government have initiated interventions serving key
populations. The MARPs Network was established to bring together community based
organizations (CBOs), and provides a platform where these organizations share experiences,
contribute to program design, forming a growing forum for knowledge management, strengthening
organizations, advocacy, and coordination. The MARPs network brings together several CBOs both
formal and informal, which serve these communities. The Most At-Risk Populations Initiative
(MARPI) clinic at the STD clinic in Mulago Hospital serves as a one-stop center providing a
comprehensive package of HIV prevention services for SWs and MSM, and has introduced ART
among the services provided. Several PEPFAR partners also support HIV initiatives for key
populations including SWs and MSM. These existing partners and networks will provide an entry
point for the scale-up and strengthening of MARPs services. The Semi-annual PEPFAR Report
May 2014 shows that 132,755 MARPs received services from various partners within the previous
six months. The MARPs that were reached include 15,059 sex workers, 429 MSM, 15917 truckers,
9334 incarcerated populations, and 76,710 fisher folk (PEPFAR Semi-Annual Report 2014). This
application seeks to further expand the MARPI clinic model to four regional referral hospitals; a
review of the access to services among sex workers and MSM in 2013 revealed more challenges
Uganda TB and HIV Concept Note

15 October, 2014 15

with access to HIV services outside Kampala.

Gender based violence and social protection
Generally there is a noticeable reduction in the proportion of PLHIV that report cases of SGBV from
39% to 25% between 2011 and 2013 (UAC Draft NSP, Page 36). In 2013, USG- PEPFAR
supported programs reached 543,833 individuals with interventions that explicitly addressed GBV;
609,020 individuals with interventions and services that addressed legal rights and protection of
women and girls impacted by HIV; and 943,964 individuals with interventions that explicitly
addressed norms about masculinity related to HIV (UAC Draft NSP, Page 36).
TB Program
Uganda is one of seven countries in the World Health Organizations (WHO) list of 22 high-burden
countries that have met all of the 2015 MDG targets for reduction in TB cases and deaths (Global
Tuberculosis Report 2013 Supplement, Page 4). The summary of implementation, main outcomes
and impact of TB control in Uganda include the following:
Case notifications
In 2012, the WHO estimated the incidence of TB (all forms) in Uganda to be between 53-79,000
(Global Tuberculosis Report 2013, Table 2.1, page 9). In 2013, 47,650 patients (all forms, new and
retreatment) were notified to the NTLP, of which 44,934 were incident (new and relapses). This
translates to an effort to notify between 57 to 85% of the estimated incidence and represents a
slight increase over the 47,211 (all forms, new and retreatment) and 44,663 (new and relapses)
notified in 2012. More men were notified than women ratio 1.7:1; and as in previous years, 89%
of patients were pulmonary TB, with one smear negative being notified for every two smear positive
TB patients.
The NTLP aggregates district data into zones (9) which approximate to the administrative regions
used by the Ministry of Health and the AIDS Control Program (ACP). The NTLP is in the process of
migrating these zones into the regions defined by the MoH. Zonal contribution to national TB
notification varies considerably; some zones seem to contribute the equivalent of their populations
while in others, the contribution was not proportional. In 2013, two zones (South-west and Northeast) notified TB patients proportional to their populations, while two others (Kampala and the
North) notified more patients than expected from the national estimates Kampala notifying 4 times
more and the North zone 1.5 times more. The remaining 5 seemed to notify fewer patients in
proportion to their population. It is also evident that Kampala, South-west and North zones with
approximately a third (35%) of the countrys population notified nearly half (48%) of the national
incident notification (Uganda TB Strategic plan draft July14, Pages 30 and 31).
The ratio of people with presumptive TB to notifications (all forms) in Uganda increased steadily
from 2008 to 2012 (2.10 in 2008 and 3.51 in 2012). As such, it suggests that the reach of the
national TB program is steadily expanding over this time. Despite an increase in the number of
tests being performed with time, the number of notified cases has not increased at the same rate,
and even declined in 2012 compared with 2011. It is unlikely that the number of notified cases has
plateaued given their latest case detection rate (all forms) of 69% (2012), but further investigations
may find a change in laboratory testing methods, a change in case definitions or some other artifact
of the surveillance system. It is also possible that more cases are being diagnosed and initiated on
treatment and that the slower increase in notification rate is due to under-notification.
Overall, during 2008-2012 the proportion of all notified cases (new and retreatment) that are
retreatment cases has remained relatively stable (7.2% in 2008 and 8.2% in 2012), with a slight
increase in retreatment cases in 2009.
For the youngest age group (0-4) and for ages 15-24 the rates between males and females are
similar. Females aged 5-14 had consistently higher rates of TB. For the rest of the age groups,
rates of TB are higher in males than females. Over time, there has been a slow increase in the
rates of TB in the two oldest age groups (55-64, 65+) for both males and females, while for cases
aged 45-54, there has been a recent decrease in rates in females, but the rates continue to
increase in males. At a sub-national level, there was wide variation: Five zones North-east,
Kampala, East, South-east and Central had a lower ratio with the North-east notifying 1.02:1 in
2007 rising to 1.23:1 in 2013; three zones North, North-west and West had far greater ratios,
ranging from 1.54:1 in 2007 to 2.24 in 2010 (North-west). The current recording and reporting tools
have been revised to capture sex and age group only for all forms of TB. They also capture this
data for children under the age of 5 years (NTLP revised quarterly reporting Form pages 1-3).
The country is in the process of changing from an eight-month first line regimen without rifampicin
in the continuation phase to the standard WHO recommended six-month first line regimen with

Uganda TB and HIV Concept Note

15 October, 2014 16

rifampicin throughout.
Treatment outcomes
Treatment success rates declined slightly in smear positive and negative/extra-pulmonary cases
between 2007-2009, with a slight increase observed in 2010. Treatment success rates in
retreatment cases have continued to decline since 2007. In the retreatment cases this decrease
may be explained by increases observed in treatment failure, loss to follow-up (default) and death.
However, the large variations observed over time suggest that there may be issues with internal
consistency and reporting of treatment outcome in this group. In smear negative/extra-pulmonary
cases there has been an increase in the proportion of deaths. Increases in death or loss to followup (default) were not observed for smear positive cases. There were no treatment failures recorded
for smear negative/extra-pulmonary cases, which may suggest that there are inaccuracies in
reporting. At the sub-national level, with the exception of 2007, Kampala that notifies close to a fifth
of the national TB notification continues to have the lowest treatment success rates (35% in 2006
and 68% in 2012). The North zone has better treatment success rates at 85% or more for the last
four years; 46/112 (37%) of districts had achieved treatment success of 85% for the 2012 cohort,
while 6/112 (5%) had cure rates of over 80%. Most of the districts with good treatment success
rates tended to implement community based treatment support to patients.
MDR-TB and PMDT
Program guidelines require drug susceptibility testing to be routinely carried out on high-risk groups
for MDR-TB; treatment failures, relapses, retreatment cases, cases who are contacts of an MDRTB case, and health care workers (NTLP MDR Guidelines page 15-16). DST results are collected in
the TB register. However, to date, there is virtually no systematic process in place to successfully
capture, monitor and track all MDR-TB suspects, cases and treatment nationally. From 2009-2012,
the number of confirmed MDR-TB cases detected nationally was 57 (2009), 93 (2010), 71 (2011)
and 89 (2012). The NTLP started implementing Programmatic Management of Drug Resistant TB
(PMDT) in 2012 using a mixed model of care approach (initial admission with discharge to 100%
ambulatory care). The first cohort of patients will complete treatment in 2014. PMDT has been
expanded to include 14 sites country-wide (12 Regional Referral Hospitals and 2 general hospitals),
about 52 operational XpertMTB/Rif machines linked to a HUB system transporting sputum
samples, a full-time national PMDT Coordinator (supported through GF) and an MDR-TB Technical
Working Group within the NTLP. The cumulative enrollment into PMDT is 348 patients, with 260
currently on treatment (The vast majority of these patients are treated at one hospital Mulago, in
Kampala). While there is considerable partner support to PMDT rollout, there is also the inherent
risk to sustaining the program due to its dependence on donor funding (Uganda TB Strategic plan
draft July pages 44, 47).
TB HIV co-infection
In recent years, Uganda has made significant strides in diagnosing and treating patients with TB
and HIV co-infection. NTLP data show that while the number and proportion of all registered TB
cases with a known HIV status, a proxy for HIV testing, has increased, the overall proportion of
cases that are HIV positive has declined. The use of CPT (91% in 2013) and ART for co-infected
TB patients while on TB treatment have both increased over time, although the number and overall
proportion of cases receiving ART remains low (65% in 2013).
The number of HIV positive people screened for TB also increased between 2006-2012 (27% in
2006 to >90% in 2012). The number of TB patients diagnosed through this screening however
remains very low (1.5% of those screened versus the expected 5-7%) (Uganda Investment Case
2014, page 20).
In its current approved SSF Phase II grant, Uganda has embraced the need to implement an
integrated model for TB-HIV services. The National Policy for TB/HIV collaborative activities has
been revised to include a policy recommendation on an integrated model for TB-HIV services. With
support from partners, the MoH has taken early steps to implement an integrated model starting
with the 14 regional referral hospitals and the general district hospitals. Successful implementation
will require development and dissemination of implementation guidelines together with training,
mentoring, and supervision of health workers. The HIV program will support TB clinics to get
accredited for provision of ART and will support the accredited TB clinics to access ART and
medicines for treatment of opportunistic infections. This will also be expanded to the 136 general
hospitals in this application.
c. Limitations to implementation and any lessons learned that will inform future
implementation. In particular, highlight how the inequalities and key constraints and
barriers described in question 1.1 are currently being addressed

Uganda TB and HIV Concept Note

15 October, 2014 17

Inequitable access to services and inadequate targeting of interventions to high-risk groups

Widespread inequities in access to HIV and TB services and uptake across geographical regions,
gender, and high-risk groups have persisted over the years. Targeting of MARPs has particularly
been a major gap. The Investment case cites the limited targeting of risk groups and population
segments such as MARPs and vulnerable groups as a major gap of the current HIV response
(Annex 5, page 16). Feedback from the GF and from the Joint Mission (TB) also emphasized this
limitation. In this application CCM intends to address this gap through interventions that are
targeted to groups that are most at risk of HIV and therefore TB, including fishing communities, sex
workers and their clients, and MSM. These interventions will address barriers to service uptake
among high risk groups and gender norms and practices that put women and men at risk of HIV
and therefore TB and that limit access to services. The NTLP has very recently mobilized an
XpertMTB/Rif machine exclusively for the fishing communities to increase access to quicker TB /
MDR-TB diagnosis and through this investment application expand access to TB screening and
diagnosis prioritizing high-risk groups already under HIV care.
Inadequate attention to primary interventions
The 2014 Joint Annual AIDS Review (JAR) and other previous reviews have highlighted limited
attention to behavioral interventions and drivers of the epidemic including GBV, alcohol, substance
abuse, and multiple sexual partnerships, and decline in condom use (Uganda Investment Case
2014, Page 9,24,31). There has also been a decline in condom procurement and weaknesses in
the distribution channels (Condom Strategy 2013, page 6, 7), which were for a long time, largely
facility based and may partly explain the decline in condom use in high-risk sexual encounters.
Additionally, there is limited coverage of SMC and HCT. The Investment Case and the new NSP
emphasize scale-up of all these interventions in tandem with biomedical interventions and scale-up
HIV treatment. This application specifically includes a scale-up of SMC specifically targeting
younger men and high prevalence districts with low SMC coverage. The primary prevention
interventions will also target youth in and out of school and high-risk populations such as key
affected populations and fishing communities. In this application there are several primary
prevention interventions targeting MARPs including MSM, sex workers, fisher folk, uniformed
personnel, truckers, and youth in and out of Schools as well as enhancement of alternative condom
distribution mechanisms and condom promotion to improve access to condoms. The application
specifically includes scaling up the Most At Risk Populations Initiative (MARPI) clinic model to four
regional referral hospital in addition to support for CSOs and CBOs working with MARPs such as
sex workers and MSM. Despite the legal environment and challenges, there are several
implementers of MARPs interventions in Uganda as evidenced by the numbers reached by ongoing
programs. The health policy and guidance environment has further improved with the two newly
established MARPs technical working groups (TWGs) at MOH and UAC, and the MARPs
framework, with provision of services for all MARPs including SWs and MSM. The proposed
expansion of the MARPI model, which has thrived despite this environment will further enhance
services for SWs, MSM, and TG.
This application will also seek to implement and expand IPT for eligible PLHIV based on the revised
and approved national IPT guidelines thus protecting them from TB. ART scale-up constitutes the
mainstay for the prevention of HIV-associated TB, and must be done in the context of intensified
case finding (ICF) and infection control (IC) to minimize the risk of TB transmission in HIV care
settings. The earlier ART is started during the progression of HIV infection, the greater the
cumulative preventive effect (Lawn SD et al 2010 page 489, 490; Lawn SD et al 2011 page 571,
575, 576). However, although ART is necessary, it is not sufficient. People currently living with HIV
are likely to need life-long ART and, even if treated effectively, these will constitute a large and
expanding reservoir of people with heightened TB susceptibility for decades to come (Lawn SD et
al, 2014 page 1136). As Uganda scales up ART coverage, it is imperative that IPT is also scaled up
as an adjunctive intervention for those within ART care. The national IPT guidelines have been
finalized and provide the opportunity to implement and scale up IPT for HIV infected people under
care and as part of the 3 Is through this joint grant application. Currently IPT is available only in
three centers of excellence operated by private not for profit (PNFP). The ACP will procure the
isoniazid required for this effort (incentive funding) in this investment application to promote
integration across programs.
Additionally, this application will implement contact tracing to identify children at risk of increased
transmission from smear positive adult TB patients and provide them also with IPT. The majority of
Ugandas population is young and children under 5 are at increased risk for TB through exposure to
smear positive adult contacts. Contact tracing has already been established as a program
imperative, but is implemented weakly and is not tracked for effectiveness. It is essential that all
children (under 5) contacts of smear positive patients be protected through routine contact tracing,

Uganda TB and HIV Concept Note

15 October, 2014 18

screening for TB and protection through IPT.

There are limited studies on the nosocomial transmission of TB within the country. While rates of
MDR-TB are low among new patients according to a national survey conducted recently, the survey
also pointed out the need to enforce infection control measures within health facilities and
protection for health workers including screening them regularly and monitoring them for TB
(Lukoye D et al, 2013 page 7). A recent Joint External Monitoring Mission for the NTLP (Sep 2013)
observed that IC was not implemented in health facilities visited posing risk for patients and health
care workers. Limitations in data management systems and surveillance for MDR-TB further
compound these challenges. This application seeks investments in protecting patients and health
care workers from TB / MDR-TB in health facilities. The application also links with the HSS Concept
Note in this intervention area (procurement of N 95 respirators for health care workers).
Sub-optimal coverage of effective HIV interventions and access to TB services
Coverage of HIV testing and linkage to care and prevention services, coverage of SMC and some
components of the PMTCT has remained very low for a long time, while condom use at high risk
encounters declined, partly due to gaps in the demand creation and inappropriate distribution
mechanisms. To realize the goals of the HIV Investments Case, CCM proposes to increase and
sustain the high coverage of a combination of effective HIV prevention, care and treatment
interventions. Adjustments to the existing strategies for demand creation and service delivery are
proposed to enhance access to quality effective interventions. Access to TB screening and
diagnosis, and treatment support will be nested within these interventions in this application.
Limited integration of HIV, TB, and RMNCAH
Uganda developed policies and guidelines for integration of TB and HIV and has similarly
developed guidelines for integration of RMNCAH and HIV programs. However, these linkages have
remained weak, with resultant missed opportunities for enhancing TB and HIV as well as RMNCAH
outcomes. For example EID for children remains low, yet, immunization coverage is much high,
indicating a missed opportunity for management of exposed infants. Considering the high HIV
prevalence among women and girls, integration is critical to ensuring improved outcomes for
RMNCAH and HIV. To enhance access to HIV and RMNCAH services, this application includes
activities to integrate HIV testing and other prevention services into MNCAH settings as well as
MNCAH services into HIV care and prevention services. In this application CCM also proposes
interventions to ensure TB/HIV integration at various levels as well as RMNCAH integration. This
application seeks investments to strengthen this integration at multiple levels including a cross
cutting module on program management.
Inadequate capacity for quality data management and data use
The Investment Case highlights inadequate data management and use among the major gaps in
the response. This issue has also been highlighted in the recently completed HIV NSP mid-term
review and Joint Annual AIDS Review as well as in multiple communications from the GF Country
Team. Strengthening of data management and use is one of the key interventions that have been
included in this application and the HSS concept note. Weaknesses within the NTLP in recording
and reporting, data management, analysis and M & E have been repeatedly identified; by the
Global Fund Country team and more recently by the Joint Monitoring Mission. These data
uncertainties also contribute to the wide confidence intervals observed in the estimates provided by
WHO with respect to prevalence, incidence and mortality and compromise the programs
effectiveness and impact. This application will seek investments in strengthening the systems for
health information, data management and M & E through a cross cutting module developed jointly
by the NTLP and ACP and further strengthened by a broader investment in this area through the
HSS concept note that will also integrate program specific information systems into the countrys
DHIS-2.
Important lessons learned for TB control
A situational analysis carried in 2009 before the implementation of the WHO funded TB Reach
Project (SPARK-TB) showed that of 1,003 private facilities assessed in Kampala, only 5% provided
TB treatment services routinely. Private facilities had inadequate knowledge and skills to diagnose
and treat TB. Key outcomes of the successful model SPARK-TB project implemented in just 100
clinics over one year in Kampala included:

Significant increase in case notification - 12% of all smear positive, bacteriologically confirmed
TB patients notified to the NTLP from Kampala came from these 100 clinics, which accounted
for just 7% of all private clinics in the city.
Significant improvement in treatment outcomes - the treatment success rate for new smear
positive TB patients diagnosed and treated in private health facilities was 80%
Significant improvement in local knowledge - the local communitys knowledge about TB

Uganda TB and HIV Concept Note

15 October, 2014 19

improved
Significant demand creation for TB services - 14 private facilities were accredited to receive
anti-TB medicines directly from the NMS and distribute them to an additional 57 private facilities
more patients received free anti-TB medications of high quality.
Significant collaboration with and leverage of local communities - the community network for
supporting TB patients was strengthened through training of 56 Village Health Teams (VHT)
and peer educators
Significant potential for scale-up - the project was expanded to a further 12 municipalities and
town councils in four districts

This investment application will further scale up this model through consolidating activities in five
districts and scaling this up to an additional ten municipalities in ten districts.
The TB Specimen Referral System (TSRS) was established to facilitate transportation of sputum
samples from peripheral Diagnostic and Treatment Units (DTUs) to the National TB Reference
Laboratory (NTRL) for drug susceptibility testing (DST). The TSRS network expanded from 264
DTUs in 2010 to 325 in 2011 and 400 by end of June 2013. In this investment application, the
TSRS will be strengthened and linked with the HUB system (already described in section 1.1 (d))
and the NTRL supported with the requisite human resources to monitor, supervise and technically
support the process working closely with the Central Public Health Laboratory (CPHL). This will
further decentralize the lab network and improve diagnosis and access to new technology as well
as make it sustainable. The HUB system is also being strengthened through the investment
application via the HSS Concept Note
An important constraint for TB programming is the limited engagement of communities in all
aspects of planning, implementation, monitoring, and advocacy among others unlike the ACP
where communities contribute significantly in all areas of program implementation. To address this
issue, communities including HIV affected communities got together and coordinated a series of
consultations over the last two weeks resulting in the development of a charter of engagement to
inform programming for both the TB HIV Joint application as well as the CSS priority module within
the stand alone HSS concept note that will be submitted simultaneously by the CCM. This charter
creates space for communities to participate in the development of priorities for this concept note,
contribute to and inform the writing process and highlights interventions to upscale the communitys
role in the response to TB HIV (TB Charter pages 1-6).
The strengths of the Uganda Stop TB Partnership (USTP), especially in supporting community
based DOT will be leveraged through this investment application. Districts with poor treatment
outcomes will be identified in consultation with the NTLP and investments are planned through the
CSS cross cutting module to work with local grass root NGOs, CBOs and FBOs including key
affected populations to expand the model community based DOT recognized and appreciated by
the Joint Monitoring Mission. These investments will be further strengthened through additional
investments to the UTSP via the HSS concept note of which they are a part. Support to the USTP
through the SSF Phase II grant will be consolidated and expanded in this investment application to
leverage their support to TB control in Uganda.
d. The main areas of linkage with the national health strategy, including how
implementation of this strategy impacts the relevant disease outcomes
In the Health Sector there are two levels of planning, National and District. At the national level, the
Ministry of Health draws the Health Sector Strategic Investment Plan (HSSIP) every five years, in
close consultation with development partners. The HSSIP is linked to the National Health Policy
and the National Development Plan (NDP). At the district level, local governments draw strategic
plans, which include health related activities. This is then followed by development of annual works
plans. The HSSIP is used to guide district health planning and implementation of health services in
the country. The Ministry of Health currently has a Health Sector Strategic and Investment Plan
(HSSIP) 2010/11 to 2014/15. The HSSIP aims to promote peoples health to enhance socioeconomic development. The HSSIP strategically focuses on five core areas outlined below (HSSIP
page xvi-xvii):
Scale up critical interventions for health, and health related services, with emphasis on
vulnerable populations;
Improve the levels, and equity in access and demand to defined services needed for health;
Accelerate quality and safety improvements for health and health services through
implementation of identified interventions;
Improve on the efficiency, and effectiveness of resource management for service delivery in
the sector;
Uganda TB and HIV Concept Note

15 October, 2014 20

Deepen stewardship of the health agenda, by the Ministry of Health.

The Ministry of Health currently has a Health Sector Strategic and Investment Plan (HSSIP)
2010/11 to 2014/15 which has been reviewed in depth through the Joint Assessment of National
Strategies (JANS) process in 2011 (HSSIP Assessment report 2011 pages). The national public
health response to HIV/AIDS is guided by the HSSIP and various national policies and guidelines
for key interventions including the Integrated National Guidelines on Antiretroviral Therapy, Safe
Male Circumcision Policy, Prevention of Mother to Child Transmission of HIV, HIV Counseling and
Testing Policy (HCT), and TB-HIV collaborative Strategy, among others. The country has also
developed a scale-up plan for eMTCT The Uganda National Plan for Elimination of Mother to child
Transmission of HIV which aims to reduce the risk of MTCT to less than 5% by 2015/16. The
HSSIP is reviewed annually (including the TB and HIV related indicators). The HIV and TB NSPs
are also reviewed annually for more detailed program specific performance tracking.
The Guiding Principles of the National Health Policy and the HSSP III are leveraged by the
National Strategic Plan for Tuberculosis Control to maximize program impact and outcomes as
follows (Uganda TB Strategic plan draft July 2014/, Table 4, page 51): NTLP guidelines are
evidenced based and incorporate the most recent global recommendations including the Post-2015
Global TB Strategy; that TB services are provided free of cost to all Ugandans; that the NTLP
fosters and works through partnerships; that diagnosis and treatment for TB is integrated into
primary health care and is almost universally available; that TB control, including the control of
MDR-TB is a part of the Uganda National Minimum Health Care Package (UNMHCP); that TB
services are increasingly integrated with HIV services through the One Stop Shop Model of care;
that TB services continue to be gender sensitive; that TB services are delivered through a multisectoral response that includes other public sector (prisons, army, police), private for profit and
private not for profit; that TB services take into context international issues such as cross border
migration and that TB services are fully decentralized.
e. Country processes for reviewing and revising the national disease strategic plan(s).
Explain the process and timeline for the development of a new plan and describe how
key populations will be meaningfully engaged
Uganda has had two national HIV strategic plans (for the periods 2007/2008-2010/11 and 2011/122014/15) and before then a national strategic framework for HIV/AIDS. Every year a Joint Annual
AIDS Review of the NSP is conducted by multiple stakeholders (public, civil society, private sector
etc.). Following every annual review, an Aid Memoire is developed to highlight achievements,
challenges, recommendations (for the year under review) and key priority activities for the following
year. The current NSP, which is scheduled to run till 2014/2015, has recently been reviewed (midterm review conducted in 2014) and development of a new NSP for the period 2015/16-2019/20 is
ongoing, scheduled to be completed in October-November 2014. The reviews of the NSP are highly
participatory and consultative (Uganda HIV NSP 2015-2020 October 15 draft, Page 17). Thematic
technical working groups (TWG) comprising of key national stakeholders from various government
sectors and various self-coordinating entities including public sector, AIDS development partners,
National NGOs, International NGOs, the youth, key affected populations (PLHIV), key populations,
and the media among others participates in the review of each thematic area. All these
stakeholders are also represented at the JAR and during revisions and development of new NSPs.
The health sector also conducts annual health sector reviews that feed into the
revision/development of health sector plans. This further captures HIV health related priorities for
implementation during the health sector review process.
Key populations are represented and actively participate in the various TWGs of the NSP review
and development processes. In the recent reviews various key populations including sex workers,
transgender, and men who have sex with men (MSM) were represented and participated in the
generation of the NSP priorities through TWGs and key respondents. Key population consultative
meetings have been held for example, a joint meeting was held in Dar es salaam (July 30-31st,
2014). Separate consultative meetings were held with each community of the key populations
including sex workers, fisher folks, MSM and transgender. The Ministry of Health technical working
group on MARPs also convened consultative meetings to identify priorities for key population
communities.
The current TB NSP has been developed for the period 2015 2020 through a consultative
process that included all program partners, donor agencies and importantly key affected
populations and civil society (TB Stakeholder Engagement Report 2014 pages 1-8). The
preparation for this NSP was initiated in 2013 and developed in 2014, one year ahead of the
proposed plan period. The NTLP coordinated a full Joint External Monitoring Mission to review the
national program in September 2013 and an epidemiological impact assessment earlier that year to
Uganda TB and HIV Concept Note

15 October, 2014 21

inform the planning process for the NSP full reports attached as annex 28. Such Joint external
reviews are routinely coordinated to assist the program to assess progress against the national
strategic plan and consider revisions. These are further assisted by the on-going quarterly program
reviews as well as the considerations of the various technical working groups set up by the program
to specifically support intervention areas. All of these, in combination with the support of
international partners and global agencies such as the World Health Organization advise the review
and the revision of the NSP during its term of implementation. With respect to this particular plan
period, the opportunity provided by this Joint TB HIV application will support the integration of
planning and policy for the TB and the HIV/AIDS program and will lead to joint planning, joint
program reviews and synergy in delivery of services as well as impact for affected populations and
communities.

1.3 Joint planning and alignment of TB and HIV Strategies, Policies and
Interventions
In order to understand the future plans for joint TB and HIV planning and programming,
briefly describe:
a. Plans for further alignment of the TB and HIV strategies, policies and interventions
at different levels of the health systems and community systems. This should
include a description of i) steps for the improvement of coverage and quality of
services, ii) opportunities for joint implementation of cross-cutting activities, and iii)
expected efficiencies that will result from this joint implementation.
b. The barriers that need to be addressed in this alignment process.
a. Plans for further alignment of the TB and HIV strategies, policies and interventions at
different levels of the health systems and community systems. This should include a
description of i) steps for the improvement of coverage and quality of services, ii)
opportunities for joint implementation of cross-cutting activities, and iii) expected
efficiencies that will result from this joint implementation
The NTLP and the AIDS Control Program (ACP) are disease control programs under the
department of the National Disease Control of the MOH headed by a Commissioner of Health
Services. A national level Coordination Committee has been created for both programs this is
chaired by the Commissioner and co-chaired by both the NTLP and the ACP Program Managers
and provides a platform to integrate planning and implementation of services provided by both
programs at the policy and research levels. It also assists coordination across stakeholders, donors,
key affected populations and civil society to align with national priorities and needs.
At the district level, the District Health Officer (DHO) is responsible for the management of health
service delivery including TB and HIV/AIDS care and prevention services as part of the primary care
package described in the national health policy. The DHO assigns a district health team member
the responsibility of overseeing TB and HIV/AIDS care and prevention services in the district. At the
HSD, the in-charge of the Health Sub-district level (HSD), usually a Medical Officer, is responsible
for the management of health service delivery including TB and HIV/AIDS care and prevention
services. A health worker is assigned the responsibility of overseeing TB and HIV/AIDS care and
prevention services at the HSD level and this person is referred to as the Health Sub-district Focal
Person. At the district, HSD and health facility level, TB and HIV/AIDS care and prevention
services/services are integrated into the general health services.
Both NTLP and ACP have elaborated national strategic plans that are valid up to 2015 these
plans have guided their strategic investments in planning and implementation over the last several
years. Over the period of their implementation, both program plans have been subject to regular
and rigorous review and adaptation that has involved all stakeholders including key affected
populations, international partners and global technical agencies. This process has led to the
introduction of the WHO recommended TB HIV Collaborative activities early in the program cycles
and performance indices reveal high coverage of HIV testing in TB cohorts and a similarly high
coverage of TB screening in the HIV infected population. Scale up of CPT within co-infected
populations while on TB treatment is also very high demonstrating the close linkages with the
program. ART coverage for co-infected patients has also improved from 34.2% in 2011 to 53.5% in
2012 and 65% in 2013.
Both programs are in an advanced stage of finalizing their strategic plans for the next 5-years.
These processes have included several steps joint reviews, stakeholder consultations among
Uganda TB and HIV Concept Note

15 October, 2014 22

others. This joint TB HIV application provides an exceptional opportunity for both the programs to
review their upcoming strategic plans and incorporate key administrative and policy reforms that
could be reviewed mid-term with the consideration to integrate these strategic plans at a later time.
i) Steps for the improvement of coverage and quality of services
This joint TB HIV concept note has already initiated several processes to integrate planning and
interventions within the proposed grant. A two-day stakeholder consultation was organized by the
CCM jointly with both the AIDS Control Program and the NTLP and included representation from
key affected populations as well as NGOs working in TB and HIV. This consultation identified key
priorities to guide the preparation of the Joint TB HIV Concept Note. These priorities were
summarized into a presentation that was then presented to the CCM for endorsement (TB_HIV
Joint Priorities slides 1-10). The presentation already captured the priorities across both programs
under the key intervention areas namely diagnosis, prevention, treatment and care, PMDT,
operational research, strategic information and crosscutting issues (including HSS, CSS, Program
Management). The need to focus on key affected populations, gender and other barriers including
human rights barriers under-wrote these priorities and is further described in the modular template.
Additionally, interventions such as increasing access to IPT for the HIV infected, increasing
availability and access to new diagnostic tools such as XpertMTB/Rif for key populations at risk for
TB such as children and HIV infected, improving infection control, protecting children and homes
through contact tracing and IPT for child contacts of smear positive TB, expanding early infant
diagnosis are among several interventions that will increase coverage of both programs, ensuring
quality of services. A dedicated module for CSS that includes an intervention area to introduce and
develop community monitoring of program services will also add to the quality and the efficiency of
both programs. This module also includes interventions to build institutional capacity in civil society
and key affected populations to contribute to and hold accountable national efforts to control TB and
HIV.
Significantly, the CCM has also submitted a separate Concept Note to the Global Fund for HSS that
prioritizes investments in three important health system areas namely, health management
information systems, procurement and supply chain management and community systems
strengthening. Key additions under these areas will further strengthen the programs to assure
quality in planning, programming, implementation and service delivery.
ii) Opportunities for joint implementation of cross-cutting activities
These areas were agreed upon through a joint meeting of the two program managers during the
writing process for this application and include:

The National Coordination Committee can be further strengthened to address policy issues
through the setting up of TWGs in identified areas
Introduce biannual joint TB-HIV programme reviews that will feed into the annual MOH Joint
Review Mission (JRM) and the UAC Joint AIDS Review (JAR)
Coordinate regional review meetings targeting TB/HIV, DHOs, health facilities
Organize implementation review meetings
Introduce Joint mentorships
Expand One Stop Shop model over the grant period - at lower facilities - one health worker
for both diseases creating integration of services for the patient
At larger facilities this will also translate to same day services, same roof, but with either
health worker with capacity to treat both diseases
Accreditation and training of both TB and HIV HW in ART and TB respectively coordinate
and organize training within the new grant period to build cross learning and integration of
skills across health workers
Prioritize HR - one person from each program assigned to TB/HIV integration for close
coordination
Integrated advocacy and awareness for HIV and TB with prevention Officers at RPMTs
Ensure program management issues are clearly prioritized in each program to ensure
program functionality (transport, fuel, stationary, communication, teas) M & E
Programs to agree on indicators which are shared so that favorable programs to each
program are reported etc.

The NTLP and the ACP will also progressively implement the integrated model for TB HIV services
approved in the TB SSF Phase II grant through the One Stop Shop model. The model includes the
following elements:

All TB standalone clinics will be transformed into TB-HIV clinics and will provide the

Uganda TB and HIV Concept Note

15 October, 2014 23

following services.
o
o
o
o
o

TB diagnosis and treatment

Rapid HIV testing
Initiation of ART and follow up
Treatment of opportunistic infection.
On completion of TB treatment, the patient will be referred to the HIV clinic to
continue chronic HIV care.
The HIV clinics will continue to provide the HIV testing, care and treatment services. In
addition, they will provide the following TB related services.
o
o
o

Active TB screening among HIV clients (Intensified TB case finding)

Provide isoniazid preventive therapy to eligible HIV clients
Refer HIV clients confirmed to have active TB disease to the TB-HIV clinic to start
and continue TB treatment. This will also help to reduce the risk of transmission of
TB within HIV clinics given the current infrastructure challenges for airborne
infection control.

iii) Expected efficiencies that will result from this joint implementation
Multiple efficiencies are expected from the investment proposed in this Joint Concept Note and the
simultaneous submission of the HSS Concept Note. These include the following:
Progressive planned integration of recording and reporting from both the ACP and the
NTLP into the District Health Management Information System (DHIS-2) that is
computerized and supported by highly trained personnel in data management
(Biostatisticians). This will increase efficiency in management and utilization of health
information at all levels, improve data quality, build capacity for M & E and guide better
programming.
Progressive planned integration of procurement and management of the supply chain for
TB and HIV medicines and commodities into the national essential medicines procurement
and supply chain. This improves efficiency and guarantees sustainability since the
Government / partners do not have to fund and manage multiple supply chains. There are
still gaps in the management of the supply chain at the health facility level that need to be
addressed through training, mentoring and supervision. This will also avoid stock-outs and
overstocking at different levels.
Alignments in recording and reporting of integrated program events (will be identified over
the grant implementation period) will reduce duplication, translate into health system
efficiencies and improve data quality
Joint supervision and joint program reviews planned in this application will reduce costs,
increase information sharing, promote joint ownership and translate into improvements in
the quality of services delivered to patients who suffer from one or both of these diseases.
Strengthening laboratory support to both the ACP and the NTLP through leveraging the
HUB system established by the MoH (described in earlier section 1.1 (d) (Uganda National
Sample Transport Network Page 1-8). Optimum use of this system will translate to
strengthening health systems, cost efficiencies as multiple samples can be transported at
the same time, end-user (patient) efficiencies and importantly to informed decision making
in the clinic and in the program leading to better case management for patients and
improved public health in the country.
Careful deployment of the new technology for diagnosing TB and MDR-TB across the
health services will improve access to these services for MARPs and key populations,
especially children, and people at risk of MDR-TB, including health workers. This translates
to savings and costs averted for people suffering with illness, savings and costs averted to
the countrys health budget and importantly into DALYs saved and deaths averted.
Alignment of priorities within the concept note as well as alignment later in joint
implementation are facilitated significantly through the Community Engagement Charter that
has been developed by communities including representation from Key affected populations
of both diseases. This charter details interventions of importance to communities from both
programs and outlines pathways and processes for both programs to efficiently link with
communities inviting their contribution and partnership in creating impact. (TB Charter
pages 1-6))
Health systems strengthening improvements in the recent past
Although still a challenge to HIV programming, several advancements have been registered in
health systems strengthening. Some of the improvements include: 1) Rationalization of HIV and TB
commodity supply chain management which has significantly reduced stock out of ARVs and TB
Uganda TB and HIV Concept Note

15 October, 2014 24

drugs and consumables; 2) Improved coverage of laboratory services nationally (HIV NSP MTR
2014, page 19); Labs performing smear microscopy for TB have increased from 303 in 2006 to
1091 in 2011 (one for every 25, -30,000 population); 98 facilities (all RRH, district hospitals and
some HC IVs) received iLED fluorescent microscopes in June 2012; introduction and expansion of
rapid TB diagnostic technology such as XpertMTB/Rif there are currently close to 60 sites
delivering this service; 3) Capacity building and accreditation of health centers to provide TB
diagnosis and treatment, HCT, PMTCT, and ART services with a rapid expansion of ART and
PMTCT services; 4) M&E systems enhancement including rolling out DHIS2 countrywide; ARV
web-based ordering and reporting on commodities; 5) Establishment of the Regional Performance
Monitoring Teams to enhance data integrity, support supervision, and reporting as well as quality
improvement initiatives (although not yet fully operational); 6) Human resource improvements:
recruitments and training of additional health workers for HCIV and HCIII; and 7) MoH Implementing
Partner rationalization to improve efficiency and coordination within the districts and facilities. All
these health system improvements will support the implementation of the proposed interventions
and specifically the proposed implementation of the WHO 2013 HIV treatment guidelines.
TB/ HIV collaborative activities
Challenges to implementation of TB-HIV collaborative activities include low ART coverage among
TB clients (65%), delays in the implementation of IPT, low case detection rates for TB especially
among the HIV-infected, weak TB infection control, and fragmented integrated delivery of TB and
HIV services. However, various opportunities exist for integrating TB and HIV services and
reversing the current trends. A TB-HIV National Coordination Committee (NCC) has been in place
for several years. The expansion of accredited ART facilities with the rapid rollout of ART and
PMTCT Option B+ addresses the challenges of differential decentralization of TB and HIV services
and thus provides an opportunity to ensure quick and sustained ART for TB-HIV co-infected
patients. MOH has developed IPT guidelines to support the scale-up of IPT in PLHIV. Expanded
provider-initiated HIV testing to the lower level facilities provides an opportunity for increased HIV
testing of TB patients. The momentum that has been generated through joint stakeholder
consultations and planning for this TB-HIV joint application has generated renewed effort and
commitments towards further strengthening and synergies between the TB and HIV programs in
Uganda.

b. The barriers that need to be addressed in this alignment process

The HIV/AIDS epidemic continues to be the most important risk factor for TB incidence and
mortality in Uganda. The HIV prevalence in the general population increased from 6.4% in 2004/05
to 7.3% in 2011 (Uganda Sero-Behavioral Survey 2004/5 page 107/UAIS 2011 report page 104).
The increasing trend in HIV prevalence is likely to reverse the current declining trend in incidence
and prevalence of TB as well as mortality attributed to it, if efforts to prevent new HIV infections are
not stepped up. The prevalence of HIV among TB patients notified to the national TB program has
stabilized around 50% since 2009. (Global Tuberculosis Reports, 2009 page 153, 2011 page
107,2012 page 125 /, 2013 page 159) A few studies conducted in limited settings in Uganda,
showed that the prevalence of TB among people living with HIV ranged between 5.5%-7.2%. (Moor
D et al page 713-719; Worodria W, et al page 1, 5-7) A meta-analysis conducted by Masja et al in
2011 showed that TB related deaths among people living with HIV were three times more than
those in non-HIV infected persons (Straetemans M page 1, 3-7).
Challenge areas that both programs will address through this application include
Improving TB screening in HIV infected although the proportion screened is high, this has not
translated to identified TB patients (1.5% vs expected 5-7%). There continues to be a high risk of
MDR-TB in this population. (HIV Investment Case page 20) This application will bring in and
promote access to additional new TB diagnostic technology with increased sensitivity and the
capacity to simultaneously detect R resistance so that presumptive TB in this population is able to
access quality assured TB diagnosis and that TB / MDR-TB is diagnosed early and treated promptly
and completely. The revised version of the diagnostic algorithm and the Intensified TB Case Finding
Guide provides a pathway for HIV infected persons to access TB testing with XpertMTB/Rif early
(Combined GENEXPERT ALGORITHM page 1, TB ICF Guide page 1/). The HIV grant will also be
used to support procurement (incentive funding) of XpertMTB/Rif cartridges for this purpose
contributing to expanding access jointly for this important technology.
Improving ART coverage in the TB HIV co-infected population during TB treatment. This is currently
low and compromises TB treatment outcomes and increases AIDS mortality and morbidity. Patient
pathways to access treatments for TB and HIV need to be reviewed so that co-infected patients are
able to access TB treatment and ART easily and conveniently. This application proposes an
Uganda TB and HIV Concept Note

15 October, 2014 25

integrated model of TB HIV services and care through the One Stop Shop, which will be expanded
to 14 RRHs, 2 NRHs and 136 general hospitals across the country.
Protecting HIV infected people from TB is another challenge that will be addressed within this grant.
While IPT is now within the national guidelines, this is not routinely available to eligible HIV infected
population. Access to this involves alignment across the two programs at the policy and
procurement levels as well as service delivery, tracking and support to patients receiving IPT,
recording and reporting and routine monitoring. The HIV grant will support procurement of isoniazid
that will be used to protect PLHIV under care from TB based on screening and eligibility criteria
already established.
Protecting patients and the community, especially HIV infected populations, and health care
workers from TB and MDR-TB. This involves implementing infection control across health facilities
amongst others and will require support from the general health systems as well as coordination
across the two programs so that patients and presumptive TB patients are rapidly screened and
moved into treatment programs as appropriate. Health care workers must also be protected and
regularly screened, monitored and supported as appropriate. HIV infected health care workers must
be provided the option to serve in clinics not handling TB / MDR-TB patients routinely. The
Intensified TB Case Finding Guide and the revised diagnostic algorithm for access to XpertMTB/Rif
provides pathways for presumptive patients and health workers to be triaged and fast tracked for
screening and diagnosis of TB in health facilities and congregate settings.
Increasing detection of TB among children this is currently very low and this application articulates
actions to improve detection of TB among children. The procurement of new technology
(XpertMTB/Rif) in addition to the existing technology, the prioritization of increasing EID of HIV
amongst children are opportunities to coordinate across programs for the benefit of children. In
addition, data collection on children with TB will be disaggregated by relevant age group (<5 years,
5-14) to determine the burden of diseases and modify interventions accordingly.
The prioritization of women and children within HIV specific interventions and the clarity around key
affected populations within the HIV infected community is also the opportunity to increase access
for TB screening and diagnosis in these important populations requiring program coordination and
alignment of services across the two programs.
Increase engagement with the community in all areas of programming including planning,
development of priorities, writing of the concept note, ensuring that community engagement is a
priority intervention in each of the disease specific priority modules, identification and elaboration of
priority interventions within the priority module (engaging communities), developing a broader
framework to engage communities across the health system through the HSS concept note and
leveraging the Community Engagement Charter developed during the process of writing this
concept note (TB Charter pages 1-6).

SECTION 2: FUNDING LANDSCAPE, ADDITIONALITY AND SUSTAINABILITY

To achieve lasting impact against the diseases, financial commitments from domestic
sources must play a key role in a national strategy. Global Fund allocates resources that
are insufficient to address the full cost of a technically sound program. It is therefore
critical to assess how the funding requested fits within the overall funding landscape and
how the national government plans to commit increased resources to the national disease
program and health sector each year.

2.1 Overall Funding Landscape for Upcoming Implementation Period

In order to understand the overall funding landscape of the TB and HIV national programs
and how this funding request fits within these, briefly describe:
a. The availability of funds for each program area and the source of such funding
(government and/or donor). Highlight any program areas that are adequately
resourced (and are therefore not included in the request to the Global Fund).
b. How the proposed Global Fund investment has leveraged other donor resources.
c. For program areas that have significant funding gaps, planned actions to address

Uganda TB and HIV Concept Note

15 October, 2014 26

these gaps.
a. The availability of funds for each program area and the source of such funding

(government and/or donor). Highlight any program areas that are adequately
resourced (and are therefore not included in the request to the Global Fund)
The annual health budget allocation has averaged around 7.5% - 9.0% of the total national budget
for the last 5 years, which is well below the African Unions Abuja declaration of 15% allocation for
health (Abuja Declaration 2001/page 5).
Health sector finances come from domestically generated revenue from the central government and
local governments and from development assistance. Over 95% of financing to the district health
system is from the central government. Development assistance plays a major role in financing
health services though a bigger proportion of this is off budget. The MoH has a big challenge tracking
donor off-budget support (Joint HSSIP Assessment report pages 48-50). From FY2007/08 to
FY2011/12, the total health expenditure per capita averaged US $ 10 and increased to US $ 11 in
FY2012/13 which is less than a quarter of US $ 48, WHO recommends as the minimum required to
fund the Minimum Health Care Package (Abuja Declaration page 5 World Health Organization,
Macroeconomics and Health page 16). Donors, NGOs and individuals shoulder the rest of the health
expenditure. Out of pocket expenditure has increased from 42% in FY 2012/13 to 54% in 2013/14.
The HIV and TB programs are funded by two major funding mechanisms: 1) The Government of
Uganda (GOU) budget support to the Health sector through the Ministry of Finance Planning and
economic development; 2) Support from the development partners under a project mode funding.
The GOU finances both the recurrent and non-recurrent expenditures of the health sector. The
recurrent expenditures include the wage and the non-wage bills while the non-recurrent expenditures
relate to investments in the physical infrastructure, and other long-term developments.
In the 2012/13 budget the GOU set the health sector as one of the priority sectors. Key investments
included: recruitment of additional human resources, investments into the physical infrastructure
such as constructions and refurbishment of health facilities across the country; improvements in the
supply and delivery of drugs and pharmaceuticals from the central stores to the health facilities
(Background to the budget 2014/Page 95-97). Additionally, GOU has increased its funding to the
health sector by 52%, from Uganda shillings 737.7 billion in 2010/11 to 1,127 billion in 2013/14.
These investments benefit both the HIV/AIDS and TB national programs. Supplementary support
from development partners for TB and HIV is received through project mode. Resources secured
from the Global Fund through this concept note application will contribute towards meeting the unmet
need of the governments efforts. Table 1 below shows the national need for the proposed TB-HIV
interventions over the project period (2015-2017).
Table 1: National funding need for each of the proposed TB-HIV interventions
Summary budget by
Modules

Jul 2015-Jun
2016

Jul
2017

Prevention: general population

Prevention: MSM and TGs

44,490,248.0
178,657.6

50,501,546.2
22,312.0

33,560,050.1
357,470.0

128,551,844.3
558,439.6

Prevention: Sex workers and

their clients
Prevention: Youth, in and out
of school
PMTCT
Treatment, care and support
TB care and prevention

309,088.0

382,282.0

217,984.0

909,354.0

1,116,308.0

1,153,894.4

1,342,898.4

3,613,100.8

423,300.8
172,078,235.6
2,616,835.2

703,650.6
256,109,877.4
1,645,476.9

302,984.0
140,169,612.4
4,625,779.1

1,429,935.4
568,357,725.4
8,888,091.2

TB/HIV

293,958.4

344,868.8

171,572.8

810,400.0

MDR-TB

3,401,804.3

4,318,431.4

3,275,372.2

10,995,607.8

Health information systems

and M&E
Health
and
community
workforce
Community
systems
strengthening
Program management

672,885.2

1,123,766.8

512,252.8

405,480.0

488,970.0

202,740.0

388,931.4

336,994.5

181,956.8

1,097,190.0
907,882.7

325,561.9

238,258.5

170,374.4

734,194.7

Results-based Financing
TOTALS

Uganda TB and HIV Concept Note

2018-Jun

Jul 20172017

Dec

TOTALS

2,308,904.8

226,701,294.3

317,370,329.5

185,091,047.0

729,162,670.8

15 October, 2014 27

Table 2 below highlights the funding estimates for TB-HIV from the partners over the proposed
implementation period, with total financial gap of US $430,481,434.
Table 2: TB-HIV Partner support (commitments) for 2015-2017
Financial Year

2015/16

National Need

226,701,294.33

Government of Uganda

2016/2017

July-Dec 2017

Totals

317,370,329.52

185,091,046.96

729,162,670.80

36,700,000

36,700,000

36,700,000

110,100,000

USG/PEPFAR***

54,900,000

54,900,000

54,900,000

164,700,000

IRISH AID***

8,580,000

TBD

TBD

8,580,000

SIDA***

2,600,000

TBD

TBD

2,600,000

Germany Leprosy
Foundation for Innovative
New Diagnostics.
DFID

500,000

500,000

500,000

1,500,000

602,000

139,000

326,000

1,067,000

6,800,000

TBD

TBD

6,800,000

3,334,237

Projected resources

GF grants ( HIV and TB)

3,334,237
-

Total projected commitment

Funding Gap

114,016,237
112,685,058

92,239,000

92,426,000

298,681,237

225,131,330

92,665,047

430,481,434

*** Partner support beyond 2015/16 has not been fully ascertained.
PEPFAR currently is the principle supporter of comprehensive prevention, care, and treatment
services in partnership with the GOU. In the CCM meeting of 16th October 2014, PEPFAR
communicated that the PEPFAR global program was in a period of change, which will result in
programmatic adjustments in all PEPFAR countries. During the next several months, PEPFAR will
work in collaboration with national stakeholders to secure, validate, analyze, and use data to help
identify where the burden of disease is in Uganda, and to direct resources to those areas to achieve
control of the epidemic. Changes will likely occur in where and how PEPFAR programming in
Uganda works. Any adjustments that will arise after submission of this concept note will be catered
for during the grant making process to ensure that the Global Fund and PEPFAR resources
complement and leverage each other to maximize the impact of the limited funding and work towards
achievement of UNAIDSs 90:90:90 goals.
The NTLP is currently funded through a SSF Phase 2 grant (UGD-T-MoFPED) that started in July
2014 and will end in December 2017 the value of this grant is US $ 15,140,487. Within the
programmatic gap table in this investment application, allocation from the Government of Uganda
and implementing partners (IP) is indicated as follows: approximately 30% of costs incurred for
notification of TB (program gap 1); about 25% of the costs for treatment outcomes including costs of
first line drugs; procurement of isoniazid for IPT for children requiring this and identified through
contact tracing; about 19% of the costs for PMDT including costs of second-line drugs.
While there is significant investment in almost all areas of programming within the NTLP through
Implementing Partners (IPs), this investment is not nationwide and is strategically targeted,
geographically as well as at different levels of the health services including communities, patients
and program processes. These investments from IPs bring additionality to the Global Fund grants
that support the NTLP countrywide and across all populations (with prioritization as appropriate).
They also leverage the health sector allocations of GOU that aims to build sustainability into these
investments over the medium and long term.
b. How the proposed Global Fund investment has leveraged other donor resources
The concept note development process included a programmatic and financial gap analysis for the
HIV and TB national programs to derive the national need and also map out interventions that would
be funded by the GoU and other in-country partner support for the period of the concept note. The
total need for funding the HIV and TB from 2015/16 to 2017/18 is estimated to be US$
Uganda TB and HIV Concept Note

15 October, 2014 28

729,162,670.8. The contributions from the GOU and developments partners is estimated to be US $
298,681,237. The GF funds will supplement the current resources to consolidate gains and
contribute to closing the gaps in program implementation. GF resources requested under this
Concept note will be invested in key areas of TB-HIV, including HIV and TB prevention, care and
treatment, and the critical systems for delivery of these services. While continuing investment by IPs
in these areas is not certain, it is very likely and the Global Fund investment provides a national
platform for strategic investments by IPs in important program areas.
c. For program areas that have significant funding gaps, planned actions to address these
gaps
A total of US $ 8.7 billion will be required over the investments period 2015 to 2025. The returns from
the investment include (a) aversion of 2,160,000 new infections between 2015 and 2025 (a 77%
reduction, (b) reduction of new infections in children from 14,200 to 4,040 between 2014 and 2025
(c) Uganda will avert 570,000 deaths by 2025 and (d) the lives of 42,620 children will be saved from
AIDS related death by 2025. Recent records show that although Government has been increasing its
contribution to the epidemic, more than 80% of spending for the national HIV and AIDS response
comes from AIDS Development Partners, thus revealing a significant resource gap for financing the
investment needed for the 2015-2025 period.
The most grossly under-funded programs in HIV include HIV prevention in the general population
and HIV treatment; an estimated US$ 568,357,725.4 is required to achieve the 80% target of HIV
treatment for eligible individuals by 2018. The requested funding through this application (within
allocation) only covers about half of the required funds for treatment. Additional needs are captured
under the above allocation request. Additionally, GOU plans to increase its contribution to HIV and is
in the process of establishing the HIV Trust Fund to raise funds for scaling up the national HIV
response towards the epidemic. The HIV Control and Prevention Act has set the stage for
establishment of the HIV Trust Fund, which has been under discussion in recent years. This Fund
will augment the resources required to Implement Ugandas Investment Case and contribute to
reduction of new HIV infections and mortality in the long-term. GOU will also continue with efforts to
ensure resource mobilization and efficient use of resources for TB and HIV, from other partners. The
proposed integration of TB and HIV in this application is one such effort that will enhance synergies
and efficiencies in implementation of programs for the two diseases. Government will also ensure
practices that improve accountability and management of resources are in place (Uganda HIV
Investment Case, page ix). The Uganda AIDS Commission and AIDS Control Program have
engaged with Senior Top Management (STM) of the MOH to leverage additional domestic funding.
As part of this process, following a meeting with STM, a Cabinet information paper is being
developed to be discussed with Cabinet and Ministry of Finance to explore mechanisms for
additional funding to the HIV response.
The NTLP continues to be underfunded from the MoH and understaffed and this has been
documented as a key challenge by both the external review as well as multiple Global Fund Portfolio
briefs communicated to the CCM. The financial commitment to TB control is not commensurate to
the burden of TB disease in the country and has led to the NTLPs high donor dependence. Another
major concern is that the yearly allocation of funds is based on historical expenditure rather than on
actual needs. Because of the perception of a significant (and traditional) external support to control
the TB epidemic, several District Administrations, whose budget must include funding of district
health services operations, make often available a very limited (if any) budget for TB related,
resulting mainly in poor support to the field community work required by the community care model.
A specific area in need of urgent response is support for the scaleup and quality of care for the
Programmatic Management of Drug Resistant TB (PMDT). As compared to regular TB, deficiencies
in quality of care for drug resistant TB can have heightened consequences, with potential for more
severe adverse reactions and acquired resistance, including the development of extensive drug
resistant (XDR) disease.

2.2 Counterpart Financing Requirements

Uganda TB and HIV Concept Note

15 October, 2014 29

Complete the Financial Gap Analysis and Counterpart Financing Table (Table 1). The
counterpart financing requirements are set forth in the Global Fund Eligibility and
Counterpart Financing Policy.
a. For TB and HIV, indicate below whether the counterpart financing requirements
have been met. If not, provide a justification that includes actions planned during
implementation to reach compliance.
Counterpart Financing
Requirements

i. Availability of reliable data to

assess compliance

Compliant?

Yes

No

If not, provide a brief

justification and planned
actions
The country has not yet carried
out a resource tracking study
to establish actual spending
and specific disease spending.
National health accounts
2010/11 did not capture
disease specific spending.
Earmarked funds for TB
support are for purchase of
drugs committed by the
government. Accessibility to
partners databases remains a
major challenge. Data
submitted from partners
implementing TB programs
outside government systems
seem to portray a lower picture
of their expenditures. Annual
budgetary performance
framework reports have been
used. Data system Limitation:
1. Insufficient existing
mechanisms of sharing
information between the
TB program and partners
implementing TB programs
outside the government
funding mechanisms.
2. Lack of established
database at the NTLP.
3. Budget support spending
not earmarked by diseases

ii. Minimum threshold government

contribution to disease program
(low income-5%, lower lowermiddle income-20%, upper
lower-middle income-40%, upper
middle income-60%)

iii. Increasing government

contribution to disease program

Uganda TB and HIV Concept Note

Yes

Yes

No

The Gap analysis indicates

Counterpart Financing is
29%, which is greater than
5% requirement for a
country like Uganda. This is
due to government
commitment to purchase
Malaria, TB drugs and ARVs
up to $101million over the 3
years of the grant.

No

As indicated in the gap

analysis, government
contribution to the NTLP is
expected to grow and the
growth will depend on
15 October, 2014 30

continued government
commitment to earmark funds
for purchase of drugs and
overall annual increment in the
health budget. The health
budget is expected to continue
to grow in absolute terms
based on national budget
increases in values. Below is
the expected increase in
government contribution to
national TB program and the
contribution is expected to
double in 2017/18 as
compared to 2012/13 financial
year (see details below)

b. Compared to previous years, what additional government investments are

committed to the national programs in the next implementation period that counts
towards accessing the willingness-to-pay allocation from the Global Fund. Clearly
specify the interventions or activities that are expected to be financed by the
additional government resources and indicate how realization of these commitments
will be tracked and reported.
c. Provide an assessment of the completeness and reliability of financial data reported,
including any assumptions and caveats associated with the figures.
b. Compared to previous years, what additional government investments are committed to
the national programs in the next implementation period that counts towards accessing
the willingness-to-pay allocation from the Global Fund. Clearly specify the interventions
or activities that are expected to be financed by the additional government resources and
indicate how realization of these commitments will be tracked and reported
The period 2010/11 to 2013/14 has shown an increase in the GOU releases to the health sector. The
sector funding is the major source of resources for the health care service delivery. The GOU
provides resources for both recurrent and non-recurrent expenditures. The recurrent expenditures
cover the payment for wages and non-wage bills while the non-recurrent largely covers
developments expenditures. The two disease programs benefit directly from the sector resources as
these are integrated into the Health sector. In addition GOU allocates funds specifically for the two
disease programs to support the procurement of drugs and pharmaceutical products, the costs of
multi-sectoral coordination for the HIV response and research and innovations for the HIV and TB
programs. In fiscal year 2012/13, GOU with support from partners recruited additional health workers
for the lower level health facilities. The growing trend in GOU releases to the Health sector is an
indication of increasing commitments to the attributions to the disease programs in general.
The GOU contributions to the health sector as a proportion of the total budget stands at 8.4% for
period 2013/14. While this is still below the 15% Abuja declaration target, there is a positive outlook
on GOU nominal allocations to the Health sector that is projected to grow to about 47.2% in the year
2017/18 compared to the year 2011/12-health budget (See Figure 6). It is projected that as the
economy grows, the overall national budget will increase and therefore all sector budgets will
increase in nominal terms accordingly.
Figure 6: Annual Health Expenditure and cumulative Nominal Growth

Uganda TB and HIV Concept Note

15 October, 2014 31

Minimum threshold for counterpart financing

The willingness to pay refers to the governments direct contributions as proportion of the total
government and the Global Fund contributions to the disease programs. Uganda is classified as low
Income country and is required to fulfill a 5% counterpart-funding threshold for the willingness to pay.
Uganda has met the minimum threshold for the willingness to pay for the HIV/TB programs. The Gap
analysis indicates Counterpart Financing is 29%, which is greater than 5% requirement for a country
like Uganda. The government has put a credit line for procurement of TB, HIV (ARVs), and Malaria
drugs to the tune of 100 billion Uganda shillings (US $37 million; $34.5 for TB and HIV drugs). This
translates into US$111 million in three years. This is over and above the GOU programmatic
financing to UAC and MOH. Table 3 below shows the GOU willingness to pay.
Table3: Government of Uganda Willingness to pay
Y-2

Y-1

Y0

Y1

Y2

Y3

Government Spending and

Commitments by Program

2013

2014

2015

2016

2017

2018

HIV

37,629,340

35,290,739

34,932,231

34,661,924

33,296,881

32,847,839

Tuberculosis

11,117,936

9,017,744

5,615,133

3,743,916

3,669,725

3,598,028

Malaria

3,693,131

3,533,110

4,617,443

3,376,498

3,309,587

3,244,927

HSS*

33,505,324

43,237,650

70,847,111

94,451,142

29,215,413

12,593,099

96,216,216

117,146,361.09

113,818,141

136,162,486

HSS*
Total Wage bill for the Health sector

Table 4 below is the expected increase in government contribution to NTLP and the contribution is
expected to double in 2017/18 as compared to financial year 2012/13.
Out turn
2012/13
Estimates for
GOU funding to
TB in US $
Annual Increase
in GOU funding to
TB
Increase in GOU
funding to TB
(base year
2013/14)

Projected
2013/14

Projection
2014/15

Projection
2015/16

Projection
2016/17

Projection
2017/18

2,111,144.8

2,469,964.4

2,744,303.6

3,155,014.8

3,617,147.6

4,227,212.7

0%

17%

11%

15%

15%

17%

0%

17%

30%

49%

71%

100.23%

Evidence of the counterpart funding from GOU include;

Uganda TB and HIV Concept Note

15 October, 2014 32

a. Funds for procurement of drugs and pharmaceuticals specifically for the HIV and TB
programs, ARVs and the anti TB medicines through the National Medical stores.
b. Staff emoluments for addition staff recruited as part of GOU HR interventions for HIV
program
c. Investments into the warehousing, physical infrastructure and cold room chains.
d. Continued support to the multi-sectoral coordinating agency and the GF Focal coordinating
office.
The governments investments in the above areas can be tracked and verified through the following
government official publications:
National Health Accounts conducted by the MOH. This is however limited to public spending
through the Health sector.
Medium Term Expenditure Framework for the sector and the ministerial budget frameworks
and statements.
Program financial reports
c. Provide an assessment of the completeness and reliability of financial data reported,
including any assumptions and caveats associated with the figures
The sources for the financial data used in filling the financial gap analysis for this concept note
included:
Budget framework papers of Ministry of Finance, Planning and Economic Development
(MoFPED) for overall national budget and macroeconomic indicators - Indicative Revenue
and Expenditure Framework from National Budget Framework Paper FY 2013/14 FY
2017/2018; April 2013.

Ministerial budget framework paper; Health budgets; Budget support and health projects
under Medium Term Expenditure Framework (MTEF); Earmarked funds for tuberculosis and
HIV medicines from government commitment obtained from National Medical stores.

Sources financing the health sector outside the government systems; Off MTEF; Health
projects implemented by NGOs funded by donors

Government budget support/ Health projects include;

Government revenue from taxes and non-taxes; Data was obtained from Ministry of Finance,
Planning and Economic Development (MoFPED) under MTEF
Government revenue from debt relief; Data obtained from Ministry of Finance. ; Indicative
Revenue and Expenditure Framework from National Budget Framework Paper FY 2013/14
FY 2017/2018; April 2013;
Government loans from Overseas Development Assistance to support the health sector;
Sources of data obtained from MOFPED and Ministry of Health; Ministerial Policy
Statements that include vote allocations. ; Indicative Revenue and Expenditure Framework
from National Budget Framework Paper FY 2013/14 FY 2017/2018; April 2013;
Grants for health budget support donated by overseas development assistance; Data
obtained from; Indicative Revenue and Expenditure Framework from National Budget
Framework Paper FY 2013/14 FY 2017/2018; April 2013;
Earmarked funds for TB and HIV drugs from government commitment; National Medical
stores
Financing Data system Limitations
There has not been an agreed formula on how to allocate the cross cutting health spending
within the health sector budgets to individual disease components.
There is no central database at the MOH to track the off budget expenditures for the HIV and
TB programs.
There is no clear mechanism for verifying planned outputs. Results for these are based on
individual programmatic audits. This leaves room for partial information.

Uganda TB and HIV Concept Note

15 October, 2014 33

SECTION 3: FUNDING REQUEST TO THE GLOBAL FUND

This section details the request for funding and outlines how the investment is strategically
targeted to achieve greater impact on the diseases and health systems. While the
investments for both the HIV and TB programs should be described, the applicant should
also provide information on the expected impact and efficiencies achieved from planned
joint programming for the two diseases including cross-cutting health systems
strengthening as relevant.

3.1 Programmatic Gap Analysis

A programmatic gap analysis should be conducted for the six to twelve priority
modules within the applicants funding request. These modules should
appropriately reflect the two separate disease programs in addition to cross-cutting
modules for both programs such as Health System and Community Systems
Strengthening.
Complete a programmatic gap table (Table 2) for the quantifiable priority modules within
the applicants funding request. Ensure that the coverage levels for the priority modules
selected are consistent with the coverage targets in section D of the modular template
(Table 3).
For any selected priority modules that are difficult to quantify (i.e. not service delivery
modules), explain the gaps, the types of activities in place, the populations or groups
involved, and the current funding sources and gaps in the narrative section below.
A programmatic gap analysis was conducted and the programmatic gap table (Table 2) completed
for eight of the selected 12 modules. The eight modules included in Table 2 are: 1) HIV prevention
for the general population; 2) HIV prevention for MSM and TG; 3) HIV prevention for sex workers
and their clients; 4) PMTCT; 5) Treatment, care, and support; 6) TB care and prevention; 7) TBHIV; and 8) MDR TB. The quantifiable aspects of these modules are presented in Table 2, with
their corresponding targets and gaps based on the HIV Investment Case. Generally, there is a
major gap in coverage of interventions for key primary prevention indicators such as HIV testing
(especially couples HIV testing), male circumcision, and increasing risky sexual behaviors such as
low condom use among risky sexual encounters. There is also a significant gap in coverage for HIV
treatment, with current coverage at 48% of eligible individuals (based on the revised eligibility
criteria) and expected to increase to 50% by end of 2014.
Other modules, which are not included in the programmatic gap table including HIV prevention for
youth in and out of School and the crosscutting modules (program management; community
systems strengthening; and health information systems/M&E) are described below.
Program Gap Analysis for HIV
Services among MARPs: The coverage of HIV interventions (prevention, care and treatment)
among key affected populations (MSM/TG and sex workers) is very low as shown in the modular
tables. The other MARPs including fisher folk, truckers and uniformed personnel, are included in
the module for sex workers since available data indicates that HIV infection in these groups is
linked to sex work (clients of sex workers) (KMCC Truckers Review 2014 pages 1-4). The analysis
of the gaps for these populations is not presented in the gap table, which focuses more on sex
workers. Access to HIV services among the fishing communities, which have very poor health
infrastructure, is very low despite their high HIV prevalence (KMCC Fishing Community Review,
page 18). MoH included fisher folk among the selected populations for test and treat but its
implementation can only succeed if there are organized efforts to massively scale-up HIV testing,
linkage and retention in care. These communities are quite mobile and require innovative
approaches to ensure increased service uptake and retention. Several partners including USG and
GOU have initiated efforts to expand service access in fishing communities but access remains
limited. USG and other partners such as UNFPA and International Organization of Migration (IOM)
also have interventions targeting uniformed personnel and truckers but the reach is limited. This
application puts special focus on these populations and will provide a comprehensive package of
services for these MARPs (See proposed interventions in the Modular tables).
Uganda TB and HIV Concept Note

15 October, 2014 34

Negative gender and cultural norms and practices: As highlighted by the Investment Case and
MTR, Sexual and gender based violence (SGBV) is one of the major drivers of the HIV epidemic in
Uganda but has not been fully addressed by current interventions. Many women and girls in
Uganda have experienced SGBV while men have challenges with access to services due to
gender and masculinity beliefs and practices that increases their risk for HIV infection and creates
a barrier to HIV and other health services. Stigma and discrimination against PLHIV and key
affected populations is also prominent and affects service access by these populations.
Interventions to address these structural barriers are supported by GOU and the Joint UN
Programs, which have engaged religious and cultural leaders to address negative cultural norms
and practices. However, the coverage of these interventions is limited (HIV MTR Prevention Report
2014 page viii-ix). In this application, CCM proposes CSS interventions that will stimulate intensive
community engagement and advocacy to reverse these drivers of the HIV epidemic (under the TBHIV CSS module and the HSS application).

Program Gap Analysis for TB

Program Area: TB Care and Prevention - TB Prevention
Coverage indicator selected: Number of notified cases of all forms of TB - bacteriologically
confirmed plus clinically diagnosed, new and relapses
Analysis: Case notification has been observed to be stagnant over the last several years the
Joint Monitoring Mission and the Global Fund Portfolio Analysis document this. Target setting for
case notification is compounded due to the distinctly observed decline in prevalence and
incidence documented in successive Global TB Reports as well as the WHO Country database
for the period 1990 to 2012. The decline in incidence is marked after 2000 and the rate of
change is about 6.9% annually. This offsets any increases in the absolute number of cases
incident annually despite a rapidly expanding population (annual increase of 3.2% estimated by
UBoS). While there are wide confidence intervals to this decline, the trend is definitely markedly
downwards, with the 2013 Supplement to the WHO Global TB Report documenting that Uganda
is one of 7 countries globally to have achieved the TB related MDGs.
For this application, the CCM has endorsed targets for case notification based on the NSP 20152020 against the most recent (best) incidence estimated by WHO for the country in 2012 (Global
TB Report 2013). The country notified 44,934 incident TB cases (new and relapses) in 2013 and
this is used as the baseline translating to a notification effort of 69%. The application aims to
improve this effort to 81% by 2018.
Since smear positive / bacteriologically confirmed TB notification trends have been stagnant for
the same period despite an increase in the laboratory network to almost double as well as an
increase in the number of presumptive TB patients examined for diagnosis, it is anticipated that
the increase in notification will mostly come from smear negative patients who can access new
diagnostic technology through this investment and ongoing investments from IPs. It is also
understood that the program effort will prioritize key affected populations for this increase
namely, HIV infected (through collaboration and joint implementation with ACP, targeting
MARPS under HIV care), children and special populations such as urban slums and prisons,
scaling up ongoing successful models in these areas.
The CCM clarifies that the country is conducting its first prevalence survey and expects to have
accurate data that could modify these targets during the course of implementation. The CCM
further clarifies that although these targets are slightly below the targets in the SSF Phase II
performance framework, they are more realistic as they have been derived through multi and
expert partner consultation during the development of the NSP 2015-2020
It is estimated that about 30% of the costs for activities supporting case notification are covered
by the Government of Uganda and implementing partners
It is also planned that in this investment application, the costs for additional test cartridges that
will be required for the expanded screening among MARPS under HIV care will come out of the
ACP grant budget (incentive funding)
Program Area: TB Care and Prevention - TB treatment
Coverage indicator selected: Percentage of bacteriologically confirmed new TB cases
successfully treated (cured plus completed treatment) among the bacteriologically confirmed

Uganda TB and HIV Concept Note

15 October, 2014 35

new TB cases registered during a specified period

Analysis: Treatment outcomes have been another area of concern documented by both the
Joint Monitoring Mission and successive Global Fund Portfolio Analyses. Treatment outcomes
are not only low, but also lower than the regional averages for Africa.
For this investment application, the CCM has endorsed targets that will improve treatment
outcomes, specifically for the more infectious bacteriologically confirmed cases from the current
baseline of 77% (2012 cohort) to 85% for the 2018 cohort. These targets align with the NSP
2015-2020
The application acknowledges the findings of the Joint Monitoring Mission and seeks
investments in implementing and expanding community based DOT which has already proven
successful in Uganda as well as in strengthening recording and reporting to ensure that all
diagnosed patients are registered for treatment and monitored throughout to minimize loss to
follow-up and improve treatment success.
It is estimated that about 25% of the costs to support treatment are covered by the Government
of Uganda and implementing partners this includes procurement of some proportion of first line
TB drugs.
Program Area: TB Care and Prevention - TB Prevention
Coverage indicator selected: Number of children <5 in contact with TB patients who began IPT
Analysis: This application seeks investments in preventing TB among children less than 5
years old who are in contact with TB patients, but also in persons at increased risk of developing
TB such as HIV infected persons and in patients and health care workers in health facilities
The application acknowledges the findings of the JMM and successive GF Portfolio analyses
and seeks investments in contact tracing of children in contact with TB patients, screening them
from TB and providing eligible children with IPT.
The baseline for this intervention is not known as IPT is currently provided to children only in
three centers of excellence (PNFP) operated by IPs. Using program data, estimates of the
number of children at risk have been derived for the selected indicator.
The CCM has endorsed the targets used in Table 2, which are aligned with the NSP 2015-2020,
and the NTLP aims to protect 54% of the eligible children with IPT by 2018.
This application also seeks investments to implement and expand IPT to eligible HIV infected
persons prioritizing MARPS under HIV care in alignment with national guidelines
It is proposed that the isoniazid required for the IPT for children will be procured locally; isoniazid
required for HIV infected clients under care will be procured through the ACP grant in this
investment application (incentive funding)
Program Area: MDR-TB - Case detection and diagnosis
Coverage indicator selected: Percentage of previously treated TB patients receiving DST
Analysis: The Global TB Report 2013 estimates that about 19% of retreatment TB patients
accessed DST in 2012. Retreatment cohorts have been stable over the last decade at about 7.2
to 8.2% of all patients notified (new and retreatment). Similarly, the proportion of relapses
incident annually has also been stable at about 3.7% of all incident cases notified. These factors
have been used to estimate the population at risk and in need of DST for this indicator.
The NTLP seeks investment to improve access to DST for retreatment patients to 80% of those
eligible by 2018 in alignment with the NSP 2015-2020 targets for this indicator. These targets
have been endorsed by the CCM
To improve access to testing, it is also planned to procure 20 XpertMTB/Rif modules annually
over the three grant years these will be deployed effectively and efficiently for impact. Their
deployment is also linked to investments in TSRS and the HUB system to transport samples
from health facilities to testing centers and relay results back to the facilities and patients.
The costs for this investment have been allocated entirely to this application
Program Area: TB HIV
Coverage indicator selected: Percentage of HIV-positive registered TB patients given anti
Uganda TB and HIV Concept Note

15 October, 2014 36

retroviral therapy during TB treatment

Analysis: This is an indicator that will jointly be reported by both the ACP and the NTLP. ARV
coverage for the 2013 cohort of co-infected patients is 65% and this application aims to move
this to 83% by 2018 in alignment with the NSP 2015-2020 and the ACPs priorities for key
affected populations and have been endorsed by the CCM
Cross cutting modules
This investment application includes the following cross cutting modules that have been developed
jointly by partners, stakeholders and both programs to ensure integration and coherence. These
support modules strengthen interventions proposed in the disease specific modules. These
modules include; program management; procurement and supply chain management; community
systems strengthening; and health information systems and M & E.
Three of the above support modules find expression in the HSS Concept Note submitted by the
country along with this Joint TB HIV application - they are PSM, CSS and HMIS. Broader health
system elements have gone into the HSS investment application, while disease and program
specific interventions have been retained within the support modules in this application. For
instance, program integration is a key intervention area within the program management module
and includes scope for administrative integration, joint planning, joint supervision, joint reviews and
synergies in grant management. Key affected populations are integral to this joint management.
Supporting procurement and supply chains for TB drugs and consumables is also part of program
management and addresses issues raised in management letters from the GF Secretariat, both
within this application as well as in the nationwide strengthening of PSM proposed in the HSS CN.
Investments in the HUB system to support laboratory networks are also part of the HSS CN and
find synergy with investments sought in this application. Within the CSS module, all four priority
interventions have been included. For example, TB specific interventions to improve case
notifications and treatment outcomes include institutional capacity building of the USTP and its
networks to support social mobilization, community based monitoring and advocacy to inform
communities, generate demand for TB services and assure accountability. A framework charter
has been developed during the writing of this application that informs interventions and priorities for
CSS in this application. These interventions have been further expanded in the CSS module of the
HSS CN.

3.2 Applicant Funding Request

Provide a strategic overview of the applicants funding request for TB and HIV, including
both the proposed investment of the allocation amount and the request above this
amount. Include the specific elements related to joint programming such as health
systems and community systems strengthening. Describe how the request addresses
the gaps and constraints described in sections 1, 2 and 3.1. If the Global Fund is
supporting existing programs, explain how they will be adapted to maximize impact.
In May 2014, subsequent to the March 2014 allocation letter from the Global Fund, the CCM
communicated the program split to the ACP and the NTLP. Taking into account the funds
available within the running grants to both programs (the Costed Extension to the ACP and the
SSF Phase II to the NTLP), the funds available for this investment application are estimated as
below: US$125,091,853 for HIV/AIDS and incremental for TB US$7,343,538.
The Uganda TB-HIV funding request includes interventions across 12 modules including: 1) HIV
prevention for the general population; 2) HIV prevention for MSM and TG; 3) HIV prevention for
sex workers and their clients; 4) HIV prevention for youth in- and out of School; 5) PMTCT; 6)
Treatment, care, and support; 7) TB care and prevention; 8) MDR TB; 9) TB-HIV; 10) HIS and
M&E; 11) CSS; and 12) Program Management.
Prioritization of modules and interventions for TB-HIV, within and above allocation
HIV prioritization within allocation: The funding allocation for HIV (US$ 125,091,853)
represents 30% of the national gap for planned HIV interventions in this application, after
discounting the GOU and other partner support. Given the huge funding gap versus the
allocation, tough choices have been made to ensure continuity of critical interventions while
providing for limited introduction of new high impact interventions. The modules and interventions
Uganda TB and HIV Concept Note

15 October, 2014 37

in the allocation include: 1) HIV treatment--continued support for the existing 221,297 patients on
ART with support from Global Fund (ARVs and laboratory reagents for treatment monitoring); 2)
ARVs for PMTCT (life-long ART for HIV infected pregnant women); and 3) selected primary
prevention interventions focusing on MARPs and the 16 high prevalence districts (the districts
with fishing communities). The selected primary prevention interventions include SBCC, HIV
testing, SMC, and condom programming for sex workers, fishing communities, uniformed
personnel, truckers, and MSM.
TB prioritization within allocation: For TB, the modules and interventions included in allocation
have focused on continuity of the running TB SSF R10 Phase 2 grant that include (1) TB care
and prevention-case detection and diagnosis focusing on building capacity of health workers in
both public and private health facilities to diagnose clinical forms of TB especially childhood TB,
increasing access to diagnosis of TB in key populations; availability of first-line TB medicines and
ensuring treatment adherence (2) MDR- TB case detection and diagnosis with emphasis on high
risk MDR-TB groups, prevention for MDR-TB, availability of second-line TB medicines and
treatment adherence (3) TB/HIV collaborative activities with focus on joint planning, supervision
and building the capacity of private health providers in TB (4) Community system strengthening Social mobilization, building community linkages, collaboration and coordination, communitybased monitoring for accountability and institutional capacity building, planning and leadership
development. Table 5 below shows the spread of the TB-HIV investments within allocation.
Table 5: TB-HIV within allocation spread
Allocation
Summary budget by Modules

TOTALS
2015/16

Prevention programs for general population

Prevention programs for MSM and TGs

2016/17

2017/1
8

11,391,921.6

6,567,367.3

17,959,288.9

146,687.2

352,575.2

499,262.4

Prevention programs for sex workers and

their clients

377,526.4

483,018.8

860,545.2

Prevention programs for adolescents and

youth, in and out of school

842,509.2

303,618.4

1,146,127.6

234,763.2

118,355.6

353,118.8

44,890,672.2

53,469,513.1

98,360,185.4

2,318,395.7

3,148,840.3

5,467,236.0

277,320.0

327,719.2

605,039.2

2,726,680.9

3,031,331.2

5,758,012.1

375,113.2

16,486.4

391,599.6

150,670.4

119,234.7

269,905.0

496,922.0

268,260.0

765,182.0

64,229,181.94

68,206,320.25

132,435,502.18

PMTCT
Treatment, care and support
TB care and prevention
TB/HIV
MDR-TB
Health information systems and M&E
Community systems strengthening
Program management
TOTALS

Note: Commodities (ARVs, HIV test kits) for PMTCT, sex workers and their clients, MSM and TG are included under HIV
care and treatment, and HCT for general population

HIV prioritization above allocation: Several critical interventions to the HIV response could not
be fitted within the allocated funds and have been included into the above allocation request. The
last six months of the grant period is also not catered for, within allocation. The critical activities
that have moved into above allocation include: 1) life-long ART for additional HIV infected
pregnant women; 2) treatment irrespective of CD4 count for selected populations including
children, TB-HIV co-infected women, HIV sero-discordant couples, sex workers and MSM, and
finally treatment for the general population; 3) additional primary prevention interventions for
MARPs, in the 16 high prevalence districts, and youth in- and out of School; 4) critical enablers
such as community mobilization to address negative cultural and gender norms including SGBV;
and 5) expanded and aggressive primary prevention interventions for the general population.
Uganda TB and HIV Concept Note

15 October, 2014 38

Within primary prevention the country has further prioritized condom programming (targeting hot
spots) due to declining condom program indicators and HIV testing to enhance linkage to
prevention services (SMC, PMTCT, among others) and care and treatment. HIV testing will also
cover EID and linkage to care for exposed and HIV infected infants. Without the above allocation
funding, the country will face dire consequences in terms of equity and increasing number of new
HIV infections since these interventions are targeted towards the most high risk and vulnerable
populations.
The request within allocation will only sustain individuals on ART through ongoing GF funding
(costed extension). Further scale-up of HIV care and treatment is proposed in the above
allocation request in order to sustain the gains in reduced mortality and further reduce HIV
incidence, in the above allocation request.
The proposed scale-up of ART will be achieved through multiple interventions which will include;
enhanced diagnosis and linkage to care of infected individuals, timely CD4 testing and initiation
of ART and improved retention of individuals enrolled into care. The health systems
strengthening improvements especially in human resources, PSM, and laboratory infrastructure
(see section 1.3, pages 24-25) will support implementation of these interventions. The increased
number of accredited facilities and laboratory infrastructure as well as the recently demonstrated
increase in the number of individuals newly enrolled on treatment (described on page 15, section
1.2) is a clear demonstration of the capacity to provide the proposed services. The stability of
indicators such as retention of individuals on treatment despite the recent rapid scale-up is also a
good indicator of sustained quality. To further enhance and maintain quality, this application
includes interventions for ART resistance prevention and monitoring. Quality of the expanded
ART services will be further ensured through several interventions including training and
mentorship of providers and enhancement of quality improvement activities. CSS interventions to
strengthen community mobilization and support for retention and adherence by PLHIV and other
community groups are included in the HSS application. The HSS application also includes
additional enhancements for MIS and reporting as well as PSM.
HIV prevention interventions for youth in and out of School: Interventions for HIV prevention
for youth in and out of School, will be delivered in line with the national prevention strategy to
focus on increased adoption of safer sexual behaviours and reduction of risky behaviours. The
national HIV prevention strategy defines two groups of youth; those who are not yet sexually
active and those who are sexually active (National Prevention Strategy, Page 14). Strategies for
youth who are not yet sexually active in and out of school focus on sexual education to delay
sexual debut and to acquire skills about the risks associated with sex. For the sexually active
youth, interventions will include HCT and risk reduction counselling. The interventions will
specifically focus on increasing the age of sexual debut (towards eliminating sexual debut below
18 years and childhood marriages) and reducing cross-generational sex, both of which
negatively impact on SRH indicators and increase the risk of HIV acquisition and transmission
among youth and especially the girls. Interventions for the sexually active youth will address
reduction in multiple partnerships, transactional sex and casual sex, and will include condom
education and distribution.
The life skills interventions will focus on empowering the youth and especially the girls to make
the right SRH decisions and choices (including delaying or negotiating for safer sex)
independently or jointly with partners as well as reducing vulnerability in relation to SGBV.
Harmful socio-cultural and gender norms are a major driver of the HIV epidemic in Uganda and
will be addressed in this application.
Finally, promotion of safe male circumcision for young boys will also be integrated since a recent
modelling by MOH and PEPFAR has shown the highest impact for SMC among youth.
Additionally, young people who are HIV infected need to receive an early diagnosis and linkage
to appropriate care and treatment. These activities are further described in the modular template.
Expected outcomes from these interventions will include delayed sexual debut, reduced teenage
pregnancies and childhood marriages, reduction in multiple sexual partnerships and unprotected
sex, and ultimately reduced HIV incidence and prevalence among youth. The youth are still
impressionable and with great potential for positive change, and present a great opportunity for
reversing deeply rooted socio-cultural practices (e.g. negative masculinity and femininity
practices, SGBV, stigma and discrimination). Targeting youth with appropriate education,
reduces their risk of encountering or perpetuating such beliefs and practices, and will in the longterm create positive and sustained change.
TB prioritization above allocation: Additional activities within the supported TB modules and
interventions of the running grant have been prioritized for above allocation to increase coverage
Uganda TB and HIV Concept Note

15 October, 2014 39

of TB, MDR-TB, TB/HIV prevention and care services in key populations to improve the impact of
prioritized interventions. Priority activities in community system strengthening, program
management and health information systems have also been prioritized to successfully deliver
the intended services. The overall above allocation amount for the TB-HIV application is
259.684.021 (see table 6 below).
Table 6: TB-HIV above allocation spread

Summary budget by
Modules
Prevention programs for
general population
Prevention programs for MSM
and TGs
Prevention programs for sex
workers and their clients
Prevention programs for
adolescents and youth, in and
out of school
PMTCT
Treatment, care and support
TB care and prevention
TB/HIV
MDR-TB
Health information systems
and M&E
Community systems
strengthening
Program management
TOTALS

Above allocation

TOTALS

2015/16

2016/17

2017/18

43,084,813.2

56,314,732.9

28,396,051.6

127,795,597.7

394,986.0

186,728.4

208,802.0

790,516.4

1,219,018.4

274,944.0

265,944.0

1,759,906.4

1,985,411.6

1,060,117.6

1,079,642.0

4,125,171.2

234,763.2

763,992.6

728,748.6

1,727,504.4

58,870,301.7

88,846,551.8

77,495,663.7

225,212,517.1

497,935.1

801,246.3

1,831,871.8

3,131,053.2

228,793.6

129,336.8

105,124.0

463,254.4

1,194,254.7

1,270,580.9

2,238,927.8

4,703,763.4

1,047,664.4

1,246,238.4

694,699.6

2,988,602.4

241,222.0

273,693.7

242,229.5

757,145.2

225,177.6

185,187.6

339,767.8

750,133.0

109,224,341.4

151,353,350.9

113,627,472.5

374,205,164.8

Addressing previous weaknesses in the HIV response

The biggest weaknesses in Ugandas HIV response have been limited targeting of MARPs
(sources of new infections), inadequate focus on primary prevention and underlying drivers of the
epidemic, inadequate integration and synergies between HIV and related services such as
RMNCAH and TB, and health system challenges that limit the effectiveness and efficiency of
interventions. These issues have been highlighted in Ugandas Investment Case and the
September 2014 Joint Annual AIDS Review.
This application represents a significant shift in HIV programming for Uganda, specifically the
focus on MARPs and targeting of other high HIV prevalence and vulnerable populations such as
women and girls, and high-prevalence districts. Within districts, special attention will be given to
high-risk venues that were highlighted in the PLACE study. General population interventions will
also prioritize areas of maximum impact (e.g. targeting of the younger men 10-35 years and
districts with the highest prevalence and lowest circumcision rates for SMC). All targeted
categories of MARPs will be provided with a minimum package of HIV services, including;
SBCC, condom promotion and distribution, SMC, STI screening and treatment, aggressive HIV
testing campaigns and linkages to HIV care and treatment. Interventions for MSM/TG and sex
workers will be enhanced through opening of an additional four regional clinics based on the
MARPI model. The MARPI clinic is based within a STD/skin clinic and provides comprehensive
HIV prevention, care and treatment services at the facility and through outreaches into the
communities, with use of peers for community mobilization. An evaluation of SW and MSM
service access in 2013 showed that this model was appreciated by both SWs and MSM and that
MSM and TG particularly preferred integrated clinics that would not be earmarked for their
communities to avoid stigma and discrimination. The planned five clinics will have toll-free lines
Uganda TB and HIV Concept Note

15 October, 2014 40

and will explore use of internet technologies such as twitter and Facebook to increase access to
health information including HIV prevention and counseling. Use of toll free lines is proposed for
the five model clinics for sex workers and MSM/TG to enhance access to health information. Use
of media such as Facebook and twitter among others is also suggested for information
dissemination targeting the younger age groups (youth in tertiary institutions) and MSM (such
technology is being used by these communities for various purposes).
For the fishing communities, the country will intensify prevention, testing, linkage to care, and
retention. To address the challenges of access to care, we will identify, support and accredit
lower level facilities (including HCIIs) within fishing communities and support outreach services
since some Islands do not have functional health facilities. This enhanced support will target
Islands from the districts around Lake Victoria, with the highest HIV prevalence (Kalangala,
Mukono, Buikwe, Buvuma, Namayingo, Wakiso, Mayuge, and Kayunga district) and the districts
around Lake Kyoga (Amolatar, Apac, Buyende, Dokolo, Kaberamaido, Kayunga, Nakasongola,
and Serere). Interventions along the transport corridors targeting trading centers and hotspots
will also target truckers and sex workers.
These services will be additional to supportive interventions, including; strategic information,
capacity building, peer-led community mobilization, interventions to reduce stigma and
discrimination and safe space to access services, and referral for additional and specialized
services. This shift addresses the programmatic and health systems challenges highlighted in
sections 1, 2, and 3.1. Additional health system interventions to strengthen PSM, HMIS, and
CSS are included in the HSS application. To further mitigate vulnerability for women and girls
living with and /or affected by HIV/TB, CCM will build on evidence from the SHARE and
CEDOVIP projects (CEDOVIP, 2011; Wagman et al., 2012 page 1398-1407 ) 2012) to scale up
community mobilisation in 28 districts with high GBV prevalence. Activities for community level
mobilisation and sensitization shall be funded as part of the CSS Module in the HSS Concept
Note. Complimentary psychosocial support services specifically targeting safe disclosure, postrape care and GBV post-trauma counselling will be offered as part of HIV risk reduction
counselling for all women in HIV routine care. Working with the district level GBV champions,
survivors will be referred to regional centres for management and rehabilitation.
The funding request for HIV will provide continuity for the costed extension activities and
enhance the primary prevention interventions which are not as prominent in the costed
extension.

Uganda TB and HIV Concept Note

15 October, 2014 41

3.3 Modular Template

Complete the modular template (Table 3). Note that the template allows access to
modules that are specifically relevant to TB and HIV components, in addition to modules
that are cross-cutting for both diseases.
To accompany the modular template, for both the allocation amount
and the request above this amount, explain:
a. The rationale for the selection and prioritization of modules and interventions for
TB and HIV, including those that are cross-cutting for both diseases.
b. The expected impact and outcomes of the interventions being proposed.
Highlight the additional gains expected from the funding requested above the
allocation amount.
a) Rationale for the selection and prioritization of modules and interventions for TB and
HIV
Selection of HIV priority modules and interventions
Alignment with national priorities and cost-effectiveness: The development of this
application was informed by the priorities in the National HIV Investment Case, the National HIV
and TB Strategic Plans, and the Health Sector Strategic and Investment Plan.
Funding landscape: Analysis of the funding landscape and programmatic gap analysis was
conducted to ensure that the requested funding is complementary to existing in country
resources including GOU, GF, PEPFAR, and other resources. This application is additional to
existing country efforts, to scale up access to effective HIV prevention and treatment services.

HSS and CSS to support implementation of selected high impact interventions: Selected
HSS and CSS interventions are proposed to ensure demand generation and delivery of quality
services, including ensuring that the required commodities are available at all times, retention
and adherence support for TB and HIV patients, TB case detection and contact tracing, among
others.
Integration of TB and RMNCAH for synergies and efficiencies: This application integrates
critical RMNCAH interventions that complement the HIV and TB investments and enhance
effectiveness and efficiencies. Examples include enhanced and sustained ANC attendance and
increasing facility based deliveries, integrating FP and safer conception support for PLHIV,
cervical cancer screening, integrating EID into young child clinics such as immunization, and
integrating TB-HIV across various HIV modules including prevention, care and treatment.
The NTLP and selection of TB specific priority modules and priority interventions:

The NTLP already implements a signed Phase II SSF grant with start date of July 01,
2014 and which will end in Dec 2016. This grant includes a budget of $15,140,487. The
Phase II grant included 6 objectives as follows:
i.
ii.
iii.
iv.
v.
vi.

To expand and consolidate high-quality DOTS

To strengthen TB/HIV collaboration
To strengthen Program Management of MDR-TB (PMDT)
To strengthen TB control in Uganda Prisons Services
To strengthen partnerships to scale up TB control interventions
To strengthen program capacity to plan, implement, monitor and evaluate TB
control

All activities (already approved) within the current signed grant will move into this new
grant application expected to start in July 2015 from the existing service delivery areas
into the strategic investment framework. The NTLP is applying for investment in 3 priority
modules TB Care and Prevention, MDR-TB and TB-HIV, with TB HIV presented as a
completely integrated module implemented jointly by the ACP and the NTLP. It has also
sought investment in the following cross-cutting modules available Community
Systems Strengthening, Human rights and legal barriers, Health information systems and
M & E, program management including procurement and supply chain management of
TB drugs and lab consumables including additional XpertMTB/Rif modules incrementally.

Uganda TB and HIV Concept Note

15 October, 2014 42

The cross cutting modules are presented as joint investments by the ACP and the NTLP
ensuring that communities and key affected populations are prioritized and that systems
for program management, PSM, data and M & E are strengthened across both
programs. The areas of PSM, HMIS and CSS are also addressed in a separate HSS
concept note that will strengthen the foundation for the ACP and the NTLP to leverage
directly into programming.
o

Key issues identified in the Global Fund Portfolio Analysis for the NTLP
(September draft) (Annex 21) included: weakness in the TB surveillance system
and gaps in completeness, accuracy and quality of data - including possible
missed opportunities for notifying cases diagnosed in TB microscopy labs; gaps
(incomplete data) in MDR-TB recording and reporting are identified as a critical
issue, in relation to patient monitoring and follow-up; absence of written data
quality assurance procedures and weak monitoring systems contribute to data
accuracy issues at facility and district levels; stagnant case notifications with
potential to increase notification of smear negative TB, TB in children and TB
among HIV infected (although screening for TB in this population is high); lower
treatment success rates, both among newly diagnosed and treated cases as well
as in retreatment cases with high rates of loss to follow-up during treatment,
death and patients not being evaluated at the end of treatment suggesting
potential for improvements in case holding; higher case notification from urban
populations in Kampala, Wakiso among others and the need to target case
finding in these populations; low coverage for ART among co-infected TB
patients although HIV testing and provision of CPT was high; need to urgently
expand diagnosis and treatment of MDR-TB ensuring effective and efficient use
of new diagnostic technology (XpertMTB/Rif), assuring DOT and good patient
management including ambulatory treatment for patients and strengthening data
systems to track and monitor patients on treatment and those eligible for DST;
the need to add two indicators one to monitor drug stock-outs in facilities and
the other to assess proportion of people tested for DST amongst those eligible;
the need for long term TA within the NTLP Central Unit to support and contribute
to capacity; the need to accelerate implementation of the prevalence survey;
scale up community and private sector TB activities; address capacity issues at
district level and challenges within the NTLP in terms of decision making,
proactive problem solving, and coordination of activities including reporting,
monitoring of consumption of TB drugs; recommendation to include an M & E
plan including defining linkages with DHIS 2; ensure that a functional system to
systematically collect LMIS data for TB medicines is set up and implemented and
improve coordination with the NMS and strengthen the supply chain showing
complementarity with support from other partners;

The NTLP team has carefully reviewed the issues identified above. This has been
combined with the information coming out of the programmatic gap analysis and the
limitations identified through the process to develop the NSP (described in section 1.2
(c)) of this application, to advice the selection of the TB specific priority modules and the
priority interventions within these modules. Additionally, the ACP was consulted and
involved throughout the elaboration of the interventions to ensure integration and
alignment. Crosscutting modules were also developed jointly to ensure synergy and
inclusiveness of planning and implementation.

Within each of the three priority modules for TB TB care and prevention, MDR-TB and
TB HIV, the NTLP has ensured that priority intervention areas include engaging the
communities, prioritizing and working with key affected populations; additionally, public
private partnerships, and collaboration across sectors and partners has also been
prioritized. Successful models described in the application have been scaled up in this
investment application.

b) The expected impact and outcomes of the interventions being proposed

The proposed disease specific and cross cutting health and community systems interventions
represent a sound investment, given the current drivers of Ugandas HIV epidemic. The proposed
HIV/AIDS interventions in this application are aimed at contributing towards the national
(Investment Case and NSPs) and international goals of Universal Access to HIV care and
treatment, and eMTCT hinged on RMNACH linkages and integration approaches. Achieving
Uganda TB and HIV Concept Note

15 October, 2014 43

universal access through timely initiation of ART will not only reduce mortality and morbidity
among HIV positive Ugandans but will also reduce numbers of orphans, increase community
productivity, and reduce numbers of new HIV infectionsthereby strengthening the impact of
primary HIV prevention efforts in Uganda.
Specifically the proposed interventions will result into improved service coverage and outcomes
for the targeted Investment Case interventions including: 1) ART coverage for HIV infected
pregnant women, towards the 95% coverage target and elimination of MTCT; 2) increased SMC
coverage towards the 80% target; 3) access to and use of condoms in high-risk sexual
encounters, towards the 80% target; 4) increased uptake of HIV testing and counseling in linkage
to prevention and care and treatment; 5) improved ART coverage towards the 80% coverage
target with treatment irrespective of CD4 count for several MARPs; and 6) enhanced systems to
deliver the proposed interventions.
The preferred HIV Investment Case scenario (maximum feasible) prioritized the most effective
and high impact interventions aimed at averting more than 2 million infections and half a million
deaths by 2025. This was also the most cost-effective scenario among various models (Figure 7).
For this impact to be realized the priority interventions should be brought to scale rapidly, within
the first three years (2015-2018) (Investment case for Uganda 2015-2025, pages 26-34).
Figure 7: New HIV infections and cost-effectiveness measures

Total new infections

400000
300000
200000
100000
0
2010 2012 2014 2016 2018 2020 2022 2024
Base

Medium

High

T&T

Max Feasible

CCM proposes to expand access to and utilization of these high impact interventions as
determined in the Investment Case. Implementation of PMTCT services, using a comprehensive
four-prong approach, will contribute to the National goal of elimination of mother-to-child
transmission of HIV (MTCT). This will result into reduction in new HIV infections among children
leading to decreasing demand for pediatric treatment as well as improved child survival and
contribution to improvements in MNCH indicators. Expansion of HIV treatment from the current
48% of eligible individuals on treatment (50% by end of 2014), to 80% and treatment irrespective
of CD4 count for selected population segments such as sex workers, MSM, and sero-discordant
couples will result into reduced risk of transmission in the general population and reduced
morbidity and mortality. These changes will ultimately contribute to the 77% reduction in HIV
incidence by 2025 as projected in the Investment Case. Treatment (ART) for TB-HIV co-infected
patients will improve treatment outcomes and expansion of IPT coverage will reduce the risk of
TB disease among HIV infected individuals, and eventually in the general population.
ART and TB drug resistance prevention and monitoring: Patients with drug resistance must
switch treatment regimens, which raise medication costs, because the second-line regimens are
usually more expensive than the first-line. Prevention, surveillance and monitoring of HIV and TB
drug resistance is critical to the success of clinical and public health programs. Minimizing the
emergence and transmission of HIV drug resistance in the current era of rapid scale-up of access
to Anti-retroviral drugs (ARVs) is important for safeguarding the efficacy of ARVs.
Closing service delivery gaps through strong community systems: ART programs with
community-based patient retention and care linkages have higher adherence rates and patient
retention than those programs that do not. (Etienne M et al 2007 page78-79) This proposal will
deploy trained, motivated community groups at low unit cost, providing services at the
grassrootssuch as linking pregnant HIV positive mothers to care, patient monitoring and follow
up. The efforts of these community groups will provide value for money by delaying the
development of ART resistance and the shift to more expensive second-line regimens.
Additional gains expected from the funding requested above the allocation
The determination of allocation versus above allocation interventions was tight given the level of
Uganda TB and HIV Concept Note

15 October, 2014 44

need on the ground, across various interventions. The activities included into the above allocation
budget are extremely critical to the attainment of national goals and targets (as described in
section 3.2 above), and without these additional investments, Uganda cannot reverse the tide of
new infections and the HIV related mortality. Given the limited resources within allocation, the
scale-up of the highest cost interventions in this application has been further prioritized with
several critical interventions such as ARVs for PMTCT, HIV testing and treatment for children left
out of the allocation amount. The third year of the grant period is also not included in the
allocation.
Brief summary of the expected impact and outcomes of the TB disease specific interventions
being proposed:
In addition to consolidating the program outcomes already established through the Joint External
Monitoring Mission (Sep 2013), this investment is expected to achieve the following impacts and
outcomes over the grant period
i.

A reduction in the prevalence of TB from the 2012 baseline of 175/100,000 population to

128/100,000 population (2018).
There is already an observed decline in the prevalence of TB documented in the WHO
database. It is expected that this grant will support the NTLP in collaboration with the
ACP and partners to target key affected populations in the country including HIV infected,
children, urban slum populations, prisons and other congregate settings and key affected
populations already served with HIV care services. Joint interventions including the scale
up of IPT for HIV clients under care by the ACP will contribute to decreasing incidence of
TB with implications for prevalence, mortality and DALYs saved.

ii.

Case notification rate of all forms of TB per 100,000 population - bacteriologically

confirmed plus clinically diagnosed, new and relapse cases (disaggregated by age <15,
15+, sex and HIV status).
Additional cases are expected to come out of targeted interventions within this
investment application. These include increasing access to new diagnostic technology
(XpertMTB/Rif) for smear negative, HIV infected clients under care (priority MARPs),
children and scaling up successful models in urban settings in 15 districts and in the
Uganda Prisons Service. Investments in the TSRS and the HUB systems, already
working well, will bring patients closer to testing facilities and reduce turnaround time for
results. Improved recording and reporting will mean better data, improved analysis and
more certain inferences to guide program target setting and planning as well as
monitoring and evaluation. Strengthening community networks will generate demand for
TB services through social mobilization, improve awareness and knowledge, build
accountability through community led monitoring and build institutional capacity in
community networks and institutions.

iii.

iv.

v.

Challenges with increasing case notification rates in the context of an observed decline in
incidence and an expanding population with an annual growth rate of 3.2% have been
identified and documented in the modular template against this indicator. It is proposed
to maintain the targets identified in the signed SSF Phase II performance framework for
this investment application while elaborating the risks of these ambitious targets.
Treatment success rate - bacteriologically confirmed new TB cases (disaggregated by
age <15, 15+ and sex)
TSR is expected to improve from the baseline of 77% (2012 cohort) to 85% in 2018
Percentage of notified cases of bacteriologically confirmed, drug resistant RR-TB and/or
MDR-TB as a proportion of the estimated number of RR-TB and/or MDR-TB cases
among notified TB cases (disaggregated by sex and age <15,15+)
This is expected to increase from the baseline of 20% (2013) to 62% in 2018
Percentage of bacteriologically confirmed drug resistant TB cases (RR-TB and/or MDRTB) successfully treated (disaggregated by sex and age <15, 15+)

This is expected to increase from the baseline of 60% (2011 cohort) to 75% in 2018

Uganda TB and HIV Concept Note

15 October, 2014 45

3.4 Focus on Key Populations and/or Highest Impact Interventions

This question is not applicable for Low Income Countries.
For TB and HIV, describe whether the focus of the funding request meets the Global
Funds Eligibility and Counterpart Financing Policy requirements as listed below:
a. If the applicant is a lower-middle income country, describe how the funding request
focuses at least 50% of the budget on underserved and most-at-risk populations
and/or highest-impact interventions.
b. If the applicant is an upper-middle income country, describe how the funding
request focuses 100% of the budget on underserved and most-at-risk populations
and/or highest-impact interventions.
1 PAGE SUGGESTED
Not Applicable

SECTION 4: IMPLEMENTATION ARRANGEMENTS AND RISK ASSESSMENT

This section requests information regarding the proposed implementation arrangements
for this funding request. Defining the implementation arrangements for the program
including the nominated Principle Recipients (PRs) and other key implementers is
essential to ensure the success of the programs and service delivery. For the concept
note for TB and HIV, the Country Coordinating Mechanism (CCM) can nominate one or
more PRs, as appropriate given the country context.

4.1 Overview of Implementation Arrangements

For TB and HIV (including HSS if relevant), provide an overview of the proposed
implementation arrangements for the funding request. In the response, describe:
a. If applicable, the reason why the proposed implementation arrangement does not
reflect a dual-track financing arrangement (i.e. both government and nongovernment sector PRs).
b. If more than one PR is nominated, how co-ordination will occur between PR(s) for
the same disease and across the two diseases and cross-cutting HSS as relevant.
c. The type of sub-recipient management arrangements likely to be put into place
and whether sub-recipient(s) have been identified.
d. How coordination will occur between each nominated PR and its respective subrecipient(s).
e. How representatives of womens organizations, people living with the two diseases
and other key populations will actively participate in the implementation of this
funding request.
2-3 PAGES SUGGESTED
The PR for the public sector will be the Ministry of Finance Planning and Economic Development
(MoFPED). MoFPED will work with Ministry of Health, Uganda AIDS Commission, and other
sectors, departments and agencies to implement the public sector interventions.
In 2010, the CCM selected a Civil Sector Principal Recipient (CS-PR) The AIDS Support
Organization (TASO), using a transparent, documented process. TASO is responsible for
management of funds and coordination of activities implemented through the private/NGO sector.
The mandate for TASO as the second PR was renewed by CCM on 19 th September 2014 (see
Uganda TB and HIV Concept Note

15 October, 2014 46

attached minutes). The sub-recipients have not been selected yet. Selection of sub-recipients will
follow a transparent process initiated through advertisements in the media and a structured multilevel and multi-stakeholder review.
a) Implementation arrangements
The proposed interventions in this application will be implemented in a dual-track financing
arrangement. The PR for the public sector will be the Ministry of Finance Planning and Economic
Development (MoFPED). MoFPED will work with Ministry of Health, Uganda AIDS Commission,
and other sectors, departments and agencies to implement the public sector interventions. TASO
will serve as the second PR for the entire grant (TB and HIV).
b) Coordination across the two PRs and diseases
The relationship between the two PRs is governed by an MOU between MoH and PR2 (TASO) that
describes the roles and responsibilities of each PR, which together jointly implements the HSSIP.
To enhance and strengthen coordination with the aim of increasing absorption, program
performance, accurate, and timely reporting, GOU established the Focal Coordination Office (FCO)
within Ministry of Health (MoH). The FCO coordinates the grant functions at PR1 while the Grant
Management Unit coordinates the Grant management functions at PR2. The MOU provides for
regular interface meetings between the coordination Units, jointly reviews progress updates,
budget management (GOU support), and support supervision outcomes.
c) Sub-recipient management arrangements and selection
The sub-recipients (SRs) have not been selected yet. Selection of sub-recipients will follow a
transparent process; applications will be invited from CSOs using newspaper adverts and the
applications will be assessed based on criteria published in the newspaper adverts. The evaluation
criteria and final approval of the selected CSOs will be done by the CCM. The SR concept
proposals will undergo a two-stage process; Eligibility Criteria Review (ECR) and Technical Review
(TR). SRs with outstanding concept proposals in the priority areas will be nominated for funding
under this application. Each recipient will undertake those interventions that are consistent with its
experience, mandate and comparative advantage.
The public sector interventions in this grant will be implemented using existing national systems.
The Districts and their associated PNFP facilities will not be subjected to the above selection
process given pre-existing MOUs and constitutional mandates. The public sub-recipients have a
constitutional mandate to deliver health interventions/services in this proposal and are already
implementing health programs that complement those that will be financed by this application.
Sub-recipient management: To mitigate fiduciary risk, advance screening of all selected SRs will
be done using evidence of audited accounts for the past three years, valid legal registration status,
and endorsement by local authorities. The second PR will coordinate and manage interventions
through the non-public sector, and will provide oversight and technical support to the sub-recipients
to ensure that implementation and accountability challenges are addressed. After the proposal has
been approved, the SRs will undergo a pre-award assessment before final granting is made.
The second PR will directly disburse funds to individual accounts of the sub-recipients. The funded
CSOs will account and report directly to the second PR. The second PR and its sub-recipients will
implement activities that are consistent with the national and district priorities in line with the NSP,
HSSP, and NDP to ensure contribution to the national and international development goals.
For the public sector SRs, MOFPED will work with Ministry of Health (MoH), Uganda AIDS
Commission (UAC), and other sectors, departments and agencies to implement the public sector
interventions. Ongoing oversight is provided by several governance and oversight structures. The
office of the Auditor General has extensive roles in the financial management and oversight of the
public sector agencies, departments and ministries. Annually financial and value-for-money audits
are conducted for all public agencies, ministries and corporations. The office of the Auditor General
or his/her duly appointed representatives will audit both the public and private sector PRs.
The District Local Government Councils and technical officials within these structures undertake
technical oversight for the provision of health services. For example the District Health Officers
oversee the health programs while the District Community Development Officer oversees the
community-level HIV responses along with other development programs in the communities. The
technical function of program M&E is carried out on behalf of the public Principal Recipient (PR) by
sector Ministries with the Uganda AIDS Commission responsible for the multi-sectoral coordination.
Overall oversight will be provided by CCM; CCM receives progress reports from both public and
non-public PRs and reserved the right to undertake additional activities to audit the performance of
Uganda TB and HIV Concept Note

15 October, 2014 47

SRs. Finally, in the joint annual reviews and National Health Assembly, progress reports on the
grant will be presented and discussed by a wide range of stakeholders.
d) Coordination between each nominated PR and its respective sub-recipient(s)
Each PR (public and private) will develop a work plan, in line with the overall work plan (modular
template), for monitoring performance in its constituency. Sub-recipients will derive their work plans
in line with the overall PR work plans.
The second PR will coordinate and manage interventions through the non-public sector, and will
provide oversight and technical support to the sub-recipients to ensure that implementation and
accountability challenges are addressed. The first PR will do similarly for the public sector SRs.
e) How representatives of womens organizations, people living with the two diseases and
other key populations will actively participate in the implementation of this funding request
Involvement of stakeholders outside CCM, including women, PLHIV, and key population groups will
be done at various levels and through different approaches. The representatives of these groups at
the CCM will raise issues from their constituencies during CCM discussions. These representatives
will also be supported by CCM to arrange consultative meetings with their constituencies. Through
joint annual review processes, representatives from these constituencies will participate in program
reviews and priority setting. Advocacy activities under the CSS component will, among other
things, strengthen the role of communities, women groups, people living with HIV, and key
populations to participate in program monitoring and accountability from the beneficiary
perspective.

4.2 Ensuring Implementation Efficiencies

Complete this question only if the CCM is overseeing other Global Fund grants.
From a program management perspective, describe how the funding requested links to
any existing Global Fund grants, or other funding requests being submitted by the CCM at
a different time. In particular, explain how this request complements (and does not
duplicate) any human resources, training, monitoring and evaluation, and supervision
activities.
1 PAGE SUGGESTED
CCM Uganda currently has several ongoing grants including HIV Costed extension (ending June
2015); TB Round 10 SSF Phase 2 (ending December 2016); Malaria Round 7 phase 2 ending
November 2014, Malaria Round 10 Phase 1 ending December 2014; HSS Round 10 (ending
December 2014); and has submitted Malaria, HSS and TB-HIV applications through the New
Funding Model.
The funding requested through this grant is additional to and complementary to existing GF grants
and the new applications. The new grants will be managed within the same oversight and
management structures including CCM, PRs, the FCO, and the GMU for PR2. Other existing
personnel including the RPMTs and the 600 health care workers through the HSS grant will also
support both ongoing and new grants.
In terms of the programmatic efficiencies, a comprehensive gap analysis was conducted to ensure
complementarity of proposed interventions to existing grants and the new grants. For example,
several HSS and CSS interventions to support the new TB-HIV and Malaria grants are included
into the HSS grant. The funding that is requested through this application targets high impact
interventions that are aligned with the country NSPs for TB and HIV and represents continuity of
several interventions in ending grants (e.g. the HIV costed extension).

4.3 Minimum Standards for Principal Recipient (PR) and Program Delivery
For both TB and HIV complete the table below for each nominated PR. For more
information on Minimum Standards refer to the Concept Note Instructions.

Uganda TB and HIV Concept Note

15 October, 2014 48

PR 1 Name

MoFPED

Sector

Public

Does this PR currently manage a Global Fund grant(s)

for this disease component or a stand-alone crosscutting HSS grant(s)?

Yes

Minimum Standards

CCM assessment

1. The Principal Recipient demonstrates effective management

structures and planning

No

The MoFPED plays a pivotal role in

the co-ordination of development
planning; mobilization of public
resources and ensuring effective
accountability for the use of such
resources for the benefit of all
Ugandans. Under its mandate,
MoFPED as a PR regulates financial
management and ensures efficiency
in public expenditure. PR derives its
mandate and functions from the 1995
Constitution of the Republic of
Uganda and other related
subordinate laws, including; the
Budget Act (2001), the Public
Finance and Accountability Act
(2003) and acts establishing
agencies and auxiliary organizations.
In the delivery of health services, The
Ministry of Health provides
leadership role and responsibility for
policy and guidelines, resource
mobilization, monitoring and
accountability.

2. The Principal Recipient has the capacity and systems for effective
management and oversight of Sub-Recipients (and relevant SubSub-Recipients)

Ministry of Local Government

coordinates
and
supports
Governments in the sustainable,
efficient and effective service delivery
in the decentralized system of
governance. This is done through the
districts, Municipalities and subcounties. The Local Governments
have the responsibility for the
delivery of health services. In
addition, they are tasked with
planning,
budgeting,
resource
mobilization and allocation for health
services. The Local Government
system ensures that functions,
powers and responsibilities of PR are
devolved and transferred to local
government units, oversee monitors
the provision of Government services
or the implementation of projects in
their areas.

3. The internal control system of the Principal Recipient is effective

to prevent and detect misuse or fraud

The internal controls of the PR are

quite strong, sound and robust to
detect and prevent misuse through
the use of different reviewers
including but not limited the Internal
Audit staff. The installation of the
Navision accounting software is
hoped to greatly increase the
information reliability and flagging of
fraud such as double payments.

Uganda TB and HIV Concept Note

15 October, 2014 49

4. The financial management system of the Principal Recipient is

effective and accurate

Although, the PR currently uses the

Integrated Financial Management
System (IFMS) to track Government
and other donor`s expenditure, the
Global Fund off-budget supported
Expenditure is tracked using excel
systems that are further reviewed by
the Local fund Agent for accuracy
and appropriateness. However, the
installation of the MS Navision by
December 2014 will effectively
improve the Financial Management
System and provide accurate data for
expeditious, reliable and informed
decision making.
NMS has a perimeter wall with
24hour and alarm system with rapid
response
and
robust
security
protocols

5.

Central warehousing and regional warehouse have capacity, and

are aligned with good storage practices to ensure adequate
condition, integrity and security of health products

6. The distribution systems and transportation arrangements are

efficient to ensure continued and secured supply of health
products to end users to avoid treatment / program disruptions

NMS is approved by the National

Drug Authority and has over
13,000sqm
of
storage
and
operational area, over 3000 pallet
positions with a strong Quality
Assurance department charged with
ensuring
quality
of
medicines
supplied. It is currently transiting from
MACS&SAGE
to
Commodity
Management Platform software to
improve its financial & inventory
management efficiency.
NMS using a two-tier distribution
system. NMS closed trucks deliver
medicines directly to hospitals and
district. A 3rd party is contracted to
ensure secure and timely delivery of
commodities to lower level health
facilities.
Data used in the monitoring of
program performance comes from
two sources; first, HMIS through
which data on the majority of HIV and
TB is reported and programmatic
reports through which data for
indicators that are not routinely
reported on is obtained.

7. Data-collection capacity and tools are in place to monitor program

performance

For the data obtained through HMIS,

standard tools are used. These are
centrally developed and periodically
updated and distributed to all data
collection points, both public and
private by the Resource Center of
Ministry of Health. In addition, there
are reports that are produced on a
weekly, monthly, quarterly or annual
basis.
At every data capture point, there is a
Records Assistant who oversees
data collection and does basic data
quality control checks. It is also their
responsibility to fill and remit periodic
report through their supervisors.
There are two intermediate levels
at the Health Sub-District and
District. At each of these levels, there

Uganda TB and HIV Concept Note

15 October, 2014 50

is an HMIS Focal person who

aggregate reports, ensures quality
and enters the data into the DHIS2.
These are trained and supervised by
the Resource Center. Both PRs use
HMIS data to monitor program
performance.
To collect of data for non-routine
data, tailor-made tools are used. For
a number activities and indicators,
each PRS has a set of tools while for
some activities such as trainings, a
common tool is used.

8. A functional routine reporting system with reasonable coverage is

in place to report program performance timely and accurately

The Ministry of Health has integrated

all stand-alone disease reporting
systems into one web-based District
Health Information System (DHIS-2).
The system has been rolled-out
nationwide with all 112 district biostatisticians enabled to access and
input data into the DHIS-2. This has
increased efficiency while ensuring
sustainability of reporting to the
national level from the district level.
All
routinely
collected
malaria
indicators can be captured and
collated through the DHIS-2
The National Drug Authority (NDA) is
mandated to quality assure all
pharmaceuticals imported in the
country.

9. Implementers have capacity to comply with quality requirements

and to monitor product quality throughout the in-country supply
chain

In addition, the NDA ensures that

premises and operations of all health
facilities, pharmacies and drug shops
comply with good pharmacy practice
principles.
The Uganda National Bureau of
Standards
is
responsible
for
establishing standards and enforcing
quality
assurance
of
nonpharmaceutical commodities

4.3 Minimum Standards for Principal Recipient (PR) and Program Delivery
For both TB and HIV complete the table below for each nominated PR. For more
information on Minimum Standards refer to the Concept Note Instructions.
PR 2 Name

Sector

TASO

NGO

Does this PR currently manage a Global Fund grant(s)

for this disease component or a stand-alone crosscutting HSS grant(s)?

Yes

Minimum Standards

CCM assessment

1.

The
Principal
Recipient
demonstrates
management structures and planning

Uganda TB and HIV Concept Note

effective

No

TASO is governed by a Board of

Trustees. The Executive Director is
responsible for the day-to-day
operations of the organization and
has a Senior Management team
(comprising of Directors and Team
15 October, 2014 51

Leaders), which reports directly to

her. The Global Fund grants are
managed by the Grants Management
Unit, which is headed by the Project
Coordinator, who also reports directly
to the Executive Director and is a
member of the Senior Management
Team.
TASO has for many years now, been
sub-granting
funds
to
various
CSOs/CBOs, some of whom have
sub-sub grantees.
Under the on-going Global Fund
grants, TASO currently has 10 subrecipients and 2 SSRs.
Various controls have been put in
place,
to
ensure
effective
management of the SRs. For
example:
2. The Principal Recipient has the capacity and systems for effective
management and oversight of Sub-Recipients (and relevant SubSub-Recipients)

Capacity assessments were

performed for each of these SRs
and
areas
for
capacity
development identified, before
the SRs were taken on board.

Templates have been developed

for
SR
financial
and
programmatic reporting, and
SRs are required to report on a
quarterly basis, at which point
on-site visits are made to verify
the
SRs
financial
and
programmatic results.

Reviews are also made by the Senior

Internal
Auditor
before
a
disbursement is made to an SR.
TASO has comprehensive and up to
date
Operational
Procedures
Manuals, including the Finance
Manual, which include guidance on
internal controls are to be applied.
3. The internal control system of the Principal Recipient is effective
to prevent and detect misuse or fraud

4. The financial management system of the Principal Recipient is

effective and accurate

5.

Central warehousing and regional warehouse have capacity,

and are aligned with good storage practices to ensure adequate
condition, integrity and security of health products

Additionally, the organization has an

effective Internal Audit function,
which is headed by the Chief Internal
Auditor, who reports directly to the
Executive Director. The Grants
Management Unit also has a Senior
Internal Auditor who is specifically
involved in the day-to-day operations
of the Global Fund grants.
TASO uses the Navision accounting
system

JMS is ISO certified, approved by the

National
Drug
Authority,
has
approximately 4000sqm of storage
capacity and 4,423 pallet positions. It
rolled out its new Enterprise resource
planning software in 2013, which has
improved its inventory management
efficiency.
JMS has a perimeter wall with

Uganda TB and HIV Concept Note

15 October, 2014 52

24hour intrusion alert system.

6. The distribution systems and transportation arrangements are

efficient to ensure continued and secured supply of health
products to end users to avoid treatment / program disruptions

JMS rolled out the USAID funded,

direct distribution to all PNFP health
facilities. 3rd party transporters are
contracted to ensure timely and
secure last mile delivery

7. Data-collection capacity and tools are in place to monitor program

performance

The Grants Management Unit, which

is responsible for implementing the
Global Fund grants has an M&E
department, which is headed by the
M&E Manager and includes a team
of four M&E officers. Tools have
been developed to collect data from
PR and SR activities in order to
monitor performance. The M&E team
also regularly makes visits to SRs to
verify implementation.
The GMU reports on a monthly basis
to the TASO HQ finance team.

8. A functional routine reporting system with reasonable coverage is

in place to report program performance timely and accurately

Additionally, every six months, the

GMU team completes the PUDR
form, which is submitted to the
Global Fund within the required
timeframe.
Annually, the GMUs operations are
included into the TASO Consolidated
Financial Statements, which are
audited by KPMG (previously E&Y).

9. Implementers have capacity to comply with quality requirements

and to monitor product quality throughout the in-country supply
chain

This is the responsibility of the

National Drug Authority. Periodically
Joint Medical Stores also selects
samples and performs quality tests.

4.4 Current or Anticipated Risks to Program Delivery and PR(s) Performance

a. With reference to the portfolio analysis, describe any major risks in the country and
implementation environment that might negatively affect the performance of the proposed
interventions including external risks, PR(s) and key implementers capacity, past and
current performance issues.
b. Describe the proposed risk mitigation measures (including technical assistance) included
in the funding request.
1-2 PAGES SUGGESTED
The risk analysis for the TB and HIV programs is presented in the table below.
Potential Risk

Likelihood of
occurrence

Mitigating measures

1. Inability to achieve program goals/national

targets

Medium

2. Interruption of GF funding due to nonfulfillment of Grant agreement commitment

High

Streamline/strengthen
coordination
and
engage partners to continue supporting high
impact interventions in the Investment
Case/NSPs.
Health
Services
Delivery
System
Enhancement through strengthening HMIS,
Data integrity, DQAs, increase HR and
engage stakeholders in grant management.

Programmatic and performance

Uganda TB and HIV Concept Note

15 October, 2014 53

Enhanced internal control measures to

reduce fiduciary risk and increase funds
absorption.
Fiduciary and Financial
3. Country reputation/Corruption: Uganda has
a high corruption index. The strict control
measures instituted by GOU affect absorption
(increase turn-around time for financial
reporting, which is a prerequisite for further
disbursements).

High

4. Country health budget: GOU contribution to

health is still below the Abuja declaration
target of 15%. The health budget is heavily
reliant on donor funding with multiple players,
which makes it difficult to have optimal
performance and resource tracking.

High

5. Legal context (criminalization of key

populations) may affect service delivery and
financing of HIV and other health interventions.

High

Uganda adopted commodity financing to

increase fund absorption and improve
service delivery.
The
non-commodity
requests in this application will largely be
implemented under the non-public sector
PR. The two PRs will also pay attention to
the integrity and controls within the SRs.
Enhanced internal control measures to
reduce fiduciary risk and increase funds
absorption.
GOU has been increasing allocations in the
national budget for HIV, TB, and Malaria.
Establishment of the AIDS Trust Fund to
generate resources for HIV is in the process.
In addition to monitory contribution, there are
additional support areas including HR,
Infrastructure, equipment, and out of pocket
contributions.
UAC and MoH have established MARPs
technical working groups and frameworks to
guide service delivery within the current legal
context

Health systems
6. Health information systems, M&E and
reporting: Delays in reporting as well as
incomplete data due to the challenges within
the M&E system. DHIS2 still experiences gaps
in generating quality data for certain indicators.
Evaluations of outcomes and impact of
interventions has gaps and may limit scale-up
of evidence based effective interventions

High

7. PSM challenges

Medium

There are several ongoing studies to

evaluate the outcomes and impact of
interventions (primary prevention), treatment
program effectiveness, the NSP has been
revised and development of the new NSP in
progress. The MOT study is almost complete
and the Investment Case was completed
(informed this application). There is support
to
community
Strategic
Information
initiatives.
Partner coordination has improved through
PSM rationalization, Commodity security
Group and establishment of the QPPU to
streamline
forecasting,
quantification,
procurement, warehousing, distribution, and
monitoring. In addition, the country adopted
dual track financing to improve participation
of non-public entities to improve coverage
and equity. Additional PSM improvements
have been addressed in the HSS
application.

Governance, oversight and management

Issues around CCM oversight, PR1 and PR2;
CCM oversight of grant implementation and
coordination between the two PRs

Low

Interrupted partner support to human resource

and program management at ACP

High

CCM oversight and coordination has been

significantly enhanced through effective
engagement by having regular CCM subcommittee meetings attended by the PRs,
monitoring visits by the CCM, and
participation in DQAs by both PRs and CCM.

GOU has taken up all HR positions (on

contract basis through Health Service
Commission) that were under partner
support
NTLP In addition to the tables below, highlighting risks and mitigation submitted at the time of the SSF Phase II
application, the MoH has recently outlined several additional steps. These include a) Fiduciary control measures to
safeguard grant resources and ensure risk mitigation (Annex 66) and b) Risk mitigation strategy for strengthening
Government of Uganda Internal controls and management of Global Fund grants in Uganda (Annex 67)

Uganda TB and HIV Concept Note

15 October, 2014 54

Issues
Stock-out or expiry of anti-TB
medicines due to un-reliable or
incomplete consumption data and
stock out of laboratory supplies
(reagents and slides) at health
facility level

Partial implementation of activities

by SSRs due to limited coverage
and capacities

Limited implementation time and

human resource capacity for the
prevalence survey

Limited human and financial

resources for rolling out PMDT and
conducting follow up activities

1Public

Action taken
To address the risk of stock-out or expiry of anti-TB medicines due to un-reliable or
incomplete consumption data and stock out of laboratory supplies at the health facility
level, a data officer has been recruited with support from partners and is based at
NMS to analyze health facility reports, collate data on stock status and write reports
that will be shared with the Pharmacy division of MoH, NTLP and other partners
supporting to strengthen the procurement and supply chain. The Pharmacy division
will use this information and correlate it with morbidity data to compute stock needs
and advise NMS and GF on the future quantities of medicines and laboratory supplies
to procure. Further, in TB SSF phase 2 the MoH will integrate the ordering and
reporting on stock status of TB medicines, laboratory reagents and related supplies
into the web-based ordering system used by the national HIV/AIDS control program
(WAOS). This will ease reporting and ordering of TB medicines and laboratory
supplies and will provide timely information on stock status to all stakeholders at
national and district level. Health workers at the health facility level will be trained,
mentored and supervised to improve the Logistics Management Information System
(LMIS), with support from TB SSF phase 2 and the additional funding through the
Joint TB HIV Concept Note.
The activities of the SSRs were reviewed, most especially the activity on coverage of
1010 sub-counties by three SSRs. Due to inadequate funding to engage the three
SSRs (NGOs), the SSRs withdrew from implementing this activity. In regard to
facilitation of sub-county health workers to identify and supervise community
treatment supporters for TB patients, delivery of funds to the sub-county health
workers1 was difficult to administer because of their wide geographical spread. This
activity was to be undertaken by partner NGOs but as there was no management cost
for the implementing NGOs it never got executed. Partners are supporting this
activity in six out of nine zones (North, SW, SE, East, West and Kampala). With TB
SSF Phase II and the current application through the Joint TB HIV CN, the program
will facilitate sub-counties in three underserved regions (NW, NE and Central) in the
first year and subsequently expand to additional districts as partners support phases
out (49 in year 1, 80 in year 2 and 112 in year 3). The sub-county health workers will
deliver medicines in the communities and identify community treatment supervisors.
Management costs for delivering the facilitation funds to the sub-county health
workers in the districts have been included in the TB SSF Phase II budget and now in
the Joint TB HIV CN budget. Through another GF health systems strengthening grant
to MOH Uganda, the MoH is strengthening the capacity of Village Health teams
(VHT) to identify and support treatment supporters for TB patients. Expanding the
coverage of VHTs and strengthening their capacity to support TB patients will
complement the support provided by sub-county health workers and improve
treatment outcomes while reducing the risk of development of drug resistant TB. The
NTLP will proactively monitor the VHT and sub-county health workers related
activities to ensure that the TB community activities are effectively implemented.
The MoH is partnering with Makerere University School of Public Health (MakSPH) to
conduct the TB prevalence survey. A Memorandum of Understanding (MoU) was
signed between MoH and MakSPH. The MoH fast tracked procurement of equipment
and by end of August 2013, all the equipment had been delivered to MoH except the
Xrays which are expected in September 2013. Technical assistance was received
from WHO-Geneva and by end of August 2013, preparations for the survey were in
final stages and the study was scheduled to start in October 2013.
The NTLP received technical assistance from international partners to complete the
PMDT guidelines, the M&E tools and the training materials. Further, the NTLP
received technical assistance from partners on the architectural and structural
requirements that were needed to remodel Mulago National Referral Hospital MDRTB Unit. Mulago and Kitgum hospital MDR-TB Units were remodelled by partners.
More staff was recruited for Mulago, Kitgum and Mbarara hospitals with support from
partners. Staff at NTLP and 09 MDR treatment facilities were trained on PMDT with

health cadre who links the health facilities to the community

Uganda TB and HIV Concept Note

15 October, 2014 55

Risk of diverting funds for social

support and transport refund to
patients to unintended beneficiaries
and delays in procurement for
service providers

support from partners. The 09 MDR treatment facilities are currently treating and
following up MDR patients. Five additional facilities are being prepared to treat MDR
patients.
The NTLP presented to GF secretariat a concept on the Management of living
support (Food and Transport refund) for MDR patients, outlining internal controls to
ensure that intended beneficiaries receive the support. The concept was approved by
the GF on 30 July 2013. (Annex 8)

B. Financial absorption was generally low during the first 12 months of implementation. The cumulative cash outflow
after one year of implementation was US$ 4,179,783 against a cumulative budget of US$ 12,788,524. This
represented a ratio of cash outflow versus budget of 33%. The cash balance as of 31 December 2012 was US$
2,069,548. The major factors that contributed to low absorption are discussed in the table below with actions that
were taken in phase I TB SSF or will be taken during Phase II TB SSF to improve absorption.
Issues

Action taken

Procurement of medicines and their

associated procurement and supply
management costs which comprised 64%
of the budget for year 1 delayed because
of delayed approval of the procurement
and supply management (PSM) plan. This
delayed procurement of additional drugs
using grant funds.

The country will soon (before end of December 2013) be submitting a GF

country profile which covers procurement of commodities related to the three
diseases (HIV, Malaria and TB). The program anticipates that the country
profile for the year 2014 will be submitted and approved before signing of the
Phase II Grant. This will help to reduce delays in procurement.

Late submission of the progress update

and disbursement request report for June
2012, submitted in January 2013. This
contributed to delays in disbursement of
funds from GF to the PR.

The late submission of PUDR has been recognized by the PR as a weakness

and the PR is improving systems to have the reports submitted on time.

Disbursement
of
monitoring
and
evaluation (M&E) funds which, accounted
for 17% of year 1 budget was frozen due
to misuse of funds.

MoH has started putting in place measures to address the related weaknesses
in accountability of funds.

There were cases of misuse of funds

related
to
trainings,
supervision,
communication, fuel, perdiem, radio
messages and talk shows in another grant
managed by MoH.

These activities have been reintroduced in phase II TB SSF as they are

critically needed to improve program performance.

In addition, the newly recruited PSM local expert at the Focal Coordination
Office (FCO) will fast track PSM issues as soon as they arise and thus reduce
the delays in making decisions that affect procurement of medicines and other
commodities.

For Phase II TB SSF, the country will identify a non-public sector sub-recipient
with adequate internal controls to manage the funds for the risk prone
activities.

In the interim, MoFPED, MoH, and the

Global Fund agreed that the PR engages
in reallocating funding meant for such
budget
items.
The
process
of
reprogramming further delayed the
disbursement.
Part of the M&E funds (US$ 881,858 for
year 1) was meant to support the TB
prevalence survey. Half of these funds
were disbursed to the PR, however,
delays in finalizing the protocol of the TB
prevalence survey, selection of the survey
coordinator and contracting of the School
of Public Health to lead the survey, have
resulted in zero absorption of the funds in
Uganda TB and HIV Concept Note

Since December 2012, progress was made: an MoU was signed with the
School of Public Health, the survey protocol was finalize and teams staff for
the survey were recruited. Preparations for the prevalence survey are in the
final stages and the field activities are expected to start in October 2013. Once
completed, this activity will not affect absorption in Phase II.

15 October, 2014 56

year 1.
Delays by the PR in addressing conditions
precedent (CPs) relating to programmatic
interventions (MDR-TB, training, M&E
etc.) contributed to low absorption of
funds.

The CPs relating to programmatic interventions have been addressed s . The

and the program expects smooth implementation of the second phase without
further delayed disbursements.

CORE TABLES, CCM ELIGIBILITY AND ENDORSEMENT OF THE CONCEPT NOTE

Before submitting the concept note, ensure that all the core tables, CCM eligibility and
endorsement of the concept note shown below have been filled in using the online grant
management platform or, in exceptional cases, attached to the application using the offline
templates provided. These documents can only be submitted by email if the applicant
receives Secretariat permission to do so.

Table 1: Financial Gap Analysis and Counterpart Financing Table

Table 2: Programmatic Gap Table(s)

Table 3: Modular Template

Table 4: List of Abbreviations and Attachments

CCM Eligibility Requirements

CCM Endorsement of Concept Note

Uganda TB and HIV Concept Note

15 October, 2014 57