Strenghtening Sustainable Primary Healthcare and Maternal-Child Health Systems (SUSTAIN PHC) in Kosike, Uganda

Organisation: Sign of Hope e.V.
Partner organisation in partner country: None

An expectant mother's blood pressure is measured by a midwife during ante natal clinic outreach

Situation:

Amudat District in Uganda’s Karamoja region is a remote, arid, and highly marginalized area, home primarily to the Pokot pastoralist community. Extreme poverty, climate shocks (recurrent droughts, floods, and pest outbreaks), insecurity, and harmful cultural practices severely undermine livelihoods and health outcomes—especially for women and children. Access to healthcare is limited by long distances, poor roads, seasonal flooding, and insecurity, while malnutrition and preventable diseases remain widespread.

The Kosike Health Centre has significantly improved access to care in the project region, yet over a third of the population still lives far beyond its reach. Health indicators remain fragile, with low antenatal attendance, high malaria burden, poor immunization coverage, and malnutrition rates above emergency thresholds. The local health system is understaffed, under-resourced, and heavily donor-dependent, with weak referral capacity and limited digital and community-based health mechanisms. Despite progress, the situation on the ground remains one of chronic humanitarian stress, where environmental shocks, poverty, and system gaps continue to put pregnant women and young children at high risk.

Objectives:

The project represents the third phase of the development of the health centre and places a strategic focus on sustainability. Its aim is not only to secure the progress already achieved in primary healthcare (PHC) and in maternal, newborn, and child health (MNCH), but also to further strengthen these gains for long-term impact. Building on the findings of the final EKFS evaluation, this phase focuses on financial diversification, institutional transition, and more efficient service delivery models to ensure the long-term viability of Kosike Health Centre III and its affiliated Lower Level Health Units.

The overall objective is to improve the well-being of vulnerable communities in Amudat District by providing high-quality, accessible, and sustainable primary healthcare as well as maternal and child health services. This will be achieved through innovative financing approaches, community-driven solutions, and the strengthening of local health systems.

Specifically, the project pursues three interrelated objectives:

To strengthen the sustainable delivery of equitable and high-quality primary healthcare and MNCH services in Kosike and the surrounding communities.
To increase the utilization of integrated promotive, preventive, and curative PHC services, particularly among marginalized and underserved populations.
To ensure long-term access to and continuity of MNCH services through strengthened health systems and locally adapted sustainability mechanisms.

Indicators:

Outcome Indicators

Reduction of 35% – from 56.6% – in maternal and child morbidity cases (representing 771 cases based on WRA and CU5) by the end of 2027.
By the end of 2026, there is a 25% decrease – from 55% – (i.e., only 2,549 people report common illnesses/conditions) in the incidence and prevalence of common illnesses and conditions (e.g., respiratory infections, diarrhoea, and malaria).
On a continuous basis, 6,372 patients (2,124 per year) adhere to prescribed treatment regimens for acute and chronic conditions.
Each year, 2,549 patients report satisfaction with the quality and accessibility of primary health care services.
By the end of each year, 51 children are fully immunized according to the national immunization schedule.
By 2027, 8,496 persons are covered by essential health services and financial protection.
By 2027, at least 40,000 Euros of total health expenditure is paid directly by households.
By the end of 2027, 5,522 persons are covered by health insurance schemes (community-based health insurance).

Output 1 - Sustainable, equitable, and quality healthcare in Kosike and surroundings is improved.

By the end of 2027, 804 registered pregnant women access Skilled Birth Attendance (SBA) services at the facility.
504 expectant women access first ANC services from Kosike HC and its outreach programs during the first trimester.
By the end of 2027, 462 expectant women attend the fourth ANC visit at Kosike HC III.
By the end of 2027, 672 women delivering at Kosike HC III receive postnatal care from trained health staff within 2 days.
By the end of 2027, 154 children aged 12-23 months accessing services from Kosike HC and its outreach programs receive all basic vaccinations; at least 224 receive DPT3.
Each year, 698 children under five with symptoms of childhood illness receive advice or treatment from Kosike health facility and outreach services.
At least 160 pregnant women are tested for HIV during their first ANC visit annually.
At least 110 pregnant women attending their first ANC visit at the facility receive the third IPT (IPT3) dose each year.
630 sick children are seen by Village Health Teams (VHTs) and receive treatment for fever within 24 hours.
840 children receive nutritional supplements (e.g., vitamin A, iron).

Output 2 - Utilization of integrated, quality promotive, preventive, and curative primary healthcare among marginalized communities in Kosike and surroundings is increased.

6,797 people have access to healthcare facilities within a reasonable distance and regularly use healthcare services.
An e-Health platform is designed, established, and operationalized to strengthen health care access for at least 3,500 individuals per year.
By the end of 2025, at least 3 strategic satellite outreach sites are set up in hard-to-reach and marginalized areas, reaching at least 12,000 people annually.
A 66% utilization rate (representing 1,869 people) for new outpatient department (OPD) attendance is reached and sustained every 6 months.
At least 5,522 confirmed cases of communicable diseases (focused on malaria, diarrhoea, respiratory infections, TB, and HIV/AIDS) are treated annually (directly or via referral).
5,608 individuals are screened annually for common non-communicable diseases (e.g., hypertension, diabetes, mental health, malnutrition) with 100% of those needing treatment receiving it (directly or via referral).
Annually, at least 2,832 people are reached with promotive and preventive health messages.
By the end of 2025, one fully equipped ambulance is procured and commissioned.
Each year, 120 target persons requiring emergency referral receive timely referral services.
6,372 individuals requiring follow-up adhere to scheduled visits for monitoring recovery and treatment adherence.
7,647 patients report satisfaction with the quality of care received.

Output 3 - Long-term access and continuity of MNCH services through strengthened health systems and locally adapted sustainability mechanisms is ensured.

By the end of 2027, Kosike HC III establishes and operationalizes at least one viable Health Enterprise Approach (HEA) that generates income to support the sustainability of the health center.
By the end of 2026, 2,500 Euros income is generated from outreaches and HEA (e.g., laboratory tests, ultrasound scanning, ambulance services, private rooms, etc.), disaggregated by income source.
Kosike HC III receives at least 8,000 Euros annually from performance-based funding (PBF) from the Ministry of Health to support its operations.
A Community Health Insurance Scheme (CHIS) is developed and operationalized in Kosike HC III and all 8 LLHUs of the Diocese of Moroto, reaching at least 2,500 people by the end of 2027.
The Kosike HC III Management Committee/Board holds quarterly meetings annually, consistently attended by at least 9 members.
By the end of 2026, Kosike HC III uses health information systems for patient management and data reporting at all stages of patient care.
Kosike HC III is consistently stocked with essential medicines, equipment, and supplies.
Kosike HC III undergoes at least one annual quality of care assessment.
By the end of 2025, 60 staff from Kosike HC III and the 8 LLHUs of the Diocese of Moroto are trained on e-Health and its applications.
By the end of 2025, 22 staff are trained on and use the IMCI case management form.
54 staff are trained in Infection Prevention and Control protocols.
80 Village Health Team (VHT) members are trained and supported to conduct community surveillance, identify, and refer cases.
80 VHT members are trained and equipped to implement the e-Health approach.
80 VHT members are trained and supported to work as Community Health Referral Agents (CHRA).

Measures:

Activities

Introduction of sustainable health financing through the implementation of Community-Based Health Insurance (CBHI), User Fee Models (UFM), and Health Enterprise Approaches (HEA) to establish predictable revenue streams, reduce reliance on external donor funding, and ensure the long-term financial sustainability of Kosike HC III. The project also implements institutional sustainability and transition planning, which remains a priority, and will gradually transfer governance and financial management of Kosike HC III to the Diocese of Moroto. This includes a phased handover of management contracts, securing increased government support, and implementing institutionalized cost-recovery mechanisms to strengthen long-term ownership and operational sustainability of the facility.
Introduction of digital health and data systems by improving data-driven decision-making and efficiency through the adoption and integration of e-Community Health Information Systems (e-CHIS), enabling health staff, community health workers, and Village Health Teams (VHTs) to track real-time health data and use it to optimize service delivery.
Strengthening the health workforce and its retention by expanding and supporting Village Health Teams (VHTs) and Community Health Referral Agents (CHRA) through targeted training, facilitation, and mentorship, enabling effective implementation of integrated community case surveillance, referral systems, and adherence to IMCI protocols, thus improving early detection and response to maternal and child health issues. The project also ensures continuous supportive supervision, mentoring, and on-the-job coaching for health workers, enhancing clinical competencies, compliance with Infection Prevention and Control (IPC) protocols, and the integration of e-health approaches into service delivery.
Introduction of optimized service delivery models for cost-effective and high-impact health services by improving outreach strategies and service delivery models, identifying and establishing strategic high-impact outreach sites, and rationalizing outreach services to maximize efficiency and coverage. This includes integrating telehealth and e-health platforms to improve access to outpatient services and strengthen referral pathways between communities and health facilities.
Sustainable management of essential medicines and supply chains by improving supply chain management, forecasting, procurement, and stock control, ensuring uninterrupted availability of life-saving treatments for maternal, newborn, and child health (MNCH) as well as communicable diseases.

Sustainability:

Sustainability

Sustainability is a central pillar of the project and is firmly embedded in the design and implementation of Kosike Health Centre III (KHCIII) to ensure long-term functionality, local ownership, and impact beyond EKFS funding. The project adopts an integrated, multidimensional approach that addresses the social, financial, institutional, and environmental challenges of this historically marginalized region.

Social Sustainability: Through continuous community engagement and culturally sensitive health promotion, harmful health practices are addressed. Proven models such as the Extended Parallel Process Model (EPPM) help to change health behaviors, build trust in conventional healthcare, and increase service utilization, particularly in maternal and child health. Decentralized primary healthcare models with outreach services and Village Health Teams (VHTs) provide education, surveillance, and referrals even in remote areas. The facility also serves as a safe space for dialogue and peacebuilding, strengthening social cohesion and support for the health system.

Financial Sustainability: Local revenue-generation mechanisms are combined with external funding sources. A user fee model is implemented and gradually extended to outreach services, supported by community participation and economic empowerment initiatives to ensure long-term viability. KHCIII also leverages government-supported primary healthcare and results-based financing (RBF) schemes to improve service delivery. Additionally, a Community-Based Health Insurance (CBHI) scheme is introduced to enable risk pooling and financial protection for low-income households. A Health Enterprise Approach (HEA) with fee-based services—such as ambulance referrals, laboratory and ultrasound diagnostics—and a nutrition-sensitive agricultural project provide supplementary income and support operational costs.

Systems Sustainability: Institutional capacity is strengthened, staff retention is promoted, and the health centre is integrated into public systems. High-quality staff housing, infrastructure, and transport improve personnel well-being. Governance and management are reinforced through partnerships with government and technical partners such as FMU, CUAMM, and the Ministry of Health. A comprehensive training plan for 60 healthcare professionals and 80 VHT members ensures clinical competence, e-health utilization, community surveillance, referral management, and health education.

Environmental Sustainability: The facility is fully solar-powered, construction activities were environmentally assessed and planned, the compound is fenced, and landscaping supports biodiversity and passive cooling. An on-site incinerator ensures safe disposal of medical waste. The community is sensitized to resource conservation, and agricultural activities are guided by soil testing to ensure sustainable land use.

Special features:

The project is distinguished by its holistic approach, integrating social, financial, institutional, and environmental sustainability. Key features include decentralized primary healthcare with outreach services and Village Health Teams, the introduction of digital health and data systems (e-Health), innovative financing models such as Community-Based Health Insurance and Health Enterprise Approaches, comprehensive training and mentoring programs for healthcare staff, as well as environmental sustainability measures like solar energy, resource-efficient agriculture, and safe disposal of medical waste. This approach not only improves healthcare delivery in a historically marginalized region but also strengthens long-term community ownership and resilience.