A nurse giving iron tablets to a pregnant women during her routine antenatal care visit at Jinja Regional Referral Hospital. Photo credit: URC

Regional Health Integration to Enhance Services in East Central Uganda Activity (RHITES-EC)

The Challenge

The East Central region of Uganda, home to 4.4 million people, faces unique challenges due to its waterside geography: seven of the 12 EC districts are bordered by water. Not only does the geography impede access to health facilities and create breeding grounds for mosquitoes, the small-scale subsistence and commercial fishing in the area attracts seasonal migrants from across Uganda and neighboring Kenya, which poses a challenge for client follow-up and infectious disease control.

The burden of disease – including HIV, HIV/tuberculosis (TB) co-infections, and malaria – varies amongst districts, though malaria remains a leading cause of morbidity and mortality for children under five, pregnant women, and people living with HIV/AIDS. Immunization coverage for children 12-23 months is low and prevalence of moderate to severe anemia is high.


USAID’s RHITES-EC is supporting Uganda’s Ministry of Health to improve regional health outcomes by increasing the use of high-quality health care services within 12 districts in EC Uganda. The activity works to:

  • Increase demand, access, availability, and quality of health services;
  • Expand the availability of resources for public sector health services;
  • Strengthen systems for management, information, and health service delivery; and
  • Increase the adoption of healthy behaviors and practices in households and communities.
Warriors’ Camps – The fight to achieve viral load suppression among HIV-Positive adolescents in East Central Uganda

URC and its partners share the vision that these goals are achievable through an integrated service delivery approach that prioritizes gender and youth-friendly services, local capacity development for sustainability, learning and adaptation, and improved district stewardship. Key activity strategies include working to establish:

  • Quality services at all levels of care, progressively and appropriately integrated at facility and community levels;
  • Targeted service delivery mechanisms to reach marginalized vulnerable and underserved populations and effective linkages and referrals at all levels;
  • Quality improvement methods and approaches institutionalized at district, sub-district, and facility levels and improved transparency and accountability in managing decentralized service delivery;
  • Improved/expanded laboratory diagnostic capabilities and healthcare infrastructure and equipment; and
  • Engaged national, district, and community leadership.


RHITES-EC is building district capacity to manage and deliver quality health services at both facility and community levels. The activity has made significant progress on its goals and, in many cases, has met or exceeded them.

HIV/AIDS: The activity has surpassed annual targets for HIV case finding and treatment initiation, bringing Uganda closer to achieving control of the HIV epidemic, partly due to its successes with index client testing as well as strong client and peer support programs that help link clients to care on the same day as diagnosis. RHITES-EC has supported national efforts to decrease HIV/TB coinfection by successfully rolling out TB preventative therapy to eligible patients.

Malaria: By supporting health facilities implement test and treat policies, the proportion of malaria cases treated for malaria based on positive malaria results increased from 60% at the start of the activity to 98% four years later. The activity also helped decrease the number of patients being wrongly treated for malaria and taking artemisinin-based combination therapy (ACT) from 70% to 1.9% in the activity’s first four years, significantly reducing ACT waste from inappropriate use.

Maternal and child health: RHITES-EC has improved maternal and newborn survival through quality improvement methods, supportive supervision, clinical mentorships, and increased community engagement with village health teams to strengthen linkages between facilities and communities. And by addressing skills gaps, the successful resuscitation of babies with birth asphyxia increased from 20% to 89% in the activity’s first four years. Also, the percentage of maternal deaths that were audited – a critical step for identifying and addressing gaps in quality of care – increased from 13.9% to 97%.

Nutrition: Implementation of nutrition assessment, counseling, and support (NACS) through procurement and distribution of essential nutrition equipment and job aids has yielded results: Nutrition assessment for children 0-23 months seen at outpatient departments improved in the activity’s first four years from 7.2% to 63.4%, exceeding a target of 45%. At the same time, the burden of acute malnutrition at the facility level decreased from 3.3% in 2017 to 1.1%, compared with a target of 1.5%.

Likewise, nutrition assessments among lactating women increased from 10.4% to 70.4% in the activity’s first four years, exceeding the target of 55%; NACS in HIV clinics has been sustained above the annual target of 90%.

And RHITES-EC’s use of innovative quality improvement methods coupled with implementation science resulted in a doubling of access to iron-folic acid supplements among pregnant women attending antenatal care clinics in intervention districts compared to control districts.

Supply Chain: RHITES-EC works to strengthen supply chain and logistics management to ensure improved availability and access to essential medicines and health supplies. Key achievements include:

  • Improved stock management of essential medicines – As a result of Supervision, Performance Assessment, and Recognition Strategy (SPARS) supply chain capacity-building activities, SPARS scores increased from 44% (11/25) in December 2017 to 75% (18.7/25) by September 2021.
  • Improved availability of uninterrupted supply of HIV care commodities – through timely ordering at 141 antiretroviral treatment (ART) accredited sites, which increased from 90% in 2016 to 100% in 2021.
  • Improved availability of essential medicines and supplies – e.g., decrease in stockouts of insecticide-treated nets (ITNs) at health facilities from 60% in 2016 to 20% in September 2021.

TB: RHITES-EC supports districts and facilities in implementing national TB program strategies, resulting in an improvement in the TB case notification rate from 92/100,000 at activity start to 100/100,000 beginning in 2018.

Water/Sanitation/Hygiene (WASH): The activity has supported facility- and community-level WASH improvement initiatives through capacity-building activities. All high-volume facilities and the 34 PEPFAR Health Center IIs have been trained in infection prevention and control. A total of 780 outdoor handwashing facilities and assorted facility WASH information, education, and communication materials were distributed to all high-volume facilities and the PEPFAR HC IIs within the region.

Through targeted home-to-home WASH improvement campaigns and aligned social behavior change activities, the percentage of individuals who wash their hands with soap after visiting the latrine has improved from 60.5% to 80.7%.

And reporting on community indicators – such as safe latrine coverage and hand washing facilities – in the national Health Management Information System has improved from 27.8% to a record-high of 90.1% in the last three years.




Adolescent Health, COVID-19, Health Service Delivery, HIV/AIDS, Infectious Diseases, Malaria, Maternal, Newborn, and Child Health, Nutrition, Quality Health Systems, Social and Behavior Change, Supply Chain, Tuberculosis, and Water, Sanitation, and Hygiene


AIDS Orphans Education Trust Health Centre (AOET), Children’s AIDS Fund Uganda (CAFU), Communication for Development Foundation Uganda (CDFU), Iganga Islamic Medical Center (IIMC), Jinja Regional Referral Hospital, Makerere University Joint AIDS Program (MJAP), St. Benedict's Health Centre III, St. Francis Hospital, Buluba, The AIDS Support Organization (TASO), and Youth Alive