HEROES - Health Systems Strengthening through Results Based Financing for improved Adolescent Health Sexual and gender-based violence (SGBV) is one of the most severe forms of gender inequality and discrimination in Uganda and remains a critical Sexual and Reproductive Health and Rights (SRHR) problem. National GBV indicators show that 56% of people in Uganda aged 15 – 49 have experienced Intimate Partner Violence (IPV), of which the far majority are women. SGBV is an issue that affects women disproportionately, as it is directly connected with the unequal distribution of power between women and men. Therefore, Amref Health Africa in Uganda, Cordaid, MIFUMI and the International Centre for Research on Women (ICRW) have combined their strengths to empower young girls, boys, and women in nine selected hard to reach districts of Uganda to fully enjoy their SRHR and live in a gender-equitable society free from SGBV.

The ‘Integrated Sexual and Reproductive Health & Rights Programme in High Burden Districts of Uganda’ (ISPHD) programme will target young girls and boys (age 10-24) and women of reproductive age (age 25-49) including underserved groups, in the districts of East Central: Kalangala, Bugiri, Mayuge, Iganga & Namayingo; and the East: Mbale, Budaka, Bukwo, and Kween.  

The partners will specifically address the lack of empowerment of young girls, boys and women regarding SRHR and SGBV decision making, low quality of SRHR and SGBV service provision, which are not well integrated, lack of action by gatekeepers and communities regarding unequal gender norms and practices and weak SGBV response systems. The COVID19 pandemic has further complicated this situation by creating fear and heightened vulnerabilities among young girls, boys, and women, having disrupted social services. 

To address these challenges, the programme works with the socio-ecological model at the individual, relational, communal, and institutional level, because evidence shows that standalone interventions do not address the synergistic nature of SRHR violations and SGBV. Partners invest in the empowerment of young girls, boys and women regarding SRHR/SGBV, strengthen SRHR/SGBV service delivery, work with gatekeepers to reject gender negative norms and practices, and enhance access to justice. Throughout ISPHD, a gender transformative approach will be used.

The objectives are: (i) Better information and greater freedom of choice for young people about their sexuality; (ii) Better public and private healthcare for family planning, pregnancy and childbirth, including post abortion care(PAC); (iii) More respect for sexual and reproductive rights for all; (iv) Enabling environment for young girls and women's elimination of violence against girls and women.

To achieve these objectives, key evidence-based approaches have been selected. One of them is the delivery of rights-based, comprehensive, and transformative SRHR education that includes discussions on gender norms and roles. Another is health systems strengthening through the fully functional site model to facilitate SRHR/SGBV care integration at all service delivery points (SDPs). A third key approach is results-based financing, which uses contracting to formalize the relationship between health system actors and will link payments to results, which are defined in quantity, quality, and client satisfaction terms. Also, the programme will apply value clarification processes to challenge and reject gender negative norms and practices. Alongside the SRHR/SGBV interventions, the programme will integrate interventions to address COVID19 and its impact on the overall SRHR/SGBV landscape in target districts.

Youth leadership and women’s leadership is a core element of this programme, because ‘nothing about us, without us’.  Therefore, Amref Health Africa in Uganda and partners work closely together with young girls and boys and women from the target districts to design and lead the interventions, but they also have a central role in monitoring and research. Next to this, there is close collaboration with district duty bearers, CSOs, Ministries of Health, Gender, Education and Justice, implementing partners of similar projects such as the SRHR Alliance, UNFPA, and UN Women. The programme is aligned to the goals and objectives of target district sector strategic plans, the National Development Plan (NDP III), and the Multi-Annual Country Strategy(MACS) of the Netherlands Embassy in Uganda. Outcome 2: Increased uptake & quality of SRHR-SGBV services by hard to reach groups. The project will address the systemic challenges of the healthcare system in the nine selected districts. Project interventions will address the identified gaps across all building blocks of the health system including service delivery, health workforce, health information systems and technology, essential medicines and other supplies, leadership and governance, infrastructure, community engagement, and health care financing (see details under section 7.3). The aim is to increase demand and improve the quality of SRH and SGVB services which in turn will increase service utilization especially for young girls, boys, and women in hard-to-reach areas. The programme will reach 890,000 people in nine hard to reach and currently underserved districts. The primary targets are young boys and girls (aged 10-24) in and out of school and women of reproductive age (15-49). This group is targeted because it bears the highest burden of SRHR violations and SGBV. More specifically, the programme will focus on ensuring that adolescent girls and young women (10-24) are reached because they distinctly face harmful practices yet they are disempowered to address them on their own. The ISPHD programme will conduct a Knowledge Attitude and Practice (KAP) survey coupled with age disaggregated gender analysis to ensure the strategic needs and practical needs of these groups (programme impact groups) are better understood and integrated in the content of the different strategies /interventions that will be undertaken or implemented.   

Secondary target groups will include a diverse group of persons who relate to young girls, boys, and women. Men and boys (10-24, 25+) will be targeted because they are the primary dischargers of power against women and girls.  Other immediate relations such as peers, mothers, grandmothers, and family members will be targeted because they discharge pressures on young girls, boys, and women and directly affect what happens to them.   Social influencers:  the programme will target social influencers such as opinion leaders, village health team members, market vendors, boda-boda riders, bar and hotel owners, traditional sex educators (Ssengas); women and youth group leaders, media personalities, local celebrities, and politicians.  Social influencers are important as they are vehicles of opinions, myths, and misconceptions regarding SRHR and may be perpetrators of SRHR violations or protectors of SRHR of young people. Gatekeepers: The programme will also target cultural and religious custodians such as cultural and religious leaders, teachers, and heads of institutions, political leaders. Targeting gatekeepers will be critical as the potential and opportunity to transform the current cultures into those that promote SRHR for young peoples. Duty bearers/service providers. Duty bearers include the police, health workers, family, community development workers, teachers, judicial officers, and district councillors, local government leaders both political and technical, will be targeted because they have the obligated duty to ensure young people’s wellbeing and rights are respected