Findings Against the Evaluation Criteria

The preceding sections established what the intervention delivered against its logical framework. This section interprets that evidence against the OECD-DAC evaluation criteria and the complementary humanitarian criteria specified in the terms of reference: relevance, effectiveness, efficiency, impact, sustainability, connectivity/coherence, coordination, coverage, ownership and participation, and cross-cutting issues. Each criterion is assessed through the triangulation of project monitoring data, the comparative baseline–endline household surveys (baseline n=815; endline n=796), and qualitative evidence from Key Informant Interviews (KIIs) and Focus Group Discussions (FGDs), and is examined comparatively across the three implementation contexts of Kampala, Kyaka II and Adjumani.

Relevance (Adequacy and Relevance)

The evaluation finds the intervention to have been highly relevant. Its design, objectives and modalities were closely aligned with the documented health and protection needs of refugee populations in the three target areas, with the policy framework governing refugee health in Uganda, and with the strategic priorities of the donor and implementing consortium. Relevance was, moreover, actively maintained throughout implementation through context-sensitive adaptation rather than fixed at design stage alone.

Alignment with refugee needs

The intervention responded directly to needs that were independently documented in the project’s diagnostic assessments and corroborated by the baseline survey. Across all three sites, refugees faced compounding barriers to health: medicine stock-outs, out-of-pocket costs, distance to services, limited specialist and diagnostic capacity, high psychosocial distress, and weak, stigmatized pathways for survivors of sexual and gender-based violence (SGBV). The baseline confirmed the salience of these barriers, with high proportions of households reporting out-of-pocket health expenditure (83.5% in Adjumani, 56.2% in Kyaka II, 53.8% in Kampala) and substantial difficulties accessing clinicians (42.7% in Adjumani). The decision to combine essential medicines, mobile outreach, specialized referral, MHPSS and survivor-centered SGBV response within a single integrated model was therefore well-matched to a needs profile in which health, protection and psychosocial vulnerabilities were tightly interlinked.

Crucially, relevance was differentiated by context. In Kyaka II, the emphasis on settlement outreach, infectious disease prevention, maternal and child health, and VHT-based first contact addressed a geographically dispersed population for whom distance and intermittent service coverage were the dominant constraints. In Adjumani, the intervention addressed the realities of a large, remote settlement environment characterized by recurrent outbreak risk, weak specialist availability and high unmet psychosocial need. In Kampala, the intervention progressively reoriented toward the distinct profile of urban refugees — fragmented and privatized service access, chronic and non-communicable disease, orthopedic and mental-health conditions, and complex protection vulnerabilities linked to poverty and social isolation. The capacity of the consortium to recognize and respond to these divergent profiles is a central reason the evaluation judges relevance to be high. The one area where the standard design under-fitted local need was the essential medicines model in Kampala, which struggled to meet specialized and chronic pharmaceutical demand, a relevance gap the evaluation flags for future design.

Alignment with national policies and frameworks

The intervention was well-aligned with Uganda’s progressive refugee policy environment and with national health policy. By delivering through public health facilities, District Health Offices in Kyegegwa and Adjumani, Kampala Capital City Authority (KCCA), Village Health Teams and the Office of the Prime Minister (OPM) coordination architecture, the project operated within — rather than parallel to — the national systems that govern refugee inclusion under Uganda’s settlement and self-reliance model and the Health Sector integration of refugees. Joint needs assessments with KCCA and the District Health Offices, alignment of distribution with OPM, OCHA and UNFPA guidance, and the harmonization of referral protocols with Ministry of Health (MoH) standards demonstrate deliberate policy coherence. This alignment reinforced both the legitimacy and the sustainability potential of the intervention.

Design coherence (log frame and theory of change)

The internal logic of the intervention was coherent. The four results areas — health services (R1), community capacity and GBV prevention (R2), awareness and advocacy (R3), and participation and accountability (R4) — map onto a plausible theory of change in which improved service availability, strengthened community systems, increased awareness and functioning accountability mechanisms jointly contribute to the specific objective of improved health and SRH status and reduced SGBV. Indicators were, in most cases, specific and measurable, and the baseline–endline architecture provided a credible means of tracking change. The principal design weaknesses were a small number of indicators framed primarily at the output level (limiting outcome attribution) and the absence of indicators capable of capturing the chronic-care needs that proved material in Kampala. These are refinements rather than fundamental flaws.

Complementarity with other actors

The intervention was designed to complement, not duplicate, the wider humanitarian and public-health architecture. By channeling specialized referrals to national referral hospitals (including Mulago), coordinating with AIRD on logistics, linking with police and protection actors on SGBV case management, and operating through OPM/OCHA/UNFPA-guided systems, the project positioned itself as a gap-filling and system-reinforcing actor. This complementarity strengthened relevance by ensuring that project resources were directed toward documented gaps — diagnostic access, MHPSS, survivor support and accountability — rather than toward services already adequately provided by others.

Effectiveness

The evaluation finds the intervention to have been highly effective. The overwhelming majority of logical-framework targets were met or substantially exceeded, frequently by large margins, and the specific objective was, on the available evidence, largely achieved. Effectiveness was strongest in service delivery, outreach, MHPSS and survivor support, and accountability; it was more qualified regarding the durability of capacity gains and the conversion of awareness and service contacts into sustained outcomes, particularly in the urban context.

Summary results matrix

The following matrix consolidates performance against the principal indicators, drawing on the final project report and triangulated evidence.

Result	Indicator (verbatim from matrix)	Target (verbatim from matrix)	Baseline (LB)	Verification Sources	Achievement	Performance	Triangulating Evidence
R1	I.O.V.1.R.1: The health needs of refugees are met at medical access points and through mobile health teams in the three locations.	Target 1: At least 10,600 refugees (6,500 Kyaka II, 3,000 Kampala, 1,100 Adjumani) (60% women and children under 5) receive medical care and medicines at health centres. Target 2: 19,200 people (60% women and children) treated by 240 mobile health teams deployed (80 per location).	At project start, 0 refugees treated. In 2022, FM-E and partners treated 13,900 people (7,506 women) in health centres and through 97 mobile teams in Adjumani, Kyaka II and Kampala.	F.V.1 Record of unmet demand for medicines. F.V.2 Records of medicines/medical supplies delivery. F.V.3 Photographic dossier. F.V.4 Record of care at health centres. F.V.5 Record of persons treated by mobile teams.	T1: 23,596 refugees received medical care and medicines. T2: 24,115 people served by 243 mobile health teams.	T1: 223% – substantially exceeded T2: 126% – exceeded	Out-of-pocket spending fell in Kyaka II (56.2→38.2%) and Adjumani (83.5→66.0%); first-contact VHT use rose in Kyaka II (9.0→36.1%).
R1	I.O.V.2.R.1: Refugees in settlements requiring reliable testing, analysis and diagnosis are referred to the national referral hospital in Kampala for appropriate and safe care.	Target: At least 1,500 refugees referred (60% women and children under 5).	At project start, 0 refugees referred. In 2022, 5,683 people (2,632 women) were referred from Adjumani, Kyaka II and Kampala settlements.	F.V.1 Reports of medical tests performed. F.V.2 Register of refugees referred to the national referral hospital in Kampala.	1,780 specialised referrals for testing/diagnosis.	119% – exceeded	Access-to-clinician difficulty fell in Adjumani (42.7→30.9%); KII confirmation.
R1	I.O.V.3.R.1: Quality of care to refugees in Uganda improved through training of health professionals and dissemination of the action protocol and standardised procedures based on gender and human rights approaches.	Goal 1: 75% of the 60 health professionals (20 per location, 50% women) participate in specialisation courses and apply the knowledge acquired by the end of the intervention. Goal 2: One action protocol disseminated among healthcare personnel.	Selected health professionals had not yet attended specialisation courses on project topics. In 2022, FM-E trained staff in Kyaka II on information systems, rational use of medicines, GBV referral systems and mental health quality standards; Kampala focused on infectious disease prevention (Ebola, COVID-19); no training in Adjumani.	F.V.1 Training team report. F.V.2 Teaching materials. F.V.3 List of participants. F.V.4 Pre/post-test knowledge assessment. F.V.5 Photographic dossier. F.V.6 Copy of validated Action Protocol. F.V.7 Report on protocol dissemination meetings.	G1: 241 health personnel trained. G2: 1 protocol disseminated + complementary SOPs.	G1: 402% – substantially exceeded G2: 100% – met	GBV-competent responders doubled in Kyaka II (KII); harmonised case management across actors.
R1	I.O.V.4.R.1: Refugees have access to quality MHPSS services to improve mental health through psychosocial therapy sessions and mobile teams.	Goal 1: 320 people served (60% women and minors) in at least 60 sessions. Target 2: 1,800 refugees (60% women and minors) access MHPSS through 240 mobile teams.	No mobile mental health mechanisms currently in any project locations. Some NGOs offer MHPSS services to refugees, but reach is very limited.	F.V.1 Record of visits and care by mobile mental health units. F.V.2 Photographic dossier. F.V.3 Report on psychosocial therapy sessions. F.V.4 List of participants in therapy sessions.	G1: 1,129 people reached with psychosocial therapy. T2: 6,279 refugees accessed MHPSS services.	G1: 353% – substantially exceeded T2: 349% – substantially exceeded	High pre-existing unmet need, especially Kampala; endline MHPSS demand confirmed by KIIs.
R2	I.O.V.1.R.2: After the first quarter, capacities of community leaders and members of community committees in prevention, mediation and referral of GBV cases have been strengthened.	Goal 1: At least 80% of the 60 community leaders (50% women) participating in training modules are familiar with relevant techniques for prevention, mediation and referral of GBV cases. Goal 2: Six community committees (two per location) established with a work plan for resolving cases of violence against women.	Selected community leaders had not yet received training on prevention, mediation and referral techniques for GBV survivors. In 2022, Farmamundi trained leaders in Kyaka II on gender equality and human rights, GBV identification, referral services, infectious-disease prevention and stigma reduction/interculturality. No training conducted in Kampala/Adjumani. No active community committees at start.	F.V.1 Training programme. F.V.2 Training team report. F.V.3 List of participants. F.V.4 Pre/post-test evaluation. F.V.5 Activity reports and follow-up on GBV cases by committees. F.V.6 Committee work plan. F.V.7 Photographic dossier.	G1: 62 community leaders trained and applying knowledge. G2: 8 community committees established.	G1: ~Met (62/60, ≥80% threshold) G2: 133% – exceeded	Functioning as referral/awareness multipliers; operational identification/referral/feedback role.
R2	I.O.V.2.R.2: Refugee populations have access to information on health promotion and SRH, gender equality, and available prevention, care and protection services for survivors of sexual and gender-based violence.	Target: 20,000 (4,500 Kampala, 11,000 Kyaka, 4,500 Adjumani) reached through information sessions by community leaders.	Despite ongoing information campaigns by FM-E, given constant flows (131,223 new refugees in Uganda in 2023) and the lack of general information in intervention areas, the refugee population does not have full access to information on health promotion, SRH, gender equality and available services for GBV survivors.	F.V.1 Activity reports and planning of awareness campaigns. F.V.2 IEC materials produced. F.V.3 Photo dossier.	22,660 people reached through awareness sessions.	113% – exceeded	Improved awareness of services/rights (endline).
R2	I.O.V.3.R.2: Improved access to personal and menstrual hygiene items and infectious-disease prevention items according to specific gender, age and diversity needs among refugee households (HHs) in vulnerable situations.	Target 1: 750 HHs receive personal hygiene kits and mosquito nets. Target 2: 750 women receive dignity kits. Target 3: 75% of refugees surveyed positively assess the quality and relevance of items for improving their health.	Due to constant arrivals at the three locations, refugee households in vulnerable situations will not yet have had full and continuous access to personal/menstrual hygiene items and infectious-disease prevention items per their specific gender, age and diversity needs.	F.V.1 Delivery and receipt records for hygiene kits, mosquito nets and dignity kits. F.V.2 Breakdown of kit contents distributed. F.V.3 Photographic dossier. F.V.4 Refugee satisfaction surveys.	T1: 875 HHs received hygiene kits. T2: 875 women received dignity kits. T3: 82% beneficiary satisfaction.	T1: 117% – exceeded T2: 117% – exceeded T3: Exceeded	82% beneficiary satisfaction; dignity/protection need addressed.
R2	I.O.V.4.R.2: Care for refugee women survivors of GBV is strengthened through access to mechanisms for psychosocial and legal redress for the restoration of violated rights.	Target 1: 450 women receive psychological assistance through 850 individual sessions and 50 group sessions. Target 2: 90 women receive legal assistance. Target 3: 75% of women surveyed positively assess the quality and relevance of psychosocial and legal services for restoration of violated rights.	At project start, care for refugee women survivors of GBV is insufficient to restore violated rights. According to UNHCR (Feb 2023), only 9% of refugee needs in Uganda are met.	F.V.1 Individual assistance and support reports. F.V.2 Record of referrals through existing protocol forms. F.V.3 Surveys of refugee women survivors of GBV.	T1: 1,443 women received psychological assistance. T2: 144 survivors received legal assistance. T3: Survivor satisfaction >75%.	T1: 321% – substantially exceeded T2: 160% – exceeded T3: Exceeded	Survivor-centred protection outcomes; satisfaction >75%.
R3	I.O.V.1.R.3: Assessments of the situation of the refugee population in Kampala, Kyaka II and Adjumani carried out from a gender and human rights perspective, highlighting the situation of GBV survivors as the main challenge.	Target: 3 assessments carried out (one per location).	To date, no assessments of the refugee population in Kampala, Kyaka II and Adjumani have been carried out from a gender and human rights perspective highlighting the situation of SGBV survivors.	F.V.1 Report on the process of preparing the assessments. F.V.2 Final document of the assessments carried out.	3 assessments completed (+ complementary studies).	100% – met	Evidence base for design/targeting.
R3	I.O.V.2.R.3: Ugandan media outlets informed about the situation, opportunities and challenges in the reception and protection system for the refugee population, especially survivors of GBV.	Goal 1: At least 20 journalists participate in the event. Goal 2: At the end of the workshop, a document with recommendations for the media is produced.	Despite the large number of refugees in the country, Ugandan media does not provide sufficient coverage or analyse the reception and protection system for refugees, especially GBV survivors.	F.V.1 Activity report. F.V.2 List of participants. F.V.3 Photographic dossier.	G1: 20 journalists engaged in media workshop. G2: Media guidance document produced.	G1: 100% – met G2: 100% – met	Media guidance document produced.
R3	I.O.V.3.R.3: Ugandan citizens participate in seminars on Refuge, Gender and Human Rights as spaces for analysis and debate, with special attention to prevention, protection and care for women survivors of sexual violence.	Goal 1: At least 100 people (50% women) participate in the seminars. Target 2: At the end of the seminar, a document with conclusions is produced for advocacy.	To date, no such seminars have been organised.	F.V.1 Activity report. F.V.2 List of participants. F.V.3 Photographic dossier.	G1: 91 participants (44 women). G2: Conclusions document produced.	G1: 91% – largely met G2: Met	Minor shortfall on reach and parity.
R3	I.O.V.4.R.3: EAC citizens expand knowledge and awareness of access to healthcare for people affected by conflict and violence in Uganda, especially refugees and GBV survivors.	Goal 1: Academic research conducted on barriers to healthcare access in EAC for people in migration processes. Target 2: 90 rights-holders (60% women) participate in awareness activities through human libraries in EAC. Goal 3: At least 70% (50% women) of rights-holders surveyed report improved knowledge of access to healthcare and underlying causes in Uganda's humanitarian crisis.	At project start, no awareness-raising activities had been carried out through human libraries in EAC on access to healthcare for vulnerable populations in Uganda.	F.V.1 List of participants. F.V.2 Research document. F.V.3 Photographic/technical report. F.V.4 Evaluation questionnaires.	G3: ≥70% participants reported improved awareness (achieved).	Met	Human Libraries/testimony advocacy.
R4	I.O.V.1.R.4: The target population participates in decision-making throughout the project through the Coordination and Monitoring Committee.	Target: At least 60 people (30 women) make up the committee, ensuring representation in terms of gender, age and origin.	At project start, the Coordination and Monitoring Committee has not yet been formed.	F.V.1 Report on selection of committee members and objectives. F.V.2 Accountability and community participation plan for local partners.	118 participants (85 women) in coordination committees.	197% – substantially exceeded	Strong gender inclusion.
R4	I.O.V.2.R.4: Learning and accountability meetings held with stakeholders throughout the project cycle, ensuring participation and protection of refugees and GBV survivors.	Target 1: At least 14 meetings with rights-holders, responsibilities and obligations. Target 2: At least 1 final feedback meeting.	At project start, no meetings have been held with rights-holders, responsibilities and obligations.	F.V.1 Community meeting reports. F.V.2 Final project assessment report. F.V.3 Lists of participants. F.V.4 Photographic dossier.	T1: 48 participatory meetings/dialogues with rights-holders. T2: Final feedback meeting held.	T1: 343% – substantially exceeded T2: Met	Dense participatory verification.
R4	I.O.V.3.R.4: The refugee population exercises its right to submit suggestions, complaints and claims (FRRM) through mechanisms that follow up, provide feedback and offer appropriate solutions to problems detected.	Goal 1: 75% of those surveyed are aware of the suggestions, complaints and claims mechanisms. Target 2: 100% of suggestions, complaints and/or claims are addressed.	At project start, 100% of complaints/claims being addressed. Despite availability, a high percentage of refugees are unaware of their right to submit suggestions/complaints due to recent arrival and distance from main service centres.	F.V.1 Quarterly reports on FRRM feedback. F.V.2 Quarterly reports on complaints/suggestions mechanisms. F.V.3 Surveys on awareness of mechanisms.	G1: ~100% of beneficiaries aware of feedback mechanisms. T2: 100% of complaints/grievances addressed.	G1: Exceeded T2: 100% – met	Interpret self-report with caution; functioning feedback loop.
R4	I.O.V.4.R.4: Humanitarian management teams strengthen institutional capacities to ensure quality management of aid to vulnerable people in Uganda, following CHS.	Goal 1: At least 80% of participants demonstrate improved capacity for quality aid management. Target 2: At least 80% of participants positively assess the relevance, quality and applicability of knowledge acquired.	AHA, Emesco and FM-E have pre-identified training needs based on current team gaps. Training plan focuses on accountability, mainstreaming cross-cutting approaches throughout the project cycle, and quality community care (CHS).	F.V.1 Training team report. F.V.2 Evaluation of participants. F.V.3 Training modules. F.V.4 Pre/post-training evaluations. F.V.5 Photographic dossier.	100% of participants with improved accountability capacity.	Exceeded	CHS embedding in partner institutions.

R1 – Health services (SRHR, MHPSS, GBV response)

R1 was the strongest result area. Service-delivery targets were exceeded by wide margins — 23,596 refugees reached with medicines (223% of target), 24,115 served through mobile teams (126%), 1,780 specialized referrals (119%), and 241 health workers trained (402%). The MHPSS sub-component is particularly notable, with psychosocial therapy reaching 353% and MHPSS service access 349% of target — a scale of over-achievement that reflects both strong delivery and the depth of unmet mental-health need exposed once services became available. SRHR and survivor-centered clinical care were strengthened through training, protocol harmonization and supply support. The qualified element of R1 is durability: capacity gains were eroded by high staff turnover, and supply support could not meet the demand for urban chronic care. Overall, R1 is judged highly effective at output and access level, with partial outcome durability.

R2 – Community capacity and GBV prevention

R2 was achieved effectively. Community awareness reached 22,660 people (113%), eight community committees were established (133%), 62 community leaders were trained, and survivor support far exceeded target (1,443 women in psychological care, 321%; 144 in legal assistance, 160%). The combination of trained community structures, awareness multipliers and direct survivor support created a coherent community-level prevention-and-response layer. The principal limitation is translating awareness and committee activity into sustained behavioural and normative change, which remains constrained by persistent stigma and structural barriers. R2 is judged highly effective, with the strongest protection-relevant results in the survivor-support stream.

R3 – Awareness and advocacy

R3 was largely achieved. The three contextual assessments, media engagement (20 journalists), academic seminar series (91 of 100 participants) and testimony-based advocacy delivered the intended awareness and advocacy outputs, with the only material shortfall being a marginal under-achievement on seminar participation and gender parity (44 women against a 50% target). Awareness-improvement targets among participants were met. In Euskadi, Farmamundi's education team complemented the field work by producing four short testimony videos — two recorded with human-book protagonists in the Basque Country and two recorded in Uganda with AHA (a lawyer working on gender-based violence) and EMESCO (a refugee from the DRC resettled in Uganda) — and used them, together with a contextual study on barriers to healthcare faced by people of African origin in Euskadi, to run "human library" sessions with nursing, medicine and pharmacy students and to brief Basque health professionals and institutions, thereby extending the project's advocacy reach from the field into the donor public and into the training pipeline of future health practitioners. The outcome-level influence of advocacy on public discourse and institutional attitudes is plausible but inherently difficult to attribute and was not systematically measured. R3 is judged effective at output level, with advocacy outcomes credible but partially evidenced.

R4 – Participation and accountability (AAP)

R4 was strongly achieved and represents one of the intervention’s distinctive strengths. The baseline study institutionalized evidence-informed monitoring; coordination committees engaged 118 people including 85 women (197% of target, with notable gender inclusion); accountability capacity targets were met at 100%; feedback mechanisms were functional with all recorded complaints addressed; and 48 participatory meetings were conducted against a target of 14 (343%). The principal caveat is methodological — self-reported full awareness of feedback channels should be interpreted cautiously. R4 is judged highly effective, embedding Core Humanitarian Standard principles within both partner institutions and community structures.

Achievement of the Specific Objective

On the strength of the result-level evidence and the corroborating baseline–endline and qualitative findings, the specific objective — improving the health and SRH status of refugee populations by addressing SGBV as both a human-rights violation and a public-health issue — is judged to have been largely achieved. The intervention demonstrably expanded access to integrated care, strengthened survivor support and community protection systems, and improved accountability. The qualification “largely” reflects that some structural drivers of poor health and protection outcomes — chronic-disease financing in urban settings, specialist availability, stigma and staff turnover — lie beyond the project’s reach and remained only partially addressed.

Differences across locations

Effectiveness varied by context in instructive ways. Kyaka II showed the clearest evidence of system-level change, including a pronounced shift toward VHT first contact (9.0→36.1%) and reduced out-of-pocket spending — evidence of successful task-shifting and supply stabilization. Adjumani registered the strongest improvement in access to clinicians (42.7→30.9%) and reduced out-of-pocket spending, but retained the highest residual unmet need, particularly in MHPSS. Kampala generated the strongest MHPSS demand and uptake and improved on-the-spot treatment availability (87.3→100.0%), but was also where the essential-medicines model underperformed, and out-of-pocket expenditure rose (53.8→73.6%), reflecting the chronic-care and privatised-service realities of the urban context. Effectiveness was thus high across all three sites, but it was expressed through different mechanisms.

Contribution of partners

The consortium model was a significant contributor to effectiveness. Farmamundi provided overall coordination, technical leadership, donor accountability and the consortium’s quality and accountability architecture. AHA (Action Africa Help) drove settlement-based health delivery, the referral pathway, and the Kampala medical hostel function, which underpinned referral overachievement. EMESCO anchored community-based delivery, awareness and accountability work, particularly in Adjumani. The complementarity of these roles — strategic and quality oversight by Farmamundi, health and referral delivery by AHA, community mobilization by EMESCO — was central to the breadth of results achieved, and the partner exchange and joint coordination structures (R4) reinforced coherence across the three organizations.

5.3 Efficiency

The evaluation finds the intervention to have been efficient, achieving substantial over-delivery against most targets while operating through cost-conscious, system-leveraging modalities. Efficiency was strengthened by the deliberate use of existing public and community systems and by an integrated delivery model that generated economies of scope; it was constrained by the inherent costs of dispersed outreach and by external supply-chain and turnover pressures.

Use of financial resources

The relationship between resources and results was favorable. Many indicators were achieved at two to three times their planned level (medicines 223%, MHPSS therapy 353%, survivor psychological support 321%, participatory dialogues 343%), indicating that resources were converted into outputs at a rate well above appraisal expectations. Procurement was conducted through competitive supplier selection in accordance with procurement guidelines and through established suppliers, with reinforced stock-management and accountability systems at facility level — features that support an assessment of sound financial stewardship. The external audit and external evaluation provisions (Activity 4.6) provided independent assurance over financial and operational management.

Timeliness of implementation

Implementation proceeded broadly on schedule and demonstrated responsiveness to emerging demands, including the redeployment of resources to address public-health threats (Ebola, Mpox, Crimean-Congo Hemorrhagic Fever) through sanitation, infection-prevention and diagnostic commodities. The capacity to absorb and respond to outbreak risks without derailing core delivery is itself an indicator of operational efficiency. The principal timeliness risks identified were external — referral-loop delays at receiving hospitals caused by incomplete paperwork and staffing rotations.

Use of existing systems

Efficiency was materially enhanced by delivery through existing systems rather than parallel structures. Reliance on public health facilities, District Health Offices, KCCA, VHTs and OPM coordination reduced fixed costs, leveraged sunk public investment and strengthened sustainability simultaneously. The documented task-shifting toward VHTs as the first point of contact (Kyaka II 9.0→36.1%; Adjumani 3.9→12.8%) is a particularly efficient outcome, moving routine primary-care demand to lower-cost community service points and reserving facility and referral capacity for more complex cases. The introduction of reverse-referral approaches (specialist outreach to settlements) and increased appropriate use of lower-level facilities further improved system efficiency.

Cost-effectiveness

While the evaluation did not have access to disaggregated unit-cost data sufficient for formal cost-effectiveness ratios, several proxies point to strong value for money: high over-achievement against targets, the leveraging of public and community infrastructure, the multiplier effect of training community leaders and VHTs, and the economies of scope from integrating health, MHPSS and protection through shared outreach platforms. The clearest efficiency limitation was in Kampala, where specialised and chronic-care needs were comparatively costly to meet, and the essential-medicines model offered lower marginal value. The mobile-outreach model, while highly effective for reach, is also intrinsically resource-intensive and fuel/logistics-dependent.

Coordination efficiency

The consortium and inter-agency coordination mechanisms reduced duplication and transaction costs by clarifying partner roles, harmonizing protocols and aligning with OPM/OCHA/UNFPA systems. Joint assessments and shared committees lowered the cost of needs identification and referral. The principal coordination inefficiency identified was the funding-dependence of urban referral coordination, which left the pathway vulnerable when financing tightened.

5.4 Impact

The evaluation finds credible evidence of positive impact (in the short-term) across health access, survivor support, community awareness and institutional capacity, with the strongest, best-evidenced changes at the level of access and service utilization and more emergent changes at the level of health and protection outcomes. Consistent with good evaluative practice, the assessment frames these as the intervention’s contribution to observed change rather than as sole attribution.

Changes in health access and outcomes

The clearest impact is on health access. Out-of-pocket health expenditure fell substantially in two of three sites (Kyaka II 56.2→38.2%; Adjumani 83.5→66.0%), the proportion receiving treatment when seeking care rose (Kyaka II 94.4→98.9%; Kampala 87.3→100.0%), and difficulty accessing clinicians fell in Adjumani (42.7→30.9%). The shift toward VHT first contact indicates a structural change in care-seeking behavior toward accessible community service points. These changes are consistent in direction and magnitude with the project’s inputs and are corroborated by qualitative accounts of safety nets created by partner-supplied commodities. The countervailing finding — rising out-of-pocket spending in Kampala — reflects the urban chronic-care reality rather than a failure of impact, but it tempers the overall picture.

Changes in GBV response and reporting

The survivor-support results (1,443 women in psychological care; 144 in legal assistance; satisfaction above target), the doubling of GBV-competent clinical responders in Kyaka II, harmonized referral protocols and functioning community committees together indicate a strengthened SGBV response system and improved survivor pathways. Improved survivor confidence and the availability of credible response points plausibly contributed to greater willingness to seek help. As is common in SGBV programming, increased reporting should be interpreted as a sign of improved system trust rather than rising incidence, and the evaluation treats this as a positive, if difficult-to-quantify, contribution.

Changes in community behaviour and awareness

With 22,660 people reached through awareness activities, improved endline awareness of services, rights and referral pathways, and testimony-based de-stigmatization work, the intervention contributed to measurable shifts in knowledge and earlier care-seeking. The translation of awareness into durable behavioral and normative change is partial and uneven, constrained by entrenched stigma around mental health and GBV and by structural barriers to access — an honest limitation on the depth of behavioral impact.

Changes in institutional capacity

Institutional impact is evident and among the more durable effects: 241 health workers trained, 100% of participants improving accountability capacity, harmonized protocols, functioning coordination committees and embedded feedback mechanisms. These represent capacity that, when retained, persists beyond the project. The main threat to this impact is staff turnover, which erodes the institutional retention of individually held competencies.

Intended versus unintended effects

Beyond intended effects, the evaluation notes several plausible unintended effects. Positively, the project’s outbreak-response contributions strengthened general facility preparedness beyond the refugee caseload; the medical-hostel model created an unplanned but valued continuity-of-care asset; and strong female participation in coordination committees (85 of 118) advanced women’s institutional voice beyond the explicit target. Less positively, the very success of outreach and referral may have generated demand and expectations that current financing cannot sustain, creating a risk of service-withdrawal effects post-project — a dynamic explicitly raised by health workers concerning the urban referral pathway.

Differences across locations and contribution versus attribution

Impact was strongest and most clearly evidenced in the settlement contexts (Kyaka II and Adjumani), where the counterfactual of weak baseline access made the project’s contribution more visible. In Kampala, impact was concentrated in MHPSS and on-the-spot treatment availability, while chronic-care financing remained a structural constraint. Throughout, the evaluation adopts a contribution rather than attribution logic: in the absence of a control group, observed changes are interpreted as the intervention’s plausible and substantial contribution, triangulated across data sources, while acknowledging the influence of the wider humanitarian and health-system environment.

5.5 Sustainability (Viability)

The evaluation finds sustainability prospects to be moderate and uneven — strong where the intervention is built on and embedded within existing systems and capacities, and fragile where outcomes depend on continued external financing. This is the criterion on which the intervention is most exposed.

Institutional ownership

Institutional ownership is a relative strength. Delivery through MoH-aligned public facilities, District Health Offices, KCCA and OPM coordination, harmonization of protocols with national standards, and the training of health workers within public and refugee-serving facilities embedded project gains within institutions that will persist. The harmonized referral protocol and SOPs, and the accountability plans developed at organizational level, are transferable assets. Institutional sustainability is nonetheless tempered by staff turnover and by the dependence of some coordination functions on project resources.

Community ownership

Community ownership is similarly a strength. Eight functioning community committees, trained community leaders, VHT integration, and embedded feedback mechanisms created community-level structures with the potential to sustain identification, referral, awareness, and accountability functions. Their continuity depends on light-touch ongoing facilitation and on formal linkage to settlement and district structures rather than on intensive external inputs.

Continuity of services

Continuity of services is the principal sustainability risk. Several of the highest-performing components — mobile outreach, specialized referral coordination, the medical hostel, and specialized legal and psychological support for survivors — are intrinsically financing-dependent and would be difficult for communities or local institutions to maintain unaided. Health workers explicitly warned that the urban referral pathway was already under strain as financing tightened. The evaluation judges that, absent transition planning or follow-on financing, a portion of the access and survivor-support gains is at risk of erosion.

Financial and operational sustainability

Financial sustainability is limited, as is typical of humanitarian health programming. The intervention did not, and arguably could not, establish independent local financing for its more resource-intensive components. Operationally, the embedding of competencies, protocols and committees provides a partial buffer, but recurrent costs (commodities, fuel, referral logistics, specialized staff) remain dependent on external resources.

Integration into existing systems

The clearest route to sustainability — and the project’s strongest sustainability design feature — was integration into existing systems. The shift of demand toward VHTs and lower-level facilities, alignment with national protocols, and use of public coordination structures mean that a meaningful share of the intervention’s logic is now carried by structures that will outlast it. Consolidating this integration, rather than launching new structures, is where the strongest sustainability returns lie.

5.6 Connectivity / Coherence

The evaluation finds the intervention to be coherent and well-connected, successfully linking short-term humanitarian response with longer-term system strengthening, and aligning internally and externally with relevant policies, actors and standards.

Link between humanitarian response and system strengthening

The intervention exemplified the humanitarian–development nexus in practice. Immediate relief inputs (medicines, dignity and hygiene kits, outbreak-response commodities, emergency referrals) were consistently coupled with system-strengthening measures (health-worker training, protocol harmonization, VHT task-shifting, community committees, accountability mechanisms). This deliberate pairing meant that emergency delivery simultaneously reinforced the systems expected to carry the response forward — the defining feature of good connectivity.

Alignment with policies and frameworks

Externally, the intervention cohered with Uganda’s refugee-inclusion policy, MoH health standards, OPM/OCHA/UNFPA coordination guidance, the Core Humanitarian Standard and rights-based, survivor-centered humanitarian principles. Internally, the four results areas and the theory of change were mutually reinforcing rather than fragmented. This dual coherence strengthened both legitimacy and effectiveness.

Appropriateness of tools, equipment and approaches

The tools and approaches were appropriate to context: gender-sensitive and survivor-centered assessment and case-management tools; participatory training methodologies (simulations, case studies, role plays); mobile outreach for dispersed populations; medical-hostel and transport support for referrals; and Human Libraries and testimony for de-stigmatizing advocacy. The principal appropriateness gap was the essential-medicines specification relative to urban chronic-care needs.

Continuity post-project

Connectivity post-project is partial. The system-strengthening and integration features provide genuine continuity, but the financing-dependent components pose a risk of discontinuity. The coherence of the design means that, with modest transition support, the connected elements could continue to function; without it, the relief-oriented elements will lapse and some system gains may not be fully consolidated.

5.7 Coordination

The evaluation finds coordination to have been a clear strength of the intervention, both within the implementing consortium and between the consortium and external government and humanitarian actors.

Collaboration within the consortium (Farmamundi, AHA, EMESCO)

The three partners operated through complementary, well-delineated roles — Farmamundi providing coordination, technical and quality leadership, and donor accountability; AHA leading settlement health delivery, the referral pathway, and the medical-hostel function; and EMESCO anchoring community mobilisation, awareness, and accountability, particularly in Adjumani. Joint training and exchange sessions (Activity 4.5) and shared coordination committees harmonised approaches and reinforced consortium cohesion, with capacity and satisfaction indicators exceeding their 80% targets.

Collaboration with government (MoH, OPM, KCCA, districts)

Coordination with government was substantive rather than nominal. Joint needs assessments with KCCA and the District Health Offices of Kyegegwa and Adjumani, alignment with OPM and MoH systems, and collaboration with police and protection actors on SGBV case management embedded the intervention within national and district coordination structures. This strengthened both relevance and sustainability.

Collaboration with other actors and functionality of mechanisms

Coordination extended to OCHA and UNFPA guidance, AIRD logistics, national referral hospitals and specialised laboratories. The very high achievement on participatory meetings and dialogues (48 against a target of 14) reflects a dense, functional coordination fabric. The principal weakness identified was the funding-dependence and occasional breakdown of the referral-coordination loop at receiving hospitals, where paperwork and staffing rotations disrupted feedback — a functionality gap at the interface with external institutions rather than within the consortium.

5.8 Coverage

The evaluation finds coverage to have been broad, equitable and, in most respects, exceeding plan, while identifying specific residual gaps in reach.

Who was reached

The intervention reached well beyond its planned population: 23,596 refugees with medicines (against 10,600), 24,115 through mobile teams, 6,279 with MHPSS services, 22,660 through awareness activities, and 1,780 through specialised referral — the latter extending beyond the three target areas to refugees from Rwamwanja, Palorinya, Kyangwali and Nakivale. Coverage spanned both urban (Kampala) and settlement (Kyaka II, Adjumani) contexts.

Equity of access — gender, age and vulnerable groups

Coverage was strongly equity-oriented. Women and children under five constituted the majority of several streams (e.g. approximately 59% of referrals), survivor support was directed to an acutely vulnerable group, and dignity kits targeted women and adolescent girls. Age-sensitivity was evident in the focus on maternal and child health and on adolescents in awareness work. The strong female representation in coordination committees (85 of 118) extended equity into governance. The intervention’s explicit targeting of survivors, women, children, adolescents and people requiring chronic care reflects a deliberate prioritisation of the most vulnerable.

Gaps in reach

Notwithstanding broad coverage, the evaluation identifies residual gaps: urban refugees with chronic and non-communicable disease whose specialised pharmaceutical needs the model could not fully meet; populations in the most remote parts of dispersed settlements where outreach frequency remained a constraint; men and adolescent boys, who were comparatively less visible in protection and MHPSS uptake; and people with disabilities, whose specific access needs are not strongly evidenced in the available data. The marginal under-achievement on seminar gender parity is a minor coverage gap at advocacy level. These gaps define the priority frontier for future targeting.

5.9 Ownership and Participation

The evaluation finds ownership and participation to have been a distinctive strength and a defining characteristic of the intervention’s design and delivery.

Role of communities as rights-holders

Refugee communities were engaged as active rights-holders rather than passive beneficiaries. Through community committees, dialogue sessions, VHT networks, monitoring structures and the participatory baseline, communities contributed to identifying needs, shaping interventions and providing feedback. The 343% over-achievement on participatory meetings and dialogues (48 against 14) quantifies the depth of this engagement, and qualitative evidence shows communities embracing endline and feedback exercises as platforms to voice unvarnished needs and inform future planning.

Role of local institutions

Local institutions — District Health Offices, KCCA, OPM/settlement commandants, public facilities and local partner EMESCO — were embedded in delivery, assessment and coordination, reinforcing local ownership and aligning the intervention with the localisation agenda.

Functionality of AAP mechanisms

Accountability-to-affected-populations mechanisms were functional and well used: feedback and complaint channels were established, awareness of these channels was high, and all recorded complaints were addressed. Organisational accountability plans embedded these practices institutionally, with 100% of participants improving capacity. The evaluation notes the methodological caution attached to self-reported full awareness, but regards the AAP architecture as genuinely operational and as one of the project’s strongest legacies.

Level of engagement in decision-making

Engagement extended into decision-making through coordination and monitoring committees with strong community and female representation (118 participants, 85 women). This moved participation beyond consultation toward shared influence over implementation and review — an advanced expression of the participation principle.

5.10 Cross-Cutting Issues (Integrated Analysis)

Cross-cutting concerns were, for the most part, integrated across the intervention rather than treated as add-ons. The evaluation assesses performance against each of the following.

Gender and age

Gender was central to both design and delivery: the intervention foregrounded SGBV response, women’s and girls’ SRH, survivor support and dignity provision, and achieved strong female participation in governance structures. Age-sensitivity was evident in the maternal-and-child-health focus, attention to children under five, and adolescent-oriented awareness work. The principal gender gap is the comparatively limited visibility of men and adolescent boys in protection and MHPSS engagement, which constrains transformative change in gender norms.

Human Rights-Based Approach (HRBA)

The intervention applied an HRBA consistently, framing health and protection as rights, treating refugees as rights-holders with voice and entitlements, and orienting services around dignity, non-discrimination, participation and accountability. The advocacy stream (assessments, seminars, Human Libraries, media engagement) reinforced the rights framing at institutional and public levels.

Conflict sensitivity / Do No Harm

The intervention demonstrated conflict sensitivity and Do No Harm awareness through survivor-centered, confidential case management, inclusion of host-community considerations within public-system delivery, and participatory feedback that surfaced and addressed grievances. The main residual Do No Harm consideration is the risk of harm through service discontinuity post-project, given raised expectations — a risk the evaluation flags for transition planning.

Environmental considerations

Environmental considerations were the least systematically addressed cross-cutting issue. While the intervention’s use of existing infrastructure limited its environmental footprint and outbreak-response work included sanitation and infection-prevention measures, the available evidence does not indicate a deliberate environmental-sustainability or climate-resilience lens (for example, in procurement, waste management of medical supplies, or outreach logistics). This is an area for strengthening in future programming.

Inclusion of vulnerable groups

Inclusion of vulnerable groups was a strong feature: survivors of SGBV, women, children, adolescents, people with chronic illness and the displaced poor were explicitly prioritized, and outreach and referral models were designed to reach the dispersed and isolated. The clearest inclusion gap is the limited evidence on the targeting of persons with disabilities and older persons, whose specific access needs warrant more deliberate attention.