REPORT ON MONITORING OF HEALTHCARE SERVICES DELIVERY IN

August 2016

Health Monitoring Unit (HMU)

Plot 21 Naguru Hill Drive,

P.O Box 25497 ,

Tel: 0414-288442/5, 0800100447 (Toll free)

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TABLE OF CONTENTS

ACRONYMS ...... 2 1.0 INTRODUCTION ...... 3 1.1 Background ...... 3 1.2 Specific objectives of the monitoring exercise ...... 5 1.3 Methodology ...... 6 1.4 Health facilities ...... 6 2.0 FINDINGS ...... 7 2.1GENERAL FINDINGS ...... 7 3.2 COMMENDABLE PRACTICE ...... 9 Sseguku HC II ...... 9 Katabi HC II ...... 10 3.3 SPECIFIC FINDINGS ...... 12 Grade B General Hospital ...... 12 HC IV ...... 15 Wakiso HC IV ...... 19 HC IV ...... 20 HC IV ...... 23 Kigungu HC III ...... 25 Mpumudde HC III ...... 26 HC III ...... 29 Buwambo HC IV ...... 30 Kiira HC III ...... 31 HC III ...... 32 Ndejje HC IV ...... 33 HC III ...... 33 Kakili HC III ...... 34 Kasozi HC III ...... 34

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ACRONYMS

ANC Antenatal Care

CAO Chief Administrative Officer

DHO District Health Officer

DPC District Police Commander

EMHS Essential Medicines and Health Supplies eMTCT Elimination of Mother To Child Transmission of HIV

HC Health Centre

HIV Human Immunodeficiency Virus

HMC Health Unit Management Committee

HMU Health Monitoring Unit

JMS Joint Medical Stores

MoH Ministry of Health mTrac Medicines Tracking

NMS National Medical Stores

OPD Out Patient Department

PHC Primary Health Care

RDT Rapid Diagnostic Test

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1.0 INTRODUCTION

1.1 Background The Health Monitoring Unit (HMU) was established seven years ago with a mandate to monitor health services in the country.

HMU’s goal is to monitor the efficiency and accountability of ’s healthcare system so as to raise the bar in healthcare.

Our vision is to see a healthy Ugandan population supported by an effective and responsive healthcare system. In order to achieve this, we continue to focus on striving for better health, better systems, and better value for money.

Our core values are Quality, Undaunted, Integrity, Excellence, Teamwork.

The Unit’s operations are guided by three strategic objectives:

1. To monitor health care service delivery in Uganda

2. To strengthen the Ugandan health system

3. To improve citizen ownership of health services

Between July and August 2016, HMU undertook a health services delivery monitoring exercise in Wakiso district with an objective to establish the status of healthcare service delivery in the district, following numerous complaints reported from the public through the anonymous hotline and from whistleblowers. Table 1 below shows a snapshot of the complaints reported through the anonymous hotline mTrac dashboard.

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Table 1: A snapshot of some of the complaints received through the anonymous hotline

Facility District Date Reports Topic

Kasangati HC why is it that at our h.c.4 treat't attimes is sold to us or not there and how mach are we 2 IV HC IV Wakiso 04/08/2016 pay 4 the scane,bec'se we are charged 35000. kasangati h.c.4. Thank u. Extortion General Missing Wakiso 27/07/2016 2 de i went to kiira h/centr fo atyfod test bt i was sent 2 do it 4rom outside why? Complaint Banange mutuyambe ffe abembuto enabweru batuguza eddagala yt it supposed 2 be Missing Wakiso 16/07/2016 free Extortion I went at Kirinya healthy centre and was charged money fo testing HCG en again asked Missing Wakiso 29/06/2016 me to pay 39000 so as to get quinine drip Extortion Kasangati HC Working hours IV HC IV Wakiso 18/06/2016 No Doctors On Health Centre 4 Kasangati of HCs Kasanje HC III HC III Wakiso 17/06/2016 rs arenot available yet they are there. Malpractice

Missing Wakiso 27/04/2016 In seguku health center 3 People pay 2000 shillings for immunization Per visit Extortion Working hours Missing Wakiso 22/04/2016 at kasanje health centre lll they dont work after lunch of HCs Mutuyambe abasawo be Namayumba Health center 4 basaba abalwadde sente Missing Wakiso 21/04/2016 okubakolako Extortion

Abakulu bewakiso tubasaba mutusasule sente zaffe eza polio round eyakagwa enkuba Missing Wakiso 18/04/2016 yatukuba tukolera mubugubi nemutatufako mwagala kimu report bwemutatusas Fraud Working hours Missing Wakiso 18/04/2016 NO DOCTORS AT THIS TIME IN HEALTH CENTER of HCs

I took an 8yr old to a health centre. She was found to be with syphilis. She Was given; Missing Wakiso 14/04/2016 cipro 250 bd/5 days. Metro 200 tds/3 days. Are these the only dru General Inquiry Working hours Missing Wakiso 14/04/2016 Naye Abasawo Eno Ekyengera Nga Tebanatuka Ngate Tuwulira Bubi of HCs MUTUYAMBE KU BASAWO MUTUWEMU, KUBA BANO BATANDIKA KUSAAWA Working hours Missing Wakiso 08/04/2016 5NEBANYUKA9 GOMBE HEALTH C TWO WAKISO DISTRICT. of HCs abasawo benabweru mugambenga abalwadde bamwe nti edwaliro muja kuligulangawo Working hours Missing Wakiso 06/04/2016 sawa mukaga (12:00) emisana nakyo tukimanye of HCs No medicine in the hospital. Medical workers have a poor code of conduct. They cant Missing Wakiso 30/03/2016 even perform Widal test. ( - Wakiso) Stock Out nzize kuddwaliro ngasirina gwe ndabawo ate ngasewulira bulungi ate sisobola Working hours Missing Wakiso 28/03/2016 kuminkiriza nkya wat happened to the doctors please of HCs Nze emma from matuga rwaki tugura edagara ate ngaryangavumenti nasanyuka Missing Wakiso 25/03/2016 nganzizemu nze emma from matuga webare Drug Theft lwaki okukebera omusujja gwa typhoid mu ddwaliro ekasangati health centre iv kwa Missing Wakiso 19/03/2016 sente? Extortion

MUSAWO DARIUS TUMUKOYE KUDWALIRO EKISOOKA ALINA OLUGAMBO AGEYA ATUMA EDAGALA AYAGALA SENTE MUQUSEMU OMULALA FFE ABE Missing Wakiso 18/03/2016 SSENTEMA MWELABA. Extortion

TASABA OTUNGAMBIRAKO ABASAWO BO NKUNGOMBOIORA AKOLA MUSAYI YE GRACE NABAKO MUBEMBUTO BASABA SENTE NYIGI .KUBULIKIMU OKUNO Missing Wakiso 16/03/2016 KUVA NSANGI SENTA 3- Extortion Kasangati HC Working hours IV HC IV Wakiso 10/03/2016 Abasawo b'ekasangati balwawo okujja mudwaliro of HCs General Missing Wakiso 08/03/2016 Why do doctors of Namayumba health centre 1V only carry out one test[RDT] Complaint

Nabweru HC Banaye mutuyambe esawa nnya abasawo tebanatuku kudwariro kibinyo abarwade banji Working hours III HC III Wakiso 08/03/2016 tebarina bujajabi mutuyambe bekikwatako ndi nabweru ku dwariro ryagavumeti. of HCs

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Nsangi HC III Am raising my complant aganest nsangi healthy center 3, why are they selling labour HC III Wakiso 20/02/2016 ward materals, ie cotton, gilaves plus polythen materals? even at ahi Extortion

banafe abakulu amalwalilo gagavumenti tubegayiride mutuyambe kumusawo akulila General Missing Wakiso 17/01/2016 jebazalila alekele awo okutuvumanga.Kulino edwalilo rya kajansi tujakusayuk Complaint Missing Wakiso 16/01/2016 (...... ) Extortion

NAGENZE MUDDWALIRO EKASANGATI NGANDIMURWADDE MUUYI Kasangati HC NGANJAGALA KUMPIMA PUULESA NEBANGAMBA NGULE AMAANDA IV HC IV Wakiso 16/01/2016 BATEKEMUKUUMA BALYOKKE BAMPIME NGASIYINA WADDE ORW Extortion

Naye wabula abasawo be nsangi tebafa ku bantu kati ziweze sawa 10:15 omuntu eyaze Working hours Missing Wakiso 09/01/2016 kumakya nakati tebanamukolako neye rwaki kiri bwe kityo mutuyabe oba mu of HCs Missing Wakiso 17/10/2015 NAMAYUMBA H/W transport waffe tunamuna Ddi ? General Inquiry General Missing Wakiso 08/10/2015 NAMAYUMBA H/W transport waffe tunamuna Ddi ? Complaint EDWALIRO LYANGE ELYA MPUMUDDE HT III NAKAWUKA WAKISO TERIRINA Missing Wakiso 30/09/2015 BASAWO TUKOZE TUTYA Absenteeism ABASAWO KUMAKYA NEBAGENDA JEBASULA NEBAJJA SAAWA 5 BANYUKA 9 Working hours Missing Wakiso 29/09/2015 OBA 10 WANO E GOMBE H C TWO WAKISO DISTRICT. of HCs MUTUYAMBE KU BASAWO MUTUWEMU, KUBA BANO BATANDIKA KUSAAWA Working hours Missing Wakiso 29/09/2015 5NEBANYUKA9 GOMBE HEALTH C TWO WAKISO DISTRICT. of HCs

Missing Wakiso 23/09/2015 Wano ekajansi tetulaba ku musawo akebera bambutto.kyekyiriwo? Mutuyambe Absenteeism Kajjansi HC III Working hours HC III Wakiso 10/09/2015 saawa za lunch zaweddeko daa naye abasawo ekajjansi disipensale tebaliwo of HCs Kajjansi HC III hello,this this kiwanuka 4rm kajjansi i was disapointed by midwife Rebbeca when she HC III Wakiso 27/08/2015 demanded 40K yet iwent wiz evry thing Extortion Mwebale Emirimu,lwaaki Kajjansi Dispensary Eddagala balituguza buguzza ngate Missing Wakiso 31/07/2015 obujanjabi bwabwereere? Extortion In Healthcentrein Council Doctors They Donot Care For Patiets Missing Wakiso 22/07/2015 And The Drugs Are Not Enough, Negligence Maganjo HC II HC II Wakiso 08/07/2015 Wano emaganjo 6mls opp. Deo's chur. tulina clinic etuguza eddagala effu!! Malpractice Buwambo HC IV HC IV Wakiso 24/06/2015 MUDWALIRO BUWAMBO H/C IV TERI BIKOZESEBWA KUJANJABA TAYIFOYIDI. Stock Out Buwambo HC Working hours IV HC IV Wakiso 27/04/2015 teli ddagara mudwali of HCs here in kabaale t/c in wakiso dist,some shops which sells medcine are selling gov't Missing Wakiso 13/04/2015 drugs. Drug Theft Kyengera HC II HC II Wakiso 11/04/2015 NZE RUTH MBUZA KUKENDI ABASAWO TEBAKOLA KYENGELA Absenteeism Working hours Missing Wakiso 07/03/2015 Matugga H/C 2 has power service delivery of HCs

MUSAWO DARIUS TUMUKOYE ESENTEMA MUBI FFE ABALWADDE TATUWA Missing Wakiso 01/03/2015 DAGALA BYE FFE ABATUZE Negligence

1.2 Specific objectives of the monitoring exercise Specific objectives of the monitoring were;

1. To assess the level of effectiveness within the health service delivery systems of the district through direct monitoring of health facilities.

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2. To identify and rectify any forms of healthcare malpractice, poor administration and mismanagement of healthcare resources. 3. To provide feedback to all stake holders involved in health service delivery as well as the public, so as to jointly work-out practical solutions.

1.3 Methodology A five-man team conducted an evaluation of government health facilities in the district. The evaluation included un-announced visits to targeted health units, with the guidance of an approved data collection tool and observation checklist. Areas assessed included; infrastructure, equipment and inventory management, medicines management, financial audits, human resource evaluations, administration effectiveness and effectiveness of health services delivered at the visited facilities.

1.4 Health facilities

A total of sixteen (16) health facilities were visited across the district to follow up on these complaints as summarized in table 2 below.

Table 2: Health facilities visited in Wakiso district

Facility Level Owned by: 1 Entebbe General Hospital, Grade B Hospital Government 2 Kajjansi HC IV Government 3 Wakiso HC IV Government 4 Namayumba HC IV Government 5 Kasangati HC IV Government 6 Buwambo HC IV Government. 7 Kigungu HC III Government 8 Nsangi HC III Government 9 Mpumudde HC III Government 10 Kiira HC III Government. 11 Bweyogerere HC III Government. 12 Ndejje HC III Government. 13 Namulonge HC III Government. 14 Kakili HC III Government. 15 Sseguku HC II Government 16 Kyengera HC II Government

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2.0 FINDINGS The findings from the monitoring exercise are presented below;

2.1GENERAL FINDINGS

In each of the ten health facilities visited, the following was characteristic;

i) Mosquito nets are heaped in piles but not distributed for use by patients in wards.

ii) There are no protocols followed in medicines accountability except in Wakiso HC IV store and OPD where an audit of one of the drugs revealed proper accountability.

iii) There is gross drug theft, diversion and total lack of accountability for medicines and laboratory test kits.

iv) Rampant ACCEPTED absenteeism of staff, especially the senior cadres and In- charges.

v) Health centers were closed over the weekends and in higher facilities like HC IVs, doctors do not work over the weekends. This practice has been accepted not only in Wakiso but in other facilities visited all over Uganda.

vi) Most In-charges were not found on duty, citing that they were attending workshops. On further verification it turned out not to be true.

vii) There was no evidence of qualitative supervision, and detailed reports from the district.

viii) Expensive theatre equipment like anesthetic machines were lying idle unutilized despite the fact that the facilities had anesthetic officers.

ix) There was total lack of inventory management. Most equipment could not be traced even when the record showed otherwise.

x) Most government equipment in the facilities were not embossed.

xi) The HC IVs were grossly underperforming despite the fact that they had theatres and doctors.

xii) There was total lack of prioritization in budgeting and resource utilization in the visited health facilities.

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xiii) Governance and supervision gaps

There was lack of quality supervision from the expected supervisory heads right from the district, to health sub districts and to facility levels. Even where issues arose, there was clearly lack of responsiveness as indicated below;

Evidence of lack of action from the district when pertinent issues are raised. To date, nothing has been done on the above concerns

Unattended to patient with no mosquito net yet piles of nets in store unused. This scenario is in all the facilities visited by the monitoring team except Kasangati HC IV 8 | Page

Evidence of poor medicines accountability; it’s not clear as to whom issued out and received these medicines

Financial audits are still ongoing and a report will be available as soon as it’s complete.

3.2 COMMENDABLE PRACTICE Good and exemplary practices in facility management, medicines accountability were noted in some facilities.

Sseguku HC II In Seguku HC II, the facility was neat and organized in spite of there being only two at the time (one staff was away on study leave while the In-charge was on a one-month annual leave break). Additionally, the two staff present were smartly dressed in uniform.

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Smartly dressed staff of Sseguku HC II and neat patient consultation and examination room

Katabi HC II In Katabi HC II, the facility was neat, kempt and organized. It has only two blocks which are insufficient to support the large patient load hence resulting into congestion. The OPD structure contains one examination room, injection room, 2 tiny laboratories, dental room, mini-store and dispensary while the second structure is partitioned into two wards, and some space for storage of damaged equipment.

Services provided include OPD, dental (extractions, fillings), RDTs, microscopy, CBC, CD4 count, clinical chemistry and admissions in a small improvised space.

Katabi HC II has four (4) medical doctors however, does not conduct any operations due to the absence of a theatre, and neither does it conduct any deliveries because there is no maternity ward.

The facility however receives large numbers of patients despite the fact that it receives medical supplies for a HC II. In addition, over 70% are civilians yet the small Hospital Emergency Drugs fund of Ugx 300,000. It therefore regularly survives on support from Command and administration to provide additional funding to secure requirements which are bigger than its budget, including procurement of additional medical supplies to supplement the need.

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The table below shows the number of OPD attendances between January and March 2016;

Category of patients January February March

Soldiers 314 425 416

Civilians 934 1120 1260

% of civillians 74.8% 72.5% 75.2%

OPD block and admission ward; the only two structures at Katabi HC II which has a huge patient load

Specific noted challenges at the facility include; i) Limited working space ii) Lack of a facility van; they constantly borrow services from the institution’s ambulances iii) Shortage of qualified staff in dental, radiography, physiotherapy and the dispensary. iv) The facility budget is too small to cater for services offered

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3.3 SPECIFIC FINDINGS

Entebbe Grade B General Hospital

Infrastructure Development

Infrastructure development has been good at the hospital. More space has been created including the VIP wing. However there is no medical ward. The hospital floods when it rains. The only mechanism to stop this was to construct huge humps as barriers. This solution is not sufficient in solving the water logging and in the long run, would cause wear and damage of the new structure.

Elegant Entebbe hospital exterior yet corridors continue to be water logged each time it rains

Further, the X-Ray machine would most probably get damaged soon because of water logging. The staff had therefore improvised to stop this by creating an “artificial drainage channel” on the floor to drain the water.

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Artificial drainage channel “created” by staff to protect x-ray machine from constant water flow in the corridor.

Uncoordinated equipment procurements

The new Dental X-Ray machine was supplied without a monitor therefore rendering it not usable!

Further, of the two planned sinks only one had been installed and yet both had been included in the BOQs. This is likely to impede any plan for future expansion of dental services.

New dental chair & X-Ray machine with no monitor (left) and provision for second sink blocked

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Many of the accessories that are used alongside the X-Ray machine were not supplied for example X-Ray markers, lead shields, among others therefore hindering the machine from being used optimally. In addition, anesthetic machines that had been supplied to hospitals and HC IVs country-wide had never been used.

Newly supplied anesthetic machine but never been

Quality of Patient Care

The quality of patient care was wanting. In the maternity, there was neither a Blood Pressure machine nor a working thermometer. In addition, the attached patient clinical notes demonstrate lack observations in post-operative care.

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A sample of a patient’s clinical notes with no post-operative vital sign observations

Kajjansi HC IV

Gross absenteeism

It was discovered that the staff and In-charge of Kajjansi HC IV were constantly away from the facility. On the day of the monitoring visit the following was witnessed;

i) Out of the 26 staff scheduled to work, 15 had signed the attendance book however, only 11 (55%) were found at the facility. Of those present on duty, there were only five (5) clinical staff namely; one (1) Clinical Officer, two (2) Nursing Officers and two (2) midwives.

ii) The In-charge had signed in the attendance book but was away organizing a Health Assembly. In the past two months prior to the visit, he had worked a total of twenty five (25) days. It was however reported that he occasionally reported late between 10:00am and 1:00pm for the day shift.

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iii) The laboratory In-charge was away conducting a 20-day long survey for an NGO leaving certificate-level interns and a Vector Control Officer managing the laboratory. This had been sanctioned by the facility In-charge.

iv) The stores In-charge was off duty without permission (she habitually “excused” herself from work every Wednesday).

Medicines and supplies accountability

In the laboratory, there was no mechanism to track supplies requisitioned from the store. An audit of supplies in the laboratory revealed that out of 1,000 Determine kits received between May 1st and July 27th (the day of the visit), only 808 could be accounted. The laboratory In-charge could not explain the whereabouts of the missing test kits.

Facility mismanagement

A number of the infrastructure was being misused. The delivery suite and postnatal rooms had been converted into staff quarters for two midwives and a nurse, and deliveries were being conducted in an improvised poorly lit and untidy room and yet one of the staff houses at the premises remained unoccupied for months. The patient beds were also being used by the staff.

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Maternity ward converted into staff accomodation and with government beds used by the staff

AND YET BELOW

Part of the staff house that has remained unoccupied for months

There was lack of prioritization in allocation of resources. There had been no water for over a year and the laboratory was filthy. Instead of paying the Ugx 400,000 water bill, PHC funds were being spent to repaint the exterior of the facility. It was appalling to

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On-going painting of walls vis a vis filthy lab without running water due to unpaid water bill of Ugx 400,000 for over a year

The facility has three health inspectors however, it was very filthy and unkempt. In addition, the compound had been accepted as a grazing ground for cows and sheep, and part of it was being hired out as parking space for trucks of the express highway road contractors.

OPD block in the background

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Part of facility compound used as parking lot for Express highway contractors

Kajjansi HC IV was generally characterized by lack of stewardship and supervision as evidenced by infrastructure mismanagement, lack of medicines accountability, and the rampant absenteeism of staff.

Wakiso HC IV Wakiso HC IV is in the neighborhood of the district headquarters.

The health center has one Medical Officer however, he was not In-charge. Instead a Nursing Officer was given the responsibility of being the In-charge and accounting officer.

The medicine store was neatly organized and there was very good accountability for medicines in the store and OPD.

The maternity was generally busy with an average of 180 deliveries a month and 3,000 ANC attendances.

Records were poorly managed and figures were inflated to reflect higher performance levels for all departments.

The infrastructure layout is disorganized, and this was worsened by the ongoing renovation of the OPD, which resulted into temporary conversion of part of the in- patient ward for OPD services. This also left several equipment poorly stored in the compound.

Equipment stored in the compound awaiting completion of OPD renovation

19 | Page “We improvised this bed as a fence to stop trespassers from accessing the doctor’s house” In-charge explained

Bed put as barrier to stop trespassers from accessing doctor’s premise

This is the center of the facility as patient is transported from OPD to the laboratory

The theatre was underperforming and the newly supplied equipment is not being utilized.

Namayumba HC IV

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The facility was generally filthy and unkempt. The reception of the maternity was filled with old equipment and garbage. In addition, the beds being used in the wards were dilapidated despite the fact that newly supplied beds were piled unused in the store.

Part of the unkempt maternity reception at Namayumba HC IV crowded with equipment The surgical ward that was completed in 2015 and new beds supplied to the district store 9 months ago had just been delivered to the facility, yet still lay stacked in the stores utilized. Instead, patients were sleeping on old beds under poor conditions.

New surgical ward completed in 2015 with new beds lying unutilized and some in store (see below left). (Below right) Old beds currently being used by patients

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The store was organized and neat however, there was gross theft of medicines by the store keeper who constantly issued out supplies without any requisitions from user departments.

Neat store of Namayumba HC IV with high pilferage of medicines!

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KASANGATI HC IV

The health unit is run by a nursing officer who is the In-charge, in spite of it having a medical doctor.

The facility structures are dilapidated except the maternity ward and theatre however, it was clean and kempt. The beds in the wards are old and inadequate leaving a lot of space unutilized.

All significant staff were present and smartly dressed in uniform.

The theatre is relatively functional compared to other HC IVs visited however, it has no functional drainage hence all the waste is washed out. The new anesthetic machine is not being unutilized. It was noted that the supply of anesthetic medicine was inadequate to support all theatre operations.

All HMIS reports were not reflecting actual performance figures drawn from the departments.

The maternity is relatively busy with an average of 200 deliveries a month. There was proper record of accountability for mama kits and mosquito nets in the maternity as each recipient signed the dispensing book. However, there were gaps in accounting for laboratory test kits.

Mosquito nets were being used by mothers in the maternity ward, a practice which was non-existent in all the other facilities visited.

The medicine store was neat and well organized. However, the stock cards dates were mixed up and following a chronological order.

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Organized medicines store of Kasangati HC IV but with poor documentation in stock card; May issues were at times recorded at the end of June

Salaries of some staff were being deducted without explanations.

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Kigungu HC III

Kigungu HC III is adequately staffed and has two clinical officers however, it was characterized by general lack of accountability for medicines, poor facility management, and poor prioritization of available health unit resources. The In-charge was not knowledgeable about her facility at all, and all the noted good efforts were attributable to the midwives.

It was disappointing to note that the only thermometer available was in a poor state held together by plaster and a new one (of less than Ugx 10,000) could not be bought yet a receipt worth Ugx 450,000 for a “generous” contribution towards a wedding was found among the accountability files.

The health unit lacks significant infrastructure as it has only one block (maternity) in a substantive state. However, the old OPD structure is not maintained well. Additionally, the space that could have been used to admit patients was filled with rotting (non- medical) beds and equipment therefore, admissions are impossible. The reason given for holding onto these beds was that “they were donations and we do not want to offend the donors by putting the beds away”.

Old filthy non-medical beds and mattresses together with broken down equipment filling all the space in would-be admission ward

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Kigungu HC III has extremely poor equipment which is incapable of providing quality care to patients. The facility lacks even basic equipment like scissors, needle holder to stitch mothers, a sterilizer, and the thermometer is in poor condition.

Thermometer held intact by plaster and unacceptable sterilizing method in Kigungu HC III

The health unit had no patient toilet; the OPD toilet was in poor state and had been closed off and therefore all patients, mothers and staff had to share the maternity flush toilet which was located right opposite the maternity ward and stunk heavily.

Mpumudde HC III

Chronic absenteeism and lacking supervsion

On the day of the visit by 10am, only the In-charge and a new Laboratory technician were present moreover, the In-charge was busy inspecting medicine in the store instead of attending to the multitude of patients.

The midwives resided in the staff houses however none of them was found at home. One of the maids to a midwife explained that her boss had “gone to her place of work” early that morning. It was reported by a local leader that most of the staff had alternative jobs in the local trading centre (Nakawuka).

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Despite the fact that only two staff were present, all staff scheduled that day had signed the attendance book indicating that they had reported to work between 8am and 9am. It was reported that the staff signed the book in advance even before the actual calendar dates were reached.

Mpumudde HC III staff attendance as on the day of the monitoring visit (1st August, 2016)

NUMBER OF DAYS WORKED EACH MONTH NAME CADRE JAN FEB MAR APR MAY JUN JUL TOTAL 1 AMAYO STEPHEN SMCO 6 10 11 6 5 8 7 53 2 NSIMBE KUTESA MCO 13 15 18 15 13 11 14 99 3 NAMISANGO CHRISTINE N/O 18 13 16 18 17 15 15 112 4 TUMWEBAZE STELLA E/N 18 12 16 16 12 12 7 93 5 MUJULIZI GERALD E/N 14 10 11 14 13 16 15 93 6 TEBAMUSUULWA STELLA M/W 9 16 11 8 17 15 15 91 7 NAMUDDU ALLEN N/A 14 13 16 15 15 10 15 98 PHARMACY ORDERLY 8 ZIRABA DAVID /”LAB TECHNICIAN” 18 18 21 23 15 12 12 119 9 BIRUNGI RUTH H/A 12 11 12 8 11 9 9 72 10 BIIRA PETRONILA E/N 10 4 12 7 11 12 8 64 11 WASWA ERIAS H/A 16 14 16 16 13 22 18 115 12 RITA KAMOGA NAKAREMA M/W 15 18 14 18 19 18 12 114 13 NABAKOOZA HANIFAH R/A 0 0 0 0 0 10 15 25 14 AYASI DHUYONGERA L/A 0 0 0 0 0 13 10 23 15 BIRUNGI SARAH 0 0 0 0 0 12 0 12 Source: Daily attendance register for Mpumudde HC III, 2016

Mothers and patients stranded at Mpumudde HC III without being attended to at 10:00am

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There was generally lacking supervision. The DHO had visited Mpumudde HC III only once in the last five years (on 13th July 2015) for a District Health Monitoring Team Meeting.

Quality of patient care

The laboratory was for 11 years being run by an unqualified drunkard staff who had been posted to arrange the medicine stores. There being no laboratory staff in the facility, he had been trained “on-the-job” and he had been sanctioned by the clinicians to run tests on patients. When asked about this, the In-charge defended him saying “but he was trained on-the-job”!

The qualified laboratory technician (Mr. Ayas) who had been attached from Kasange HC III since the beginning of 2016 worked an average of 10 days a month, leaving patients to the mercy of the unqualified staff.

There was only one shared admission room despite the facility having a lot of space. One of the would-be patient care rooms had been turned into a store for timber.

Further, admitted patients were not given mosquito nets despite the stockpiles of nets found in the store. It was discovered later that morning that the cleaner had decided to distribute some nets to the mothers who had come for ANC services since the store was open and the nets readily accessible.

It was discovered that the midwives worked only half day, and did not work at night “Rita, a midwife of Mpumudde HC III sends her maid to examine mothers in maternity during night shift” one of the local leaders said.

It was also found that mothers were charged for needle holders for stitching mothers yet they were available in the stores.

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The unqualified drunk staff who has been working in the lab for 11 years, and timber stored in would-be patient care room

Medicines accountability

There was gross mismanagement of the stores. Medicines were oftentimes transferred to the district stores for redistribution yet resident patients were not given priority.

It was also discovered that medicines were picked by any staff of the facility without following any requisitioning and issuing protocols.

Mama kits were being sold to only “mothers who could afford” at Ugx 25,000. Those who did not have money were completely denied.

Nsangi HC III

The In-charge was not in touch with his facility, and did not know much of what was going on in the various departments. In addition, there was no evidence of supervision by the district technical team.

There was gross drug theft coordinated between the laboratory and stores staff. The In- charge had delegated all responsibilities regarding medicines issuing and authorizations to the laboratory technician (Joseph) and his stores counterparts. It was discovered that the lab technician regularly authorized inter-facility transfers of test kits to Kyengera HC II. However, on cross checking with Kyengera, it was discovered that none of these issues had been delivered to Kyengera HC II.

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Patients complained that they were being denied ARVs. It was also discovered that health workers asked patients for lunch facilitation as a pre-condition for seeing them.

The empty room in the maternity was being used as a storage for tent stands and motorcycles, yet newly supplied beds lay piled in the corridor unutilized.

Motorcycle and tent stands stored in maternity ward, yet beds piled unutilized in corridor.

Buwambo HC IV

Human resources:

Gross absenteeism was noted as on the day of the visit, only four staff were found present and of these, only two were clinical staff.

There was a doctor however, the facility was being managed by an elderly nurse with no managerial skills, and these was completely no accountability for PHC funds. The cash book is kept and managed at the district!

In addition, the in-charge was rarely at the facility as she spends most of her time at the district where she is the coordinator for TB project. This left a Nursing Assistant acting as the In-charge for the HC IV.

There was no evidence of support supervision by the DHO, and the few visits from other district support personnel were merely signed off in the visitors’ books with no recommendations for improvement of the facility.

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There are only two staff houses and some health workers reside as far as and Mukono. This compromises their ability to attend to duty.

Medicines and supplies

The medicine store was neatly organized and with very good accountability for medicines. However, medicines were misappropriated as soon as they were dispatched from the stores (in the wards and OPD).

Mosquito nets were in excess and piled in the OPD however, they were not being given to patients in wards.

Further, there was no proper record at the maternity to track mosquito nets and mama kits given out.

Service delivery

One of the Nursing Assistants was reported to be involved in extorting Ugx 50,000 from patients for OPD services.

Kiira HC III Human resources for health

By 11:00am on the day of the visit, the team found a long queue of patients unattended to. The only staff present included a midwife, a laboratory technician and the In-charge (a Clinical Officer) who was not concerned about the patients.

There was poor accountability for PHC funds. The In-charge had forged various receipts for several non existent service providers, and had attached them onto PHC funds accountability.

There are only six staff houses available for the health workers however, one is being utilized by the askari who is not a clinical staff.

Medicines and supplies

The store was being managed by two staff however, there was gross mismanagement of medicines and supplies. The requisition and issuing vouchers were poorly utilized and in some cases, medicines were issued without approval. Physical counts of sampled medicines reveled major discrepancies, and these could not be explained by the stores personnel.

Infection Control

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The placenta pit has no cover and has a foal smell which sears to the wards and the nearby staff houses. The In-charge was unable to give an explanation for this and has never made efforts to fix the cover.

The facility was generally dirty and unkempt. The porter had no protective cleaning gear and therefore left some infectious waste not well cleaned up.

The facility has never been connected to piped water since its inception despite having a water tap situated next to the entrance of the health unit. The health facility relies on harvested water from rain which is unsafe and insufficient during the dry season.

Bweyogerere HC III Human resources for health

The attendance of the In-charge was more regular compared to all other In-charges in the district. However, he was overstretched as he worked alone and could not hold his absentee colleague accountable. The absentee Clinical Officer spent all his time at a private clinic in Gulu where he was a permanent employee and only showed up every Friday to sign the attendance register. All the other staff including the In-charge were aware but covered up for him.

Service delivery

It was noted that extortion rates were high especially for filling in police examination forms.

One of the midwives was reported by the staff to be abusive and disrespectful to them and to the patients. However, the In-charge had never reported this to any authority and therefore no action had ever been taken against her.

Utilities

There was no piped water connection throughout the facility since inception despite there being a water tap in the compound. The reason given was that the funds were insufficient to effect the connection.

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Ndejje HC IV Human Resources for Health

The In-charge is generally negligent and not in touch with his facility. Additionally, there was no evidence of any supervisory visit from the DHO in all the documentation available at the facility.

Infection control

There had been no water supply throughout the facility including the theatre and laboratory for over a year. The reason for this was the poor initial connection by the NWSC. No efforts had been made to intervene in the matter, and the only water source was harvesting of rain water.

Medicines and supplies management

There are two staff managing the store however, medicines are poorly managed. This is evidenced by non updated stock cards, non utilization of issues and requisition vouchers, and conducting medicines redistributions without proper authorizations and documentation.

Equipment management

The generator that serves as the only power back up source has not been functional for about a year, and no assessment has been made ever since to establish the cause, or to fix the problem.

Further, the only fridge in the laboratory had broken down for over six months and no efforts had been made to repair or replace. Vaccines were being stored in the Cold chain fridge.

Namulonge HC III The facility is comprised of three structures namely the OPD, maternity and general ward is being occupied by two nurses since there are no staff houses. Therefore, there are no admissions conducted despite having a Clinical Officer.

The In-charge rarely worked as he was usually at the district attending to other focal duties in coordinating TB and Malaria programs, as well as other duties assigned by the DHO.

There was poor medicines accountability in the stores. Issues and requisition vouchers were not being used therefore it was impossible to trace medicines.

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Major expiries were noted and this was attributed to the gross absenteeism by the In- charge and his staff who were rarely at the facility to treat patients and dispense drugs.

The facility structures are generally dilapidated, dirty and unkempt.

Kakili HC III The facility is housed in the Buganda Kingdom structures and therefore no developments can be made including putting up a fence, and constricting new toilets. The only two old toilets are dilapidated and filled up however, they are undergoing renovation at a cost of Ugx 18,000,000.

Further, the facility doubles as a community market. On market days, the facility is inaccessible by patients as it extends upto the veranda.

There are no staff residing at the facility and the only available housing is occupied by the askari.

All patients including male, female, and children are admitted in the general ward.

The medicines store was being managed by the In-charge however, it was grossly mismanaged as she was never in the facility.

The facility is in the neighborhood of the district headquarters however, there is no evidence of supervision by the DHO.

Kasozi HC III Staff attendance was good compared to the rest of the facilities in the district, as the staff scheduled to work were available at the time of the visit.

There was proper inventory management and documentation.

Part of the facility land had been encroached on by local people. This was reported by the In-charge to the DHO but no action was taken. The former CAO had attempted to intervene but the district was not willing to take action including the DHO.

4.0 RECOMMENDATIONS

i) Reprimand of errant officers including sub-county chiefs

ii) There is need to conduct full drug audits in all facilities visited

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iii) Institute inventory registers at ever facility

iv) Strengthen supervision by sub-county chief, Health Sub Districts and the District Health Teams

v) Orient HUMCs to understand their roles better

vi) There is need for proper medicines supply chain management in all health facilities.

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