SIRONKO DISTRICT HEALTH STATUS REPORT June 2012

Medicines and Health Service Delivery Monitoring Unit (MHSDMU)

Plot 11 Martyrs’ Lane Ntinda

P.O Box 25497

Tel: 0414 288442/5, Toll Free 0800100447

SIRONKO DISTRICT HEALTH STATUS REPORT

BACKGROUND MHSDMU is mandated to monitor health service delivery in the country and make appropriate interventions. This is done both routinely and in response to issues raised. A team from the unit has carried out a detailed monitoring exercise in Sironko district. 23 government health centers were visited in total. The district Health office was also visited and financial audits were done.

This is a summary report highlighting findings. Part one of the report has general finding, part two has specific finding, and part three has general recommendations.

OBJECTIVES (i) To respond to complaints raised through MHSDMU toll free lines, mTrac 8200 anonymous Hotline and other sources. (ii) To conduct a medicines management audit in all health facilities and the district. (iii) To assess the utilization of the PHC and other funds released to the respective health facilities/ office. (iv) To conduct head counts in all visited health facilities, assess absenteeism and professionalism of staff. (v) To assess Infrastructure and equipment management and/or development in the facilities/district. (vi) To collect data on various service delivery parameters using the MHSDMU tool. (vii) To conduct a search in private health facilities as appropriate. (viii) To organise meetings with district leaders and discuss the findings and devise means with clear time frames of when the findings will be enforced. (ix) To write a detailed report and submit it for consideration and further follow up.

GENERAL FINDINGS

POSITIVE FINDINGS

Moderate facilities

• Moderate health facilities were identified during the course of the exercise. This was measured on staff attitude towards work, staff commitment, general cleanliness, staff attendance, patients’ attendance and community appreciation. The facilities were: i. HCII, under the leadership of Mr. Olupot James Peter. ii. HCIV, under the leadership of Dr. Bofu Levi. iii. Buwalasi HCIII, under the leadership of Mr. Matanda Edward. iv. Bulwala HCIII, under the leadership of Macheri Leonard. v. Butandiga HCIII, under the leadership of Nakakuyu Irene. vi. Buboolo HCII, under the leadership of Kainza Hasifa. vii. Bulujewa HCIII. viii. Budenge HCII, headed by Mr. Musa Otirima.

Committed staff

• MHSDMU team came across very committed staff, with good attitude towards their work during the monitoring exercise. They were: i. Mr. Odiya Clement, a clinical officer at Bumulisha HCIII, who was the only person present and the only resident at the facility. ii. Gimono Beatrice, a mid-wife at Buwasa HCIV, who was the only resident staff at the HC. iii. Wanyenze Grace, the in-charge of Bunaseke HCIII. iv. Wanyara Agnes, a registered nurse at Bugitimwa HCIII, who does tremendous work for the community. v. Oguba Lamech Tanga, the in-charge Bumumulo HCIII. vi. Maloba Getrude, an enrolled mid-wife at Simupondo HCII. vii. Wagabyalire Betty, the in-charge of Bubeza HCII. viii. Wadada Elizabeth, in-charge Buyaya HCII.

Recruitment of well qualified cadres

• The district staffing levels were noted to be at 58%. More interesting was that all health units were headed by well qualified staff. For example, all HCIIIs were headed by Senior Clinical Officers and HCIIs by Nursing Officers.

NEGATIVE FINDINGS

1. HUMAN RESOURCE

Absenteeism and Negligence of duty

• The MHSDMU team realized during the monitoring exercise that; Staff absenteeism was high in the district. This was noted in almost all the Health Centers. For example: i. At Bumulisha HCIII by 10:30am, Mr. Odiya Clement was the only person present. ii. At Buwasa HCIV, by 4:30pm, the facility was already closed and Gimono Beatrice, the mid-wife who stays at the HC was the one that opened for the team. iii. At Bugusege HCII, the facility was found closed at 10:49am and the In-charge, Kusima Mary Gorette, had locked the facility and moved with the keys the previous day, and was not planning to work that day.

Lack of Uniform/IDs

• During the course of MHSDMU’s Monitoring, the team realized that all the health workers in the district lacked Uniforms and identifications/tags.

Un-confirmed staff

• The team, also established that most of the staff had been working for over 3 years and were still not yet confirmed/ probation. For example: i. Dr. Levi Bofu, has worked for one year as in-charge Budadiri HCIV, but is not yet confirmed. ii. Okarang Gilbert, a Clinical officer at Buteza HCIII, has arrears for 8 month and he has been on probation for 3 years. iii. Wetunga Base, a nursing officer at Bugusege HCIII, who was recruited in April 2004 is still not yet confirmed.

Unpaid salaries/ arrears

For example:

• The following, were found not be getting their salaries/ missing arrears. i. Odiya Clement, attached to Bumulisha HCIII, has arrears of 4 months of 2009. ii. Chemeri Juliet, attached to Bumulisha HCIII, was recruited in February 2012 and has not yet started getting salary. iii. Dr. Levi Bofu, has worked for one year as in-charge Budadiri HCIV, but is not yet getting salary of medical officer. iv. Nakiride Judith, attached to Budadiri HCIV, is a nursing officer by appointment but gets salary for an enrolled Mid-wife. v. Mid-wife Kaari Rossette, attached to Buwalasi HCIII, was appointed in December 2011 and has not yet accessed the payroll. vi. Amecho Josephine, a lab technician at Buwalasi HCIII, has 4 months arrears for 2009. vii. Natega Derick, a lab assistant and Akiya Susan both staff of Bunaseke HCIII, are not yet on pay roll. viii. Kwaga Hadija, a mid - wife at Bulujewa HCIII, is not yet on pay roll.

Absconded staff

• The monitoring team, established that some staff had been recruited and posted to various health centers, but do not work. For example: i. Namonda Hassan, porter at Bugusege HCII. ii. Kisoro Milton, a clinical officer at Sironko HCIII. iii. The in-charge of Bunagami HCIII, Nagudi Gorrette. iv. Bulumbi Wilson, a nursing assistant at Bunagami HCIII. v. George Natanga, in-charge Bugitimwa HCIII. vi. Nabarayo Susan, a mid-wife at Bugitimwa HCIII. vii. Webombesa Beatrice, enrolled mid-wife at Mbaya HCIII. viii. Mbasha Charles, a nursing assistant at Bunagami HCIII. ix. Wangusi Geoffrey, a porter at Bunaseke HCIII. x. Natokyo Juliet, an Enrolled nurse at Bumumulo HCIII. xi. Kakayi Sylvia, a lab assistant at Bumumulo HCIII.

Lack of staff quarters

• There was lack of staff accommodation on premises, for all HCIVs, HCIIIs and HCIIs. • At Buyaya HCII, the only staff house was filled by beds by the sub-county leaders, and staff lack accommodation.

Staff house at Buyaya HCII filled with beds

Porters and Askaris manning clinical departments

• This was noted at Budadiri Health center IV, where a porter was left to handle HMIS records/ data. Because of this misdeed, the facility had lost all its data. • At Buteza HCIII, an Askari Mr. Mwere Silver was left to man the drug store, and a lot of drugs are missing. • Porters and Askari at Bunagami HCIII were found stitching patients and dispensing drugs. • Two porters at Bumumulo HCIII were found injecting and dispensing drugs.

Lack of records assistants

• There were no records assistants in all the health units visited. This challenge has however led to capture of wrong data and also loss of data as evidenced at Budadidiri HCIV.

Redundant Lab technicians

• The team noted that the district massively recruited lab staff, even in health Units where laboratory services were non-existent. The best example was in Buteza HCIII, where two lab personnel were recruited and are now redundant due to lack of a lab.

Erroneous recruitment of porters’ by personnel’s office

• The team discovered that the personnel’s office was illegally recruiting porters and posting them to health centers, e.g porter at Mbaya HCIII who was later withdrawn.

Uneven posting of porter and Askaris

• This is a very big challenge in the district; some HCIIs have three porters and two Askaris while other bigger health centers have none.

2. INFRASTRUCTURE AND EQUIPMENT

Bats infestation

For example:

• Bumulisha HCIII, Budadiri HCIV, Buwasa HCIV, Bugusege HCII, Buwalasi HCIII, Sironko HCIII, Buteza HCIII, Bunagami HCIII, Mbaaya HCIII, Bugitimwa HCIII. • The above mentioned infestation has led to damage of the facilities, and shows laxity of the District Vector Control Office.

Collapsed ceiling due to Bats infestation at Budadiri HCIV Bats infestation at Budadiri HCIV

Non-functional solar batteries

• Most of the health facilities had solar but was not functioning due to batteries, e.g Bumumulo HCIII, Bunaseke HCIII, Mbaya HCIII.

Lack of gas

• The monitoring team established that most of the UNEPI vaccine fridges lacked gas. This was noted in almost all health centers, for example Bumulisha HCIII, Sironko HCIII, Buteza HCIII, Buwalasi HCIII and Bugusege HCII.

Shoddy/ stalled structures

• The team also noted poor construction of health structures, and the structures were now a major threat to the inhabitants. For example. i. Budadiri HCIV, where the Male ward was not completed, especially the sewerage system, the manholes were now open and patients were using them as dumping areas. ii. Budadiri HC IV, the ceiling of children’s ward collapsed and now the facility is occupied by a destitute. iii. Budadiri HC IV, the ceilings in female/male wards are about to collapse. iv. At Bugusege HCII, the staff quarters that were handed over end of 2011, the roof is leaking and the ceiling has a major crack. v. At Bunaseke HCIII, the newly constructed staff quarters have cracks and the roof leaks. vi. At Bunaseke HCIII, the only Latrine for the facility has been condemned and is about to collapse. vii. At Bumumulo HCIII, the staff house which is not yet handed over has cracked. viii. The OPD structure at Simupondo HCII has major cracks. ix. The staff quarters at the Simupondo HCII, had leaking roof.

The following health centers had stalled structures

i. A lab at Mutufu HCIII has stalled since 2008. ii. Staff houses in Budadiri and Buwasa HCIVs have not been completed as required. iii. Theatre at Buwasa HCIV was constructed 6 years ago but is non-functional. iv. Stalled Eco-sun toilet at Simupondo HCII, for two years and has already cracked.

Collapsed ceiling in Children’s ward at Budadiri HCIV Destitute now occupying children’s ward at Budadiri

Incomplete manhole now filled with waste at Male ward in Budadiri HCIV Incomplete toilet at Bumulisha HCIII

Leaking chimney at new staff house in Bunaseke HCIII Shoddily constructed toilet now about collapse at Bunaseke HCIII

Dilapidated structures

• For example; Budadiri HCIV, has a very old and dilapidated staff quarters with leaking roof.

Dilapidated staff quarters at Budadiri HCIV shoddily constructed toilet at Buwasa HCIV

Filthy health facilities

• The vice was overwhelmingly evident in; Bumulisha HCIII and Buwasa HCIV, where human waste, blood stained cotton, blood on floor, syringes and vaccine bottles were all littered in the in the compound and inside the facilities.

Filth in bathroom at Bumulisha HCIII Filth in a patient’s toilet at Bumulisha HCIII

Blood spilled on entrance of theatre at Buwasa HCIV

Donation of old examination beds

• STAR-EC donated very old and non-functional examination beds to Budadiri HCIV and Buwasa HCIV. This donation was unnecessary since these beds are not serving any purpose to the facilities.

Nonfunctional examination beds donated by STAR-EC to Buwasa HCIV & Budadiri HCIV

Lack of toilets for patients and staff

For example:

• There was only one latrine at Budadiri HCIV, shared by both patients and staff. • At Buwalasi HCIII, the patients lack toilet. • At Bugusege HCII, the patients’ toilet was closed by the porter and cannot be accessed. • At Mutufu HCII, staffs share toilets with staff. • At Bumulisha HCIII, patients’ latrine was locked by the absentee porters and patients dispose off their waste in the compound.

3. THEFT OF GOVERNMENT DRUGS AND EQUIPMENTS

Theft of government drugs

• Nambafu Betty, mid-wife at Buwasa HCIV, was arrested with government drugs under her bed and some in a travelling bag.

Theft of Solar panels • The team established that; most of the solar panels at health facilities were stolen, and the community attributed this theft to absenteeism of staff at the facilities. For example; Bumulisha HCIII, Buwalasi HCIII, Bunagami HCIII.

Missing motorcycle and Bicycle

• The motorcycle for Bunaseke HCIII and bicycle for Mbaya HCIII were all found missing.

4. SERVICE DELIVERY

Underutilized HCIV and HCIIIs

• The district is severally affected by semi - functional health Centre IVs and IIIs. i. The team established that Buwasa HCIV, which is the HSD of Budadiri West, does not admit and closes at 4:00pm. ii. The remaining HCIIIs of Bumulisha, Buteza, Buwalasi, Sironko, Bunagami HCIII, Mbaya HCIII, Bugitimwa HCIII, Bumumulo HCIII etc, all headed by Senior Clinical Officers do not admit.

Lack of detailed supervision by DHO and HSD

• In all the facilities visited, there was no evidence of detailed support supervision both by DHO and HSDs. i. Looking through the support supervision books; no remarks on detailed supervision could be traced. It was only pleasantries written in the visitors’ books.

High utility bills at Budadiri HCIV and Bugitimwa HCIII

• Budadiri HCIV, had huge power bills now at a tune of over 10,000,000/=. The facility risks disconnection and being dragged to court to pay. • At Bugitimwa HCIII, water was disconnected two years ago due to failure to clear a bill of over 160,000/=

Lack of Health Management Committees

• In all the health Units visited, there were few functional health management committees. This could be one of the contributing factors to the current mismanagement of the health units.

Political interference

• For example the LCIII chairman of Buyobo, Mr. Waninga Robert, brought a teacher at Buyobo HCII to occupy part of the facility while staff lack accommodation. • The district health car has been taken over by politicians in the district. Controversy over ownership of Buyobo HCII

• There is an outstanding controversy over management of Buyobo HCII. The disagreement has led to the facility missing out on getting drugs and PHC.

Buyobo HCII still semi functional due to controversies Patients’ toilet at Buyobo HCII

5. DRUGS UTILIZATION AND MANAGEMENT

Poor drugs accountability

• This cut across all the health units in the district. However it was worth in the following health centers: i. At Budadiri HCIV, the Senior Clinical officer Mr. Wanyara Francis who heads the store could not account for drugs worth millions of shillings. ii. At Bugusege HCII, the In-charge Ms. Kusima Mary Gorrete could not account for drugs worth millions of shillings. iii. At Buteza HCIII, the drug store was run by an Askari and could also not account for drugs worth millions of shillings. iv. At Bumulisha HCIII, the in-charge Mr. Wadamba peter could not also account for the drugs. v. At Buwasa HCIV drugs worth millions of shillings could not be accounted for. 6. FINANCIAL UTILIZATION AND ACCOUNTABILITY

Poor financial accountability

• In most facilities visited by the monitoring team, proper accountability was not found. In most facilities, the available accountability found had forgeries, no receipts, and no activity reports. • At the DHO’s office, funds worth 66,000,000/= were not accounted for, and investigations are still ongoing.

SPECIFIC FINDINGS

BAMULISHA HCIII

• Absenteeism was high, C/O Mr. Odiya Clement was the only health worker on duty at time of our arrival 10:30am • Odiya Clement, C/O has arrears of 4 months of 2009 • Chemeri Juliet, E/MW was recruited in February 2012 and has not yet started getting salary. • Naburari Naume, is a N/A and has been volunteering since 2008. • All staff lacked uniform and identifications tags. • Bats infestation was very much and stench was all over. • Filthy toilets and bathrooms all covered with feaces and blood. • Solar was stolen at the HC, and the community blames it on general staff absenteeism at HC. • Empty vaccine bottles and syringes are littered in the compound. • Facility does not admit and it has 2 clinical officers. • The facility only had 2 beds in the i.e in maternity • The fridge had no gas. • Poor drugs management, no dispensing logs, stock cards not updated, no prescription books. • Maternity was too dirty. • No detailed support supervision done by the district apart from data collection staff.

MUTUFU HCII

• It’s a model HC in Sironko with very committed staff under the leadership of Alupot James Peter. • The facility sees over 1500 patients a month. • Facility has no furniture and space but the team operates on boxes, drug store and unfinished lab to serve patients. • They have functional solar. • They had no bats. • Stalled ( laboratory since 2008/2009 • No staff quarters at all. • Community wants it upgraded to HCIII • They had mama kits. • Overstocked with quinine and Diazopher. • Staff lacked uniform.

BUDADIRI HCIV

• The staff attendance was fairly well, with a committed in-charge Dr. Levi Bofu who has improved the performance of the HC. • The facility has power bills now at 10,000,000/= shillings. • Lacks a lab structure and are operating in maternity. • New staff houses not finished still lack power and water. • Shoddy work: i. Male ward not completed, especially the sewerage system, the manholes are now open and patients are using them as dumping areas. ii. Dilapidated staff quarters, leaking and about to collapse. iii. Ceiling of children ward collapsed and now the facility is occupied by a destitute. iv. Ceiling in female/male ward is about to collapse. • Bats infestation was high. • Broken down equipment were piled in former children ward. • Theatre main entrance not well done and water enters when it rains. • Theatre lacked lamp, oxygen concentrator was not functioning and suction machine. • STAR –E delivered very old non function examination bed. • The district had not yet selected a Health Management Committee for the HC. • They facility delivered 123 mothers in May 2012. • Nakiride Judith is a nursing officer by appointment but gets a salary for enrolled Mid-wife. • The facility has 1 latrine shared by patients and staff. • OPD does not open at night due to lack of power. • The facility is not fenced and this has increased thefts. • The lab technician is not yet on payroll. • STAR-E donated a CD4 machine but the facility lacks a lab to operate it. • The facility has no drug store and drugs are kept in dilapidated place with no power. • The facility had no records officer, data was being handled by a porter who had misplaced the data. • Staff lacked uniform. BUWASA HCIV

• There was theft of government drugs by Mid-wife Betty Nambafu • Absenteeism was high. Found closed by 4:30pm. Comments in visitors’ book were all about absenteeism. • Gimono Beatrice, a registered Mid-wife who is the only person based at the HC was the only person present. • Facility was abandoned and too filthy, feaces , cotton stained blood littered all over the compound. • The facility did not admit. • Found dumped old examination bed by STAR –E. • Theatre was constructed 6 years ago but not functional, lacks power. • The facility has no doctor.

SIRONKO HCIII

• The facility lacked the health management committee. • The DHOs office had not done any detailed supervision. • The clinical called Kisoro Milton has absconded from duty for so long above 2 years. • The facility was infested with bats. • The facility lacks staff quarters and has only two units for the 18 staff based attached to the unit. • The facility had a lot of expired drugs. • The health Centre had no gas. • The facility did not admit, it only had one bed in maternity. • Lacked a records assistant.

BUTEZA HCIII

• In-charge Mr. Wagoda Michael attended only 6 days in May. • The drugs delay to be delivered at the HC by couriers; they take 1 month from NMS. • The facility is unfit to be a health Centre III, it does not admit. • The staff commitment and attendance was fair. • PHC accountability was not at the health Centre. • Okarang Gilbert a clinical officer has arrears for 8 month and he has been on probation for 3 years. • The drug store was manned by an Askari Mr. Mwere Silver. • The facility has only 2 units for staff, the 2 are not yet complete. • The facility has no lab, but 2 people have been posted there and are now redundant. • Diabetic patients lack drugs and are many in the area.

BUGUSEGE HCII • The facility was found closed at 10:49am with patients stranded. • The drug store was found locked, the keys were with the in-charge and the only N/A available had nothing to use. • Abcondment, Namonda Hassan a porter does not work and the whole place was filthy. • The facility has four units but the staff do not sleep there. • Absenteeism was high, in-charge Kusima Mary had only worked 13 days in May. • There was no data for OPD attendance. • The facility was infested by bats. • The new staff quarters opened last year in October 2011, the roof leaks. • Wetunga Base who was recruited in April 2004 is still not yet confirmed. • The facility is wired but lacks power. • The facility had forged PHC accountability. • There was no drugs accountability. • Nadunga Sarah a volunteer N/A wants to be supported.

BUWALASI HCIII

• The facility was relatively good with committed staff led by Matanda Elly. • The facility had bats. • Solar panels were stolen. • Amecho Josephine a lab technician has 4 months arrears for 2009. • Patients lack latrine, the new latrine was poorly constructed. • The lab lacks equipment and supplies. • They have an HB machine donated by PREFA and it lacks supplies. • In May 2012, 234 mothers attended antenatal. • Mid-wife Kaari Rossette, was appointed in December 2011 and has not yet accessed the payroll. • The facility lacked a health management committee. • They lacked an inventory. • The facility has 3 units for 18 staff.

BULWALA HCIII

• All staff were on duty. • They had an inventory book. • They had PHC accountability. • DHO and HSD teams have never done detailed supervision. • The facility lacks accommodation for staff. • They lacked anti-malarial. • Carried 265 malaria tests in May 2012. • They had no expired drugs. • They deliver mothers at the facility BUTANDIGA HCIII

• Very committed staff and the in-charge works every day. • They lack transport at the facility. • Their PHC accountability was there and well done. • No detailed supervision done by the DHO’s office and HSD. • The facility delivered 14 mothers in May 2012. • They did not have bats at the facility.

BUNAGAMI HCIII

• Khisa Charles, was the only health worker at the facility, and the community said he’s the only one who attends to patients at the facility. • The in-charge Nagudi Gorrette has never worked. • Bulumbi Wilson a nursing assistant at the facility never works. • Mbasha, a nursing assistant does not work. • The facility lacked attendance register. • The facility does not admit. • The solar at the facility was stolen. • There was no accountability for PHC funds. • The staff quarters were abandoned and only one is occupied by the Askari. • The facility had no HMIS data. • The Askaris and porters were found stitching patients and dispensing drugs.

MBAYA HCIII

• The facility gets drugs for a health center two. • Webombesa Beatrice, an enrolled mid-wife has never reported on duty. • The facility had a lot of anti-malarial not being used. • The staff quarters were abandoned by the staff and are empty. • There was no accountability for PHC funds. • The drugs could not be accounted for. • The health center bicycle was taken by one of the nursing assistants who left the facility. • The in-charge Abdallah Meeri, worked for one day in May 2012. • The facility does not admit at all. • The solar batteries got spoilt and solar doesn’t work. • The facility had forged HMIS records which could not tally with data in user departments. • Lack of mid-wife had led the expectant mothers shun the place because of the facility being run by men only.

BUBOOLO HCII

• Staff attendance was excellent. • The facility lacked a staff attendance register. • The current in-charges is not a signatory to the account. • The facility lacks transport. • The facility lacked an inventory book. • There was detailed supervision done by in-charge of Budadiri HCIV. • The facility delivers mothers. • The porter at the facility does not do his work.

BUGITIMWA HCIII

• The in-charge Mr. George Natanga, does not work. • The facility lacked staff attendance book. • The facility had no inventory book. • The facility had no duty roster. • Detailed Support supervision had not done by DHO and HSD. • Nabarayo Susan, a mid - wife does not work. • The facility had no accountability for both PHC funds and drugs. • The facility has lacked water for the last two years due to failure to pay bills. • The staff lacked uniform. • Solar batteries got spoilt and the facility is now in darkness.

BUNASEKE HCIII

• Natega Derick, a lab assistant and Akiya Susan both staff of Bunaseke HCIII are not yet on pay roll. • Wangari Geofrey, a porter at the facility absconded from duty since beginning of 2012. • The former in-charge did not hand-over office and so some information cannot be accessed. • The newly constructed staff quarter leaks and has already developed cracks. • Staff lacked uniform. • The solar does not function due to batteries. • The facility lacks water due to blockage of water pipes. • The only latrine is condemned and is about to collapse.

BUMUMULO HCIII

• Natokyo Juliet, an Enrolled nurse and Kakayi Sylvia, a lab assistant have never reported at work. • Gimono Judith and her colleague who are employed as porters were found injecting and dispensing drugs. • The new staff quarters which are not yet handed over have a major crack. • The facility lacks power due to non-functional solar batteries. • The vaccine fridge was not functioning. • The facility had no health management committee. • The facility does not admit. • The placenta pit lacks a cover and staff are improvising with an iron sheet. • The new maternity ward is yet to be opened for use.

BULUJEWA HCIII

• The facility was infested with bats. • The facility had a lot of anti-malarial (4637 blisters). • The facility lacked a health management committee. • The former in-charge did not hand over to the in-coming in-charge. • The solar does not function due to batteries. • The facility has only 2 unit for staff accommodation. • The facility does not admit.

BUYAYA HCII

• The facility was well kempt. • The facility was infested with bats. • The solar batteries are faulty and so the facility is in darkness. • The facility lacks water. • There was no inventory.

SIMUPONDO HCII

• The OPD is has a major crack and is about to collapse. • The staff quarter leaks and the walls are cracked. • The facility has never been supervised and lacks a support supervision book. • The eco-sun latrine which has stalled for two years, is already cracked. • The facility lacks a delivery room.

BUDENGE HCII

• The facility is fairly managed with high numbers of patients flow. • The facility lacks accommodation though the new house is yet to be opened. • There was no financial accountability; the in-charge said it was at the district.

BUBEZA HCII • The facility has one mid-wife and 1 nursing assistant and five support staff. • The facility was not infested with bats. • The facility walls are cracked. • The facility lacked EPI fridge.

BUYOBO HCII

• The facility is still semi-functional due to controversy over ownership by district and the politicians.

GENERAL RECOMMENDATIONS

• The district vector control officer should help to curb down bats in the health units. • The district should immediately separate the power line of staff quarters at Budadiri HCIV, from the main Health Centre to reduce on the bills. • The district management should urgently put in place Health Management Committees in place to ensure smooth running of facilities. • Better drug management – ref to MOH or MHSDMU templates, use requisition and issue vouchers and all relevant documentations e.g. delivery notes and stock cards • Financial accountability: there is need to ensure full compliance; need for mentoring and training for In-charges by district auditing office; and detailed feedback should be availed to health units following submission of their accountability • Punitive punishment for wrong practice e.g. absenteeism and abscondment. • Underutilization of infrastructure and equipment: HCIIIs and HCIVs should admit and be supported to remain functional. • Sub-county chiefs should always supervise HCs in their area. • HMC should also make sure that staffs are at the health centers working. • Priority should be put on construction of staff houses in the district. • The district engineer should be answerable to the shoody/ unfinished structures in the district. • There should be in-depth, detailed supervision from district and central levels which should give feedback beyond pleasantries in health unit visitor’s books • Planning and prioritizing infrastructure maintenance e.g. dilapidated buildings, broken down equipment etc. • The district should work hand in hand with police to launch investigations into the increasing theft of solar panels in the health centers. • The DHO’s office should work closely with the District Service Commission to ensure that all staff that have finished probation are confirmed. • The personnel officer should ensure that staff who are not yet getting salaries are put on payroll and those with arrears are helped to get paid. • The DHO’s office should urgently supply gas for UNEPI fridges to all health centres. • The district should priotize construction of patients’ and staff toliets. • DHOs should liaise with MOH for staff uniforms. • Consultative planning with In-charges on construction and renovations should be thought about. • The district should recruit records assistants to take care of records in HCIIIs and HCIVs. • All absconders should be warned in writing if they can’t comply, be deleted off the payroll. • Controversy over Buyobo HCII should be resolved so as to make the facility functional. • Politicians should stop interfering with service deliver in the district