ST. FRANCIS HOSPITAL MUTOLERE

ANNUAL ANALYTICAL REPORT FOR THE FY 1st July 2015-30th June 2016.

KEEP THE CANDLE BURNING AND PASS ON THE LIGHT

Written by: Dr. Mugisha Jerome

Medical Director/CEO.

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ENDORSEMENT OF REPORT

This annual analytical report for St. Francis Hospital - Mutolere covering the FY 1st July 2015-30th June 2016 has been prepared by the management of the Hospital. I endorse that it represents management’s views on the position of the hospital in the period under report.

………………………………………………….

Dr. Mugisha Jerome

Chief Executive Officer

St. Francis Hospital - Mutolere

Date…………………………………..

This is to acknowledge that I have received this annual analytical report for St. Francis Hospital -

Mutolere covering the FY 2015/2016. I have read it and endorse its authenticity and the representativeness of the position of the hospital in the year under report

……………………………………………………..

Rev. Fr. Zeno Mbishinzimana

Chairperson of the Board of Governors

St. Francis Hospital –Mutolere

Date…………………………………………

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LIST OF ACRONYMS

1. ALOS: Average length of stay 2. BOR: Bed occupancy rate 3. C/S: Caesarean section 4. CORDAID: Catholic organization for relief and development 5. EDP: Essential drugs program 6. FSB: Fresh still birth 7. HBMF: Home based management of fever 8. HC: Health center 9. ITNs: Insecticide treated nets 10. OPD: Outpatient department 11. PHP: Public health program 12. PNFP: Private-Not-For-Profit 13. SUOop: Standard unit of output, outpatient equivalents 14. UDHS: Uganda demographic and health survey

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ACKNOWLEDGEMENT

I would like to acknowledge and recognize the contributions of the following individuals for the support rendered in the hospital operations and compilation of this 2015/2016 Annual Analytic Report. Mr. Pontius Mayunga (the Hospital Administrator), Mrs. Immaculate Asiimwe (The Human Resource Officer), Sr. Agnes Agaba (The Principal, Nurses’ &Midwifery Training School and her predecessor), Sr. Beatrice Kefureka (The Senior Nursing Officer), Ms. Katto Justine (Co-ordinator Public Health Program), Mr. Tuyikunde Peter (Hospital accountant), Mr. Paschal Nsekuye (head OPD) and Ms. Winnie Nyiramugisha (responsible for palliative care services) and all ward/departmental in-charges for the various technical and moral support provided during and in the process of compiling this report.

I wish to further appreciate the support the Board of Governors and its committees provide to the hospital management and staff which also enables us to continue service provision while fulfilling the mission of Christ’s healing ministry. I thank you very much.

The immeasurable contributions of every member of staff, from cleaner, receptionist, student, up to the most senior members of staff are appreciated for it is because of all the individual efforts, aggregated together, that we see this institution’s efforts all focus on bettering the wellbeing of the common man. May you forever find pleasure in bringing smiles to all those persons that are afflicted by bad health.

To our development partners, (including but not limited to Together for Uganda, Friends of Mutolere in Holland, Ministry of Health/GOU, UCMB, Kisoro district local government, Sustain for life (The Eurochange Charity), Humedica/Germany) and all others not mentioned here, many thanks for your generosity and big hearts. We sincerely thank you for your continued support for the poor and less privileged people. I pray we continue strengthening the existing cooperation so as to assure good quality health care, all in fulfillment of the mission of the Hospital.

To our clients the patients, may you continue finding and experiencing healing whenever you utilize this facility.

…………………………………..

Dr. Jerome Mugisha

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Table of Contents

1. Endorsement of report …………………………………….ii

2. List of acronyms…………………………………………………iii

3. Acknowledgement…………………………………………….iv

4. List of tables…………………………………………………….vi

5. List of figures…………………………………………………..vii

6. Important indicators and definitions……………………….viii

7. Executive summary……………………………………………….x

8. Chapter 1: Introduction…………………………………..1

9. Chapter 2: Health policy and district health services…………………..5

10. Chapter 3: Governance and management……………………………………….20

11. Chapter 4: Human resources for health…………………………………………..25

12. Chapter 5: Hospital finances……………………………………….28

13. Chapter 6: Hospital activities………………………………38

14. Chapter 7: Hospital support services……………………….60

15. Chapter 8: Quality and patient safety improvement……….64

16. Chapter 9: The training school……………………………66

17. Chapter 10: Hospital projects………………………………71

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LIST OF TABLES

Table 1: Demographic data for the catchment area compared to HSD, District and Uganda (Source: UDHS).

Table 2: Data of HCT coverage for the year 2015/16Table 3: Detailed MCH activities for the year 2015- 2016

Table 3: Detailed MC H activities for the FY 2014/15:

Table 4: Table indicating Number of OVC supported in year 2015/16.

Table 5: Performance of CCMB activities for the year 2015- 2016.

Table 6: Hospital compliance with statutory requirements

Table 7: Staffing status of the hospital

Table 8: SUOop per staff for the last 5 years

Table 9: Employment cost per SUOop comparisons 2011/12-2015/16

Table 10: Hospital budget against income for the FY 2015/16

Table 11: Trend of income over 5 years

Table 12: Hospital expenditure for FY 2015/16 compared with previous year

Table 13: Hospital expenditure categories over 5 years

Table 14: Average user fees per SUOop comparisons 2011/12-2015/16

Table 15: Average expenditure per SUOop 2011/12-2015/16.

Table 16: OPD utilization for FY 2015/16

Table 17: Mutolere hospital OPD diagnoses FY 2015/16

Table 18: Palliative care cases attended to in FY 2015/16

Table 19: Ophthalmology cases for the year

Table 20: HIV/AIDS counseling and testing activities FY 2015/16.

Table 21: IPD utilization for the year 2015/16

Table 22: Morbidity patterns 2015/16

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Table 23: Admissions and deaths per cause FY 2015/16 Table 24: Fast moving items at Mutolere hospital FY 2015/16

Table 25: Expiries for FY 2015/16

Table 26: Activities/outputs for the laboratory for FY 2015/16

Table 27: Quality/outcome indicators for the period for 2015/16

Table 28: Composition of school intakes and performance for the year under report

Table 29: School performance in last 4 years

List of Figures

Fig 1: Proportionate contribution of income sources to the hospital in FY 2015-2016

Fig 2: Proportionate contribution of User fees to total income in 5 years

Fig 3: Proportionate contribution of PHC conditional grant to total hospital income in 5 years

Fig 4: User fees plus PHC CG per SUOop and total recurrent costs per SUOop compared over a 5 yr period

Fig 5: Relative Contributions of different expenditure lines to total hospital expenditure

Fig 6: Main hospital expenditure categories

Fig 7: OPD cases over a 5 year period

Fig 8: Selected OPD diagnoses over a 3 year period.

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IMPORTANT INDICATORS AND DEFINITIONS 1. Inpatient Day / Nursing Day / Bed days = days spent by patients admitted to the health facility wards.

2. Average Length of stay (ALOS)

= Sum of days spent by all patients/number of patients

= Average length of days each in-patient during each admission. The actual individual days vary.

3. Bed Occupancy Rate expressed as %

= used bed days/available bed days

= Sum of days spent by all patients/365 x No. of beds

=ALOS x No. of patients/365 x No. of Beds

4. Throughput

=Average number of patients utilizing one bed in a year

=Number of patients/no. of beds

5. Turn over interval

=Number of days between patients

= (365 x no. of beds)-Occupied bed days/no. of patients

6. FSB (Fresh Still Birth): This is a baby born with the skin not peeling / not macerated. The fetal death is thought to have occurred within the 24 hrs before delivery. However it is important for us to know the trend of deaths of fetuses actually occurring in mothers who have arrived already in the hospital (Fetal heart sound heard on arrival). For this purpose we shall monitor FSB in total as well as FSB of fetuses who died in hospital. They have been separated in the table. The hospital should try to provide space to collect this information from the maternity ward/ delivery room.

7. Post C/S Infection Rate:

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= (No. mothers with C/S wounds infected / Total No. of mother who had C/S operations in the hospital) x 100.

= The rate if caesarean section wounds getting infected. It is an indicator of the quality of post- op wound care as well as pre-op preparations.

8. Recovery Rate:

= % of patients admitted who are discharged while classified as “Recovered” on the discharge form or register.

= (No. of patients discharged as “Recovered” / Total patients who passed through the hospital) x 100

9. Maternal Mortality Rate (for the hospital):

= Rate of mothers admitted for delivery and die due to causes related to the delivery= (Total deaths of mothers related to delivery / Total number of live deliveries) x 100

10. SUO = Standard Unit of Output. This is where all hospital outputs related to patient care are expressed into a given equivalent so that there is a standard for measurement of the hospital output. It combines Outpatients, Inpatients, Immunizations, deliveries, etc. which have different weights in terms of cost to produce each of the individual categories. They are then expressed into one equivalent. As the formula is improved in future it may be possible to include Out-patients equivalence of other activities that may not clearly fall in any of the currently included output categories.

11. SUOop = SUO calculated with inpatients, immunizations, deliveries, antenatal attendance, and outpatients all expressed into their outpatient equivalents. In other words, what would be the equivalent in terms of managing one outpatient when you manage e.g. one inpatient from admission to discharge? Please see the detail formula below or at the foot of table 9.

12. TB case notification rate = total cases of TB notified compared with the expected number for the population in one year =Total cases of TB Notified / Total population x 0.003.

13. OPD Utilization = Total OPD New attendance in the year / Total population of the area.

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EXECUTIVE SUMMARY

St. Francis Hospital Mutolere, a 210-bed capacity general hospital, was established in 1957 by the Franciscan Sisters of Breda (The Netherlands) as a church based voluntary health agency under the Catholic Diocese of Kabale. It’s located in Nyakabande sub-county, Kisoro district. In 1984, the hospital established a Nurses’ and Midwifery training school to effectively cater for the shortage of staff occasioned by failure to attract competent ones due to remoteness of the area which was still under the then Kigezi district administration. It is accredited by the UCMB.

As a health services provider as well as a contributor to the national pool of human resources for health, the hospital and its training wing have continued to achieve and contribute to the country’s national health-care system.

In the year under report, we saw an increase in SUOop from 161890 to 165913 maintaining the rise in SUOop over a 3 year period. The bed occupancy rate also increased from 66% in 2014/15 to 73% in FY 2015/16.

Economic efficiency as measured by total cost per SUOop showed a downward trend for the third year running. However staff productivity (SUOop per staff) has continued to show small increments over the years. Employment costs per SUOop have been rising as hospital makes attempts to pay salries near those of the government counterparts. The hospital continues to rely heavily on user fees to finance its activities. The other source of income, the PHC CG, is on gradual decline in real terms for the 10th year running and currently contributes about 15% of the total income.

In spite of this, employment costs continue to soar as do the costs of medical goods and services. Nevertheless, the hospital continues to post a dispensing rate above 95%, though it has a big debt burden with the drug suppliers.

The hospital and the training school continue to experience the challenges of high staff attrition which, together with high employment costs adversely affect its performance. The Hospital aspires to achieve its Mission of providing Holistic Care as is notable through Spiritual/Pastoral care as well as Social care to its health care consumers.

In the year to come 2016/17, the hospital will consolidate its gains, while continuing advocacy and lobby of major stakeholders to improve its ability to attract support necessary for offering quality services efficiently. Further, the hospital will emphasize high efficiency and frugality to reduce/contain the high costs of offering services that are threatening its long term survival.

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CHAPTER ONE INTRODUCTION

The Hospital and its environment History of the hospital St. Francis hospital Mutolere, a 200 bed capacity hospital, was established in 1957 by the Franciscan Sisters of Breda (The Netherlands) as a church based voluntary health agency under then Rwenzori vicariate. Today it belongs to the Catholic Diocese of Kabale. The hospital was run by the founding congregation of the sisters until 1994 when its ownership was handed over to the Board of Trustees of Kabale Diocese.

Starting the hospital was out of clear need to bring health services to the Bufumbira county, currently Kisoro district because the nearest hospital was located 80km away in Kabale. At the time, accessing Kabale hospital, then in Kigezi district was extremely difficult and Bafumbira were clearly deprived of health services, only relying on Kisoro dispensary that has since been converted into a district hospital.

At the time it was founded, Kisoro was definitely hard to reach owing to the geographical distance and lack of basic infrastructure. It is thus commendable that Dr. Bruno Rochus, a German, dedicated his life to the service of Bafumbira for nine years after a stint in the Second World War. By then, there was no telephone access. The roads were hardly passable. Thus his decision to come and serve the people of Kisoro, a place that is an exact opposite of his own birthplace, should forever be appreciated.

At its birth, only a dispensary and convent were built. The next 10 years saw construction of a theatre, X- ray block, main hospital building, some staff hostels, maternity unit, laundry and workshop. Today, there is in addition an OPD complex, a huge pediatric ward, medical and surgical wards, a maternity ward that has been upgraded and remodeled thanks to Mitteinender fur Uganda, a German charity organization. There is also an administration block, a new private wing, a chapel and a pharmacy. There is a training school with modern buildings donated by the people of the Kingdom of Denmark. A new girls’ dormitory has been constructed with funding from school savings and the Franciscan sisters of Breda. In brief a lot of improvements in infrastructure have occurred over the years.

The Hospital is currently governed by a Board of Governors (BOG) appointed by the Chairperson of the Registered Trustees of Kabale Diocese, the Bishop of the Diocese, currently, the Right Reverend Bishop Callist Rubaramira. The Hospital is run on a day-to-day basis by a management team appointed as outlined in the Hospital Charter. The Hospital is comprised of five (5) primary departments: Medical, 1

Nursing, Administration, Training and Community Health. The latter has for long served as the headquarters of Bufumbira East health sub-district until this mandate was withdrawn by the district. The medical section in turn consists of the medical wards (male and female), male surgical ward, female surgical ward, pediatric ward, maternity ward, gynecological ward with their support departments: X- ray, laboratory and Pharmacy. Currently the medical ward is undergoing extensive renovation and remodeling to provide space for nursing very sick patients (intensive care rooms are being provided). The surgical ward too is planned for massive overhaul to address challenges of modern day nursing.

The hospital is a general hospital providing both outpatient and inpatient services. The outpatient department runs specialized clinics in ophthalmology and HIV/AIDS. The inpatient services are organized into four major wards: medical, surgical, pediatrics and maternity. It has full time specialist in Obstetrics and gynecology and visiting surgeons from Holland as well as pediatriacian from the USA.

Location The Hospital is located in Gasiza, Nyakabande subcounty, Kisoro district. Kisoro district is a constituent of the four districts (Kisoro, Rukungiri, Kabale and Kanungu) in S.W Uganda served by Kabale regional referral hospital which provides, among other services, specialist healthcare services. The 4 districts also constitute the jurisdiction of the Catholic Diocese of Kabale and previously formed Kigezi region. Kisoro district is about 500km from Uganda’s capital Kampala which makes transportation of health supplies very costly, the resultant effect being high cost of doing business since petroleum products that drive the economy come to Kisoro from Kampala.

The Hospital is located 3 km from the headquarters of Kisoro District local government. Most of the health facilities in the Hospital’s catchment area are accessible by community roads but some become inaccessible during the rainy season. Kisoro District, neighbored by the Democratic Republic of Congo and the Republic of Rwanda, has a hilly terrain and this affects outreach and referral services during the rainy season, on top of causing damage to the hospital vehicles. Communication with lower health facilities has recently improved due to increasing access to cellular telephone networks, but is still dependent on individuals and the individuals’ phones because most health facilities lack dedicated telephone lines—either mobile or landline. Landlines are always damaged by lightening due to high mineral density in Kisoro.

The proximity of the hospital to two countries with recent history of political instability means the hospital occasionally receives casualties of civil wars and sometimes refugees seeking medical care. The

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latter are not able to pay medical bills and this has led to self- discharges and defaults on payments for medical bills.

The main road from Kisoro district headquarters to Mutolere, has been upgraded to bitumen standards. The walk-ways within the hospital have also been upgraded to bitumen standard making the problem of dust and consequent damage to delicate hospital equipment a thing of the past. This has also improved cleanliness of the hospital.

THE COMMUNITY AND HEALTH STATUS:

The population of Kisoro district is mainly Bafumbira and their local language is Rufumbira. Although this is spoken by majority of the people, those from the northern part of the district tend to speak Rukiga just like those in the neighboring Kabale, Rukungiri and Kanungu districts. English, the Uganda official language, is spoken by those with formal education. The main food crops are beans, Irish potatoes, cabbage, maize, sorghum, tomatoes and sweet potatoes. Some few animals like cattle, goats, sheep, poultry, and pigs are kept. Cash crops like coffee and tobacco are grown on a very small scale. There are two FM radio stations in our catchment area and the district as a whole. This is useful for relaying messages for example during the child days and other health campaigns.

Malaria has been the leading cause of admission among children and adults, though there is an increasing burden of trauma, respiratory tract infections and non communicable diseases. Although we are trying our best to improve maternal and child health services in the sub district and district as a whole, the difficult terrain and cultural factors remain a major hindrance. Pregnant mothers have to move long distances for pre-natal care. They have difficulties reaching the hospital to get skilled attendance at the time of delivery. More recently it has been observed that even those who are admitted waiting for labor don’t report the onset of labor for fear of possible interventions. This is premised on the belief that birth is a natural process that must be braved by a true African woman. Culturally, children are highly revered to the extent that the average woman here will produce more children than the national average of 6.5 children per woman. They detest caesarean delivery for it is believed to reduce the chances of producing more children. A number of women attempt herbal remedies before they can go to hospital for delivery.

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Table 1: Demographic data for the catchment area compared to HSD, District and Uganda (Source: UDHS).

POPULATION GROUP FORMULAE Catchment HSD District Area

(A) Total Population 15178 85662 254300 (Projected for the year under report)

(B) Total expected deliveries (4.85/100) x A 736 4155 12334 (4.85% of population)

(C) Total Assisted Deliveries 7334 in Health Facilities

(D) Tot. Assisted Deliveries (C/B) x100 7334 as % of expected deliveries

(E) Children <1 year (4.3%) (4.3/100) x A 51 3683 10935

(F) Children < 5 years (20.2/100) x A 3066 17304 51369 (20.2%)

(G) Women in Child-bearing (20.2/100) x A 3066 17304 51369 age (20.2%)

(H) Children under 15 years (46/100) x A 6982 39405 116978 (46%)

(I) Orphans (≈ 10%) = (10/100) x A 1518 8566

(J) Suspected tuberculosis in (A) x 0.003 8256 763 46 the service area:

PMTCT mothers tested 4781 14316

Mothers tested HIV 48 279

positive

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CHAPTER TWO:

HEALTH POLICY AND DISTRICT HEALTH SERVICES

Health Policy

Mutolere Hospital has been offering care in line with the National Health Policy I (NHP I) (2000- 2010) in its work implementation, and for the FY 2015/2016, it continued to align its health care delivery processes and strategies to the NHP II to fit in the National health goals. The hospital also follows Health Sector Strategic and Investment Plan 2010/11 – 2015/16 as the guiding framework for delivery of health services.

The National Health Policy II guided by the National Development Plan for the period (2009/10- 2013/14) focuses mainly on health promotion, disease prevention and early diagnosis and treatment of disease. The hospital realizes the relevance and importance of the focus of national health policy, given, as earlier noted, the majority causes of ill-health and death in the catchment area and in Uganda generally is preventable through health promotion and prevention. However, with a high density of government health centers offering primary health care in the district, we continue to invest in specialized care to address the unmet need for specialized care given the fact that the nearest regional referral hospital with specialists is in Kabale, 80km away. Furthermore, the increasing number and functionality of government health facilities implies the hospital has to move away from primary care to more specialized investigations and treatment to handle referrals from the health centers and the district hospital.

In planning for, and delivery of health services the Hospital has made use of the following policies: Uganda national policy guidelines for HIV voluntary counseling and testing (MOH, 2003), Policy guidelines on feeding of infants and young children in the context of HIV/AIDS (MOH, 2001), National Antiretroviral Treatment and Care guidelines for adults and children (MOH), 2003), ART policy as revised, the MDG,..Etc)

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In functioning as a general hospital with referral component within Kisoro district, Mutolere Hospital contributes to the District HSSP II targets which feed into the National HSSP II targets and this contributes to PEAP.

The Hospital provides Emergency Comprehensive Obstetric Care (EmOC) and comprehensive HIV/AIDS care services to the catchment area and hence contributing specifically to the Millennium Development Goals 5 and 6, but with its other services contributing to other MDGs.

The hospital has aligned its services to the Health Sector Strategic and Investment Plan (HSSIP) 2010/11—2014/15 which builds upon the previous two HSSPs. This HSSIP provides the medium term strategic framework, and focus that the Government intends to pursue in regard to attaining the health goals for the country. It is anchored on the NHP II, the National Development Plan and the Public Investment Plan, aimed at achieving the overall goals and deliverables of the country.

District Health Services

The 1995 Constitution and the 1997 Local Government Act mandates the District Local Government to plan, budget and implement health policies and health sector plans. These Local Governments manage public general hospitals and health centers and also provide supervision and monitoring of all health activities (including those in the private sector) in their respective areas of responsibility.

The hospital’s contribution to the development of the district health plan and its implementation is through the membership of various members of the hospital management team on district teams, and on other implementing partners’ teams. The hospital has a representative member on the District Health Management Team and an HIV/AIDS service providers’ committee. The Medical Superintendent or his representative attends discussion fora/meetings of the above meetings. Further, the DHO is a member of the hospital board of governors. The hospital participates in national programs like immunizations, including the national immunization days and national celebrations.

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Mutolere hospital provides services as a general hospital providing curative, preventive, palliative and rehabilitative services to its catchment area, which is according to the government and district health plan. The factors influencing the functioning of the hospital include inadequate funding (government support) for health care activities, high staff attrition, poor referral system, and poor understanding of health system functioning by politicians. This poor understanding is partly responsible for continued construction of health facilities so close to each other, ostensibly to “bring services closer to the people”, thus increasing duplication of services, and the stagnation of government subsidies to PNFP health care facilities over the last decade.

The National policy on Public Private Partnership in Health:

The public private partnership at district level is still evolving. Under this partnership, we envisage the following:

 Joint policy development and advocacy

 Joint coordination and planning

 Sharing information on resources available to ensure equitable access of the vulnerable population groups.

 Harmonization of human resource management systems including capacity building

The end result is improved collaboration between the government and the private not for profit service providers as a strategy for reducing morbidity and mortality and disparities in accessing health care.

Recommendation, Actions/Plans for the next year for the health policy and district health services.

The hospital hopes to continue to strengthen the relationship with District health services based on existing national and local policy. The second National Health Policy II (2010/11-

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2019/20) which is intended to guide the health sector for the next 10 years with a theme; “Promoting people’s health to enhance socio-economic development” will be a critical guide to strategic development of the hospital and its constituent departments.

The major focus for the NHP II shall be on health promotion, disease prevention and early diagnosis and treatment of disease with emphasis on vulnerable populations. Cost-effective and affordable primary, secondary and tertiary preventive services shall constitute the core health interventions in this policy. The hospital will align its services to the achievement of these goals.

Further, the third Health Sector Strategic and Investment Plan (HSSIP III) has been developed to operationalize the NHP II and the health sector component of the National Development Plan. The hospital will continue to align its activities to the achievement of the HSSIP III—the national minimum health care package.

At the local level, the hospital will cooperate with the requirements of the district PPPH coordination office once set up. Increased co-operation with the directorate of health in the district is expected.

PREVENTION AND HEALTH PROMOTION SERVICES

THE PUBLIC HEALTH PROGRAM

Public health department

The public health department over sees interventions/ programs geared towards disease prevention and health promotion within Bufumbira East HSD. The staff of the public health department develop an annual work plan and budget that is presented to the hospital management team by the head of department for discussion and then submitted to the district health office for approval. The work plan contains:

• Planning activities e.g. meetings

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• Activities geared towards disease prevention and health promotion e.g. integrated outreaches, environmental health outreaches

• Activities that support lower health units e.g. delivery of EPI supplies (vaccines & gas) and ambulance services for emergency obstetric referrals

The activities performed by the Public health program in the year under report include the following:  Social mobilization and Health Education both at the static unit and outreaches  Maternal Child Health (MCH) services and Prevention of Mother to Child Transmission of HIV (PMTCT),  Early Infant Diagnosis (EID) and follow up of Exposed infants  HIV Prevention services including HIV counseling and testing  Antiretroviral therapy,  Treatment for Opportunistic infections  Care and Support to people living with HIV/AIDS (PLWHAs)  Combating Child mortality among Batwa in Kisoro District (CCMB) and  Support to Orphans and Vulnerable Children (OVC).

Partners/Donors  St. Francis Hospital, Mutolere has continued to support MCH and HIV/AIDS prevention services though with much difficulties due to constraints in funding. The hospital undertook to support these activities following the withdrawal of CORDAID, hitherto the main financier.  CCMB activities were funded by Sustain for Life.  Other partners included Star South West and MOH that supported PMTCT and ART services,  OVC activities were funded by well-wishers such as ANS NALES and Together for Uganda Group. 1. MCH AND PMTCT SERVICES AT MUTOLERE HOSPITAL

Services offered included immunizations, ANC and PMTCT, Family planning and postnatal care. The activities were carried out daily at the static unit and during outreaches.

Despite the demand for services by the community, the outreaches were scaled down due to inadequate funding.

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Challenges in providing MCHC services

-Few staffs are trained in PMTCT while those who were trained left the hospital.

-Male involvement in PMTCT is still very low, this has greatly affected disclosure and PMTCT plus.

2. HCT services

These were provided daily at the static unit and during outreaches. The outputs for the year are tabulated below.

Table 2: Data of HCT coverage for the year 2015-2016

7. HIV/AIDS COUNSELING AND TESTING (HCT) No. of individuals No. of individuals No. of individuals No. of individuals No. of individuals No. of individuals Total

18mth- <5 years 5-<10 years 10 - <15 years 15 - <19 years 19 - 49 years >49 years

M F M F M F M F M F M F M F Category

H1-Number of Individuals counseled 37 45 20 16 10 25 46 86 768 1095 179 188 H2-Number of Individuals tested H3-Number of Individuals who received HIV 37 45 20 16 10 25 46 86 768 1095 179 188 test results 0 0 0 0 6 6 166 237 28 38 H4- Number of individuals who received HIV results in the last 12months 37 45 20 16 10 25 39 79 550 788 145 142 H5 – Number of individuals tested for the first time 0 0 0 0 0 0 0 2 25 37 2 4 H6-Number of Individuals who tested HIV positive 1 H7-HIV positive individuals with presumptive TB H8-Number of Individuals tested more than 7 7 218 307 34 46 twice in the last 12 months H9-Number of individuals who were 0 0 0 0 127 127 Counseled and Tested together as a Couple H10-Number of individuals who were 127 127 Tested and Received results together as a Couple 1 1 H11-Number of couples with Concordant positive results 1 1 H12- Number of couples with Discordant results 0 0 0 0 0 0 0 0 0 0 0 0 0 0 H13-Individuals counseled and tested for PEPH14-Number of individuals tested as MARPS 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 12 18 1 2 0 0 H15-Number of positive individuals who tested at an early stage (CD4>500µ) 0 0 0 0 0 0 0 1 12 18 1 2 0 0 H16-Number of clients who have been linked to care

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8. SAFE MALE CIRCUMCISION (SMC) S1. Expected Number of SMCs Performed (Monthly Target) Category Facility Outreach SC DC SC DC S2. Number of Males Circumcised (by Age Group-Years) and Technique < 2 13 (SC - Surgical SMC, DC - Device-Based SMC) 2<5 9 5<15 5 15-49 11 >49 Total SMC HIV Negative HIV Positive S3. SMC Clients Counseled, Tested and Circumcised for HIV at SMC site Total Clients Tested First Follow Up Visit within 48 Hours S4. Number of Clients Circumcised who Returned for Follow Up Visit within Second Follow Up Visit within 7 Days 6 weeks of SMC Procedure Further Follow Up Visit Beyond 7 Days Moderate S5. Clients Circumcised who Experienced one or more Adverse Events Severe (Report only Moderate or Severe AEs) Total Surgical SMC (SC) Device-Based SMC (DC) S6. Clients circumcised used circumcision Technique Other VMMC techniques Total Managed Locally S7. Action taken Referred

Challenges in providing HCT services  Trained Counselors are very few compared to the workload  We are not able to carry out HCT outreaches due to understaffing, people from hard to reach and far places can therefore not access our services.  Infrastructure; Counseling rooms are not enough to ensure privacy for clients

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Table 3: Detailed MC H activities for the FY 2015/16:

62.1 ANTENATAL NUMBER MATERNITY CONTINUED NUMBER Total 10-19 years 186 1st time this Pregnancy 2 20-24 years 635 A1-ANC 1st Visit for women No. in 1st >= 25 years 1033 M6: Women testing HIV+ in labour Trimester 1454 Retest this Pregnancy 0 10-19 years 76 A2-ANC 4th Visit for women 20-24 years 254 M7: HIV+ women initiating ART in maternity 5 >= 25 years 330 M8: Deliveries to HIV+ women in unit 144 A3- ANC 4+ for Women 787 Total 10-19 years 587 Live births 154 A4- Total ANC visits (new clients + Re-attendances) 20-24 years 1993 M9: HIV-exposed babies given ARVs 134 >= 25 years 2952 Total 1403 M10: HIV+ mothers initiating breastfeeding within 1 hr 1243 From A5: Referrals to ANC unit community services 44 M11: Babies born with low birth weight (<2.5kg) Total 14 14 A6-ANC Referrals from unit To FSG 13 M12: Live babies 2116 10-19 years 134 M13: Babies born with defect 3 A7-First dose IPT (IPT1) 20-24 years 499 M14: Mother given Vitamin A supplementation 1617 >= 25 years 815 M15: Newborn deaths (0-7 days) 29 10-19 years 93 10-19 years A8-Second dose IPT (IPT2 20-24 years 340 M16: Maternal deaths 20-24 years 1 >= 25 years 519 >=25 years 2 A9-Pregnant Women receiving Iron/Folic Acid on ANC 1st Visit 1862 Alive 15 M17: Born Before Arrival A10: Pregnant Women receiving free LLINs 1718 Dead 0 A11:Pregnant Women tested for syphilis 2121 M18: Birth asphyxia 40 A12: Pregnant Women tested positive for syphilis 28 M19 No. of babies who received PNC at 6 hours 1792 10-19 years 189 62.3 POSTNATAL NUMBER A13: Pregnant Women newly tested for HIV this pregnancy 20-24 years 652 10-19 years 115 (TR & TRR) >= 25 years 992 20-24 years 459 10-19 years 1 >=25 years 745 A14: Pregnant Women tested HIV+ for 1st time this 20-24 years 5 P1-Post Natal Attendances 6 Hours 1404 pregnancy (TRR) at any visit >= 25 years 11 6 Days A15: HIV+ Pregnant women assessed by CD4 or WHO CD4 15 6 Weeks 45 clinical stage for the 1st time WHO clinical stage only 3 6 Months A16: HIV+ Pregnant Women initiated on ART for EMTCT P2: Breastfeeding mothers tested for (ART) 14 1st test during Postnatal HIV Total (TRK + TRRK) 49 Retest during Postnatal A17: Pregnant Women who knew status before 1st ANC HIV+ (TRRK) 30 P3: Breastfeeding mothers newly 1st test during Postnatal testing HIV+ A18: HIV+ Pregnant Women already on ART before 1st ANC (ART-K) 31 Retest during Postnatal A19: Pregnant Women re-tested later in pregnancy (TR+ &TRR+) 560 P4: Total HIV+ mothers attending postnatal A20: Pregnant Women testing HIV+ on a retest (TRR+) 2 P5: HIV+ women initiating ART in PNC A21: HIV+ Pregnant Women initiated on Cotrimoxazole 15 P6: Mother-baby pairs enrolled at Mother-Baby care point Total 487 18 A22: Male partners received HIV test results in eMTCT HIV+ 3 349 P7: Vitamin A supplementation given to mothers 62.2 MATERNITY M1: Admissions 2508 P8: Clients with pre-malignant conditions of breast M2: Referrals to maternity unit 210 M3: Maternity referrals out 4 P9: Clients with pre-malignant conditions of cervix 10-19 years 208 20-24 years 205 >= 25 years 1191 M4: Deliveries in unit Total Fresh still birth 30 Macerated still birth 27 Live births 2108 Pre-Term births 90 1st time this Pregnancy 148 M5: Women tested for HIV in labour Retest this Pregnancy 151

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62.4 EXPOSED INFANT DIAGNOSIS (EID) SERVICES NUMBER 62.6 CONTRACEPTIVES 2.6 CONTRACEPTIVES NO. DISP. AT 62.4 EXPOSED INFANT DIAGNOSIS (EID) SERVICES NUMBER DISPENSED NO. DISP. AT UNIT NO. DISP. BY CBD OUT-REACH 1st PCR 32 D1: Oral: Lo-Femenal (cycles) E1: Exposed infants tested for HIV below 18 2nd PCR 16 D2: Oral: Microgynon (cycles) months of age < 2 months old 12 D3: Oral: Ovrette or other POP E2: 1st DNA PCR result returned Total 21 D4: Oral: Others (cycles) 4 HIV+ D5: Female condoms (pieces) E3: 2nd DNA PCR result returned Total 17 D6: Male condoms (pieces) HIV+ D7: IUDs (pieces) Total 29 D8: injectable (doses) E4: Number of DNA PCR results returned Within 2 weeks 29 D9: Emergency contraceptives 1414 from the lab Given to caregiver 26 62.7 MINOR OPERATIONS IN FAMILY PLANNING Numbers E5: Number of HIV Exposed infants tested Total 17 O1: Female sterilization (tubal ligation) 66 by serology/rapid HIV test at ≥18 months Positive O2: Male sterilization (vasectomy) 10-19 yrs E6: Number of HIV+ infants from EID enrolled in care 20-24 yrs E7: HIV exposed infants started on CPT Total 25 O3: Implant new users >= 25 yrs Within 2 months 25 O4: Implant revisits 7

62.5 FAMILY PLANNING METHODS NEW USERS REVISITS O5: Implant removals 1 10-19 Yrs

F1-Oral : Lo-Femenal 20-24 Yrs >=25 Yrs 62.8 CHILD HEALTH SERVICES 10-19 yea rs CHILD HEALTH 6 – 11 Months 12 – 59 Months 1 – 4 Years 5 – 14 Years F2-Oral: Microgynon 20-24 Yrs SERVICES M F M F M F M F >= 25 Yrs 10-19 Yrs C1-Vit A supplem 1st F3-Oral: Ovrette or another POP 20-24 Yrs 381 365 57 30 Dose in the year >= 25 Yrs 10-19 yea rs C2-Vit A supplem 2nd F4-Oral: Others 20-24 Yrs 11 6 207 194 Dose in the year >= 25 Yrs 6 2 10-19 yea rs 254 252 173 144 C3-Dewormed 1st dose F5-Female condoms 20-24 Yrs 53 63 75 40 in the year >= 25 Yrs 24 10 198 217 10-19 Yrs C4-Dewormed 2nd dose F6-Male condoms 20-24 Yrs 144 in the year >= 25 Yrs 10-19 Yrs C5-Dewormed 1st dose F7-IUDs 20-24 Yrs in schools in the year >= 25 Yrs 10-19 Yrs 26 25 C6- Deworming 2nd F8-Injectable 20-24 Yrs 179 348 dose in schools in the >= 25 Yrs 164 550 year 10-19 Yrs F9-Natural 20-24 Yrs >= 25 Yrs 62.9 TETANUS IMMUNISATION (TT VACCINE) 10-19 Yrs 7 Pregnant women Non-pregnant women Immunization in F10-Other methods 20-24 Yrs 9 6 Doses Static outreach Static outreach School >= 25 Yrs 16 14 T1-Dose 1 636 58 321 10-19 years T2-Dose 2 396 9 6 Total family planning users 20-24 years T3-Dose 3 339 11 29 >= 25 years T4-Dose 4 223 3 1 F11: Number HIV+ FP users T5-Dose 5 204 9

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62.10 HPV VACCINATION School Community Vaccination of girls 9 Yrs 10 Yrs 11 Yrs 12 Yrs 13 Yrs 14 Yrs 9-14Yrs 15+ Yrs V1-HPV1-Dose 1 81 113 48 53 27 13 V2-HPV2-Dose 2 V3-HPV3-Dose 3 62.11 CHILD IMMUNISATION Under 1 1-4 Years Doses Static Outreach Static Outreach M F M F M F M F

I1-BCG 992 909 146 60 I2-Protection At Birth for TT (PAB) I3-Polio 0 926 830 36 30 I4-Polio 1 369 340 109 116 I5-Polio 2 294 292 117 147 I6-Polio 3 291 282 147 143 I7-IPV 50 60 32 20 I8-DPT-HepB+Hib 1 359 335 118 117 I9-DPT-HepB+Hib 2 315 309 127 150 I10-DPT-HepB+Hib 3 294 296 149 144 I11-PCV 1 339 342 119 105 I12-PCV 2 303 256 126 137 I13-PCV 3 274 296 167 154 I14-Rotavirus 1 I15-Rotavirus 2 I16-Rotavirus 3 I17-Measles I18-Fully immunized by 1 year 227 237 106 131 I19-DPT-HepB+Hib doses wasted 139 124 43 56 2.12 HEPATITIS B VACCINATION Category Male Female HBV1-Number of health workers in a Unit HBV2-Number of health workers Immunized Doses1 HBV3-Number of health workers Immunized Doses2 HBV4-Number of health workers Immunized Doses3 HBV5-Number of health workers fully Immunized HBV6-Number of health workers not Immunized

63. OUTREACH ACTIVITIES Category Number Planned Number Carried out

OA1-EPI Outreaches 168 168 OA2-HCT Outreaches 4 4 OA3-Environmental Health Visits OA4-Health Education/Promotion Outreaches OA5-Maternal Death Audits OA6- Perinatal Death Audits OA7-Other Outreaches

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OTHER ACTIVITIES OF PUBLIC HEALTH PROGRAMME INCLUDE;

Health Education. Health education talks were carried out daily at the static unit, during outreaches and to some organized groups such as the Ngobyi groups. There are also education talks targeted to specific groups of people like mothers nursing malnourished children.

We also continued to use the TV set with tapes/CDs in Local languages to supplement on Health education talks. These are running throughout the day for continuous delivery of health messages especially to mothers attending ANC and YCC. However we have a challenge of producing enough materials in the local language. Most of the materials we have are in English and other languages that our clients could not easily understand.

VHTs gave health education talks and did home visits to individual families and communities. During Homes visits, Trained VHTs screened and referred clients for services such as HIV counseling and testing, ANC, immunizations, screening for T.B and Family planning.

Nutrition education and Cooking Demonstrations

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We continued to carry out cooking demonstrations weekly to mothers attending YCC and those attending children admitted to the pediatric ward. Mothers were taught how to prepare weaning foods using available local foods to prevent malnutrition in the under-fives.

Support to people living with HIV/ADS.

 We provided ongoing and adherence counseling to PLWHs. This has improved positive living and adherence to drugs.  PLWAs were encouraged to join the Health insurance Scheme of the Hospital so that they are able to access health care services easily. This improved drug adherence and retention in HIV care. Support to OVC:

Support to OVCs included School costs, scholastic materials and other necessities for students in Primary schools and secondary schools plus institutions. OVCs were also trained in simple skills development.

Simple skills development and trainings was done on Saturdays. Under skills development children were trained in sustainable Agriculture methods.

Training OVCs in sustainable Agriculture.

The training was sponsored by Together for Uganda.

The purpose of training the OVCs was to provide them with skills which would enable them earn some income through using low cost technology. We also aimed at improving the health of children through good nutrition.

During the training OVCs got exposed to the following;

 Vegetable grooming and management,  Preparing organic manures,  soil and water conservation,  home hygiene  food and nutrition  food processing / juice and jam making At the end of the training the beneficiaries were given inputs e.g. seedlings. Majority planted them and produced a variety of vegetables for consumption and some surplus for income. 16

Challenge

Most of the OVCs do not have startup capital; some do not even have where to practice the acquired skill. In addition the funding for this program is gradually reducing and could stop in the very near future.

Future plans;

We shall be using the produce for food for OVCs during the training days.

The surplus will be sold for income for maintenance of the garden. However sustainability is likely to be a big challenge.

There is hope that a new project to support the orphans will commence in the near future. It is expected to be funded through Together for Uganda.

Table 4: Table indicating Number of OVC supported in the year under report.

Activity Number supported

Number Support in Primary schools 88

Number supported in Secondary schools 67

Number supported in tertiary institutions 21 (3 were from university)

Number trained in sustainable agriculture 60

Challenges

 The number of OVCs continues to rise and yet the support is minimal.  The number of school drop outs is still high among the orphans due to failure to get school fees for secondary schools and tertiary institutions.  Some drop out of school to look after their old grandparents or their young siblings. 3. Combating Child Mortality among Batwa in Kisoro District (CCMB project) The project began in January 2009 under the Initiative of CARE International in Uganda and was later taken over by SUSTAIN For LIFE to date. The main objective of the project is to reduce mortality among

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Batwa children in Kisoro District. Batwa are a marginalized group of people who previously lived in/adjacent to Bwindi National park. When Bwindi was gazetted into a national park in mid 1990s, the Batwa were displaced and became homeless. They had nowhere to grow food and they started dying from preventable health conditions, including malnutrition in large numbers. The survival of their under 5’s was bleak. The strategy under this project is to provide integrated health services during outreaches.

The services provided during outreaches included: Community Mobilization for health services, Health education talks for positive behavior change among the Batwa. Other services included immunization and growth monitoring, Antenatal care, family planning and postnatal care. HIV counseling and testing services plus treatment for common diseases was also offered. Mothers are encouraged to deliver at the health facility. The above services have been offered to 31 Batwa communities who converged in 12 places/outreaches every month to access health services.

Table 5: Table indicating performance in CCMB activities for the year 2015- 2016.

Activity Total Remarks

Total Immunizations 1899 These include all vaccines for batwa and non-batwa

Growth monitoring 213 Both batwa and non-batwa.

Total number of Batwa children who were 13 One child died due to severe malnutrition. These were rehabilitated under weight from home.

ANC for Batwa mothers 164 Most of them attended from outreaches

Deliveries at health facilities. 32 5 were delivered by C/S

Family Planning 34 Were all batwa 27 were new acceptors, 21 were re-attendencies.

Total number of Batwa treated at the 329 . hospital as out patients (OPD)

Total number of Batwa admitted 179

Total number of patients treated at 3528 These included batwa and non-batwa. outreaches.

HIV Counseling and Testing 336 2 male tested HIV positive.

Challenges in providing CCMB activities  Most of the Batwa are landless and very poor, this hinders positive behaviour change.

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 We get many Batwa coming in the hospital with injuries due to fighting or as a result of falling down after excessive alcohol consumption  The funding for the CCMB project is soon ending and we are worried we may not get more funding to continue the activities. Achievements:

 Health seeking behaviour has improved, most of the Batwa go to health facilities or outreach posts for treatment. It is hoped that if this culture is maintained, the Batwa will start attending to free health units nearest to them.  Batwa no longer fear to be admitted at the hospital when they are sick.  Mothers go to deliver at the health facilities.  Environmental and personal hygiene has gradually improved.  Some Batwa are engaged in Income Generating Activities. This is a sign of development.  Integration of Batwa with other local communities is gradually improving. Efforts to overcome the constraints:

All activities were integrated.

If the support continues we hope for continued positive change among the Batwa.

Appreciation.

We appreciate the support from:

-St. Francis hospital, Mutolere supported Immunizations and ART services.

-PHC funds through Kisoro District LG.

-MOH which provided us with HIV Testing kits and ARV’s

-Star-SW for continuous support supervision and support to Family Support Groups

-Together for Uganda, Ans Nales and all well-wishers who supported orphans education

-SUSTAIN FOR LIFE that supported outreaches to Batwa communities

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CHAPTER THREE:

GOVERNANCE AND MANAGEMENT The legal and registered owner of the Hospital is the Roman Catholic Diocese of Kabale in the person of the Board of Trustees of the diocese. The Hospital by-laws and powers of signatory are held by the Board of trustees who are the custodian of the Mission and maintain the continuity of the Hospital by assigning and delegating functions to the Board of Governors (the supreme policy making, governing and controlling organ) and its Committees, and Management Team. All the details about Governance, Accountability and Management are embedded in a document “St. Francis hospital Mutolere Charter” which was updated and approved in October 2010 by the BoG. The Charter details on issues of ownership, the mission, goals and values of the hospital and further provides guidance on the terms of reference for BoG members and management team. The employment manual which describes how human resource is to be managed has had some amendments to put into consideration current changes in the labor laws of Uganda. At the diocesan level, the hospital is represented to the diocesan health board where vital policy decisions regarding diocesan health services are taken.

THE BOARD OF GOVERNORS:

This is the overall policy making body for the hospital. Policies are made in accordance with guidelines/standards from UCMB as well as the MOH. The Bishop, in consultation with the hospital management team appoints them. They meet twice in a year (in May to, among other things analyze budget performance and forecast the revenue and expenditure for the coming year; and then in December to, among other issues receive report on performance towards indicators of faithfulness to the Mission). This schedule has however been adjusted by the board to allow three meetings to provide closer supervision and guidance to the hospital management team.

The BOG is assisted by committees to carry out its functions. The committees include:

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1. The Executive Committee (Standing / Finance Committee): this committee is charged with assisting the management team with developing sound financial policies and plans, monitoring and adapting implementation.

2. The Quality Assurance, Discipline & Grievance Committee: this is charged with enabling the hospital bodies and staff to continuously improve the quality of the health services and to improve the confidence in- and satisfaction with- the health facility of the internal and external communities. The latter includes assuring impartial management of discipline and grievances. Thus the committee advises staff, department heads, HMT and BOG with respect to all matters pertaining to quality improvement, handling of complaints and grievances of patients and or their attendants, staff, and external stakeholders.

3. Pastoral, Social and Ethical Committee: this is charged with enabling the hospital bodies and workers uphold the highest holistic care standards for health services as determined by the RCC in Uganda. The committee therefore firstly assists the BOG, HMT, and the hospital staff in detecting pastoral, social, ethical, deontological and human rights issues arising from clinical practice and management processes. It then assists these hospital for a in determining the correct answers in the light of RCC pastoral care and social welfare teachings, RCC ethics , the guidelines of the Health Commission and the codes of conduct.

4. Recruitment and training committee: this is charged with enabling the hospital to uphold transparent personnel development and promotion of standards as determined by the RCC in Uganda. It advises departmental heads, personnel office, HMT and the BOG with respect to general and individual principles and procedures for staff recruitment and training. It also acts as training sponsorship award committee.

5. The HTI BOG subcommittee: This is charged with responsibility of overseeing the activities of the nurse training school and advice the Board accordingly.

In terms of compliance with the UCMB requirements, the hospital has endeavored to meet the requirements for accreditation for the year 2015/16, the reason it was accredited. The statutory requirements for UCMB affiliated hospitals are tabulated below:

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Table 6: Hospital compliance with statutory requirements

No REQUIREMENT Did you Comment achieve it?

Yes, Partly, No

Government / MOH Requirements

1 PAYE YES Always paid on time. The hospital has won the vintage award for being the most compliant tax payer in western region.

2 NSSF YES Always paid on time and hospital has received recognition from NSSF for being compliant.

3 Local service tax YES

4 Annual operational licence YES Processed through UCMB

5 Practicing licence for staff

7 Monthly HMIS YES Given on time

UCMB statutory requirement

1 Analytical Report end of FY year YES

2 External Audit end of FY year YES

3 Charter (still valid)* YES

5 Contribution to UCMB for the year YES

6 HMIS 107 PLUS financial report / quality YES indicators ending FY

7 Report Status of staffing as of end of financial YES year

8 Manual of Employment (still valid) YES

9 Manual of Financial Management (still valid) YES

10 Report on Undertakings and Actions of the YES year

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*GOU statutory requirements are a must not for accreditation but ensuring the hospital operates in a regulated legal framework. There is another GOU statutory requirement that has been complied with: attaining a license to operate radiation equipment. This however followed an unpleasant experience of closure of our radiation equipment.

The hospital management team:

The hospital management team comprises of the Medical Superintendent—who also chairs the team’s meetings, the hospital Administrator, The Principal of the Nurses’ & Midwifery training school, The Senior Nursing Officer, The Human Resource Officer, the co-coordinator public health program and the hospital bursar. The HMT is charged with day-to-day running of the hospital, implementing BoG policies and providing to the Board information necessary for policy formulation, and strategic decision making.

The HMT implements activity plans in consonance with BoG approved annual budgets, and ensures prudent management of resources (including Financial, Human, and Capital resources) and information.

Hospital Management team normally meets every 2 weeks (there may be some variations depending on availability of members) to discuss major issues arising and review progress of works and plans. The HMT ensures consistent compliance with statutory requirements of the hospital and the Nurses’ & Midwifery Training school with UCMB, Ministry of Health, Uganda Revenue Authority (URA), National Social Security Fund (NSSF), and Ministry of Education & Sports. The team ensures compliance with the statutory requirements.

Communication between the BoG and HMT is mainly through the bi-annual BoG meetings, and this is mainly documented in board minutes. Occasionally and in exceptional circumstances, HMT communicates to BoG members in between the BoG meetings usually by telephone or verbally— sometimes to seek opinion and guidance.

BoG policy decisions and recommendations are communicated to HMT in HMT meetings that immediately follow the Board meeting by either the M/S or the Hospital Administrator, where as well, implementation strategies are laid out. The decisions and/or recommendations from BoG are communicated to the staff through written notices to departmental notice boards and the staff conference. For day-to-day information dissemination from HMT to staff is through departmental written notices, and intra-departmental communication is through unit in-charges in liaison with

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respective heads of departments. External (outside the hospital) communication for information or communication is through the Medical Superintendent or a specific approved designate. The storage and access to important hospital information is rather lax, and would easily land in wrong hands.

Recommendations, Action Plans for FY 2016/2017 for Management

The HMT will endeavor to sustain the good practices (such as regular HMT meetings, and timely submission of reports for accreditation), and improve on the shortfalls for the past year, the hospital now employs a person responsible for information, communication and marketing who, though attached to the public health program, assists the main hospital; we intend to develop some guidelines such as the Information, Communication and Data Management guidelines, which are not in existent and other related documents as well as development of other Policy documents such as the Volunteers’ policy, donations policy and trainees’ policy etc. for review and consideration by the BoG.

Advocacy, Lobby and Negotiation

For the year under review, FY 2015/2016 the hospital continued, albeit with challenges, to implement activities under the strategic plan, 2012 - 2016.

Advocacy activities are conducted at every opportunity as it arises with church leaders, politicians— particularly the District council members, and members of parliament and technical staff from the relevant ministries.

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CHAPTER 4: HUMAN RESOURCES FOR HEALTH

Labour capacity as at 30th June 2016

The total workforce for the year under report was 178 staff as compared to 176 as at 30th June 2015, inclusive of Clinical staff, non- Clinical staff & Training school staff. Replacements were done to fill the gaps for those who leave in order to be able to offer good health service to our patients.

Table 7: Staffing status

June 2015 June 2016

Clinical Staff 88 92

Non Clinical staff 67 64

Training school staff 21 22

Total 176 178

As shown from the table above, of the 178 staff for the year under report, 52% were employed to offer clinical services, then 36% to provide non clinical support services like administrative work, cleaning and security services, and 12.5% for the training school. It is however still a big challenge to the hospital given the fact that our staff most especially the clinical staff keep leaving for government jobs and better job opportunities as it will be shown in the trend of attrition below.

Staff Productivity

As shown on table 1 above, total number of staff that directly offer health services to the patients for the year under report was 156. Below is a table showing staff productivity over five years.

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Table 8: SUOop Per staff for the Last five years

2011/12 2012/13 2013/14 2014/15 2015/16 SUO op 170168 162489 153546 161890 165913 Number of Staff 155 156 155 155 156 Av. SUO per staff 1098 1042 991 1044 1064

The above table shows the contribution of staff for the past five years. For the year under report, the average SUOop per staff was 1064 which is a slight improvement compared to the previous year. On average, every staff works 2080 hours in a year. Considering the year under report, the Hospital’s productivity is 79.8 meaning that for each hour of total labor in a year, the staff contributed 79.8 output per hour.

Analysis of the Employment Cost

The hospital over the years has had a desire to motivate employees. It is however still a bigger challenge since most of the staff especially the clinical staff that keep running away to government and other organization that are offering slightly bigger remuneration. The table below shows a comparison of the employment cost over the Standard Unit of output for the past five years.

Table 9: Employment Cost per SUO op comparison from 2011- 2016

2011/12 2012/13 2013/14 2014/15 2015/16

Employment cost 768,803,577 752,377,168 885,023,697 945,962,483 987,418,803

SUO op 170168 162489 153546 161890 165913 Av.Emply.cost per SUO 4518 4630 5764 5843 5951

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The above table, manifests the efforts made by the hospital over years in attempting to have the staff motivated. There is an increase over the years in average employment cost per SUO op, implying a motivational strategy to retain staff.

Staff turnover of key selected staff (Clinical staff)

The key clinical cadres include Doctors, Clinical officers, Allied health professional staff, Enrolled Nurses, Enrolled comprehensive nurses and Enrolled midwives. The turnover rate for the clinical staff for the year under report 58%, with the enrolled comprehensive nurses having the highest rate which is 33%. Most of them joined the government others went for further training. Efforts have been made to replace this cadre with the Enrolled Nurses following information from the MoH that soon the enrolled comprehensive nurses shall be phased out.

Existing gaps

In as far as filling the existing gaps, the hospital needs a radiographer. Currently, there is a part- time radiation safety officer assisting us in offering X-ray services. There is also a need of anesthetist. However, the hospital has sent one of the staff to pursue training in this course with hope that he will be with us after completion of the course. Further the hospital has identified another committed staff to pursue the same anesthesia course and he should go to school as soon as he has the requirement i.e two years’ experience post qualification as a registered nurse.

Our training school is faced with a challenge of lack of tutors. It has proven to be difficult to get those interested in coming here. To be able to solve this, 3 of our staff have been sent for training.

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CHAPTER FIVE:

HOSPITAL FINANCES St Francis Hospital Mutolere currently keeps financial records centered on modified accounting procedure which handles both cash based and accrual-based accounting system. This is where income is recognized when it is received or when it is not yet received and expenses are incurred when it is paid and when it is expected to be incurred. All financial records are manually kept aided by excel.

Up to date reports on the hospital’s monthly, quarterly and annual financial status are prepared for the management, finance and board of governors to review. Such reports include: income versus expenditure report, trial balances, annual budgets as well as annual financial statements especially

income versus expenditure and balance sheet statements.

Table 10: A table showing Hospital Budget against actual income for FY 2015-2016

% ge Annual Actual Income Budgeted Income Actual Income FY Income of the Income Line FY 2014-2015 FY 2015-2016 2015-2016 budgeted

User Fees 1,158,337,700 1,207,000,000 1,328,883,891 110

PHC CG(Hospital) 287,746,352 287,756,400 289,358,126 101

Donations 130,871,476 520,000,000 488,058,580 94

Other Incomes 189,987,813 250,380,652 193,857,884 77

TOTAL INCOME 1,766,943,341 2,265,137,052 2,300,158,481 102

The overall financial performance in terms of income was 102%. The hospital received 110% of the budgeted user fees and 101% of the budgeted PHC CG. User fees continues to form the bulk of the

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hospital income, a sign of inevitable fall in equity as a result of stagnating government support in form of PHC CG over the last couple of years. This is inspite of increasing cost of rendering health care.

Figure 1: PROPORTIONATE CONTRIBUTION OF INCOME SOURCES TO THE HOSPITAL IN FY 2015-2016

User fees accounted for 58% of the total income of the hospital. There has been a decrease compared to last year, when user fees accounted for 66% of the total income. However, this can’t be registered as reduction in total user fees but increase in other source of income like donations. With the increasing cost of doing business occasioned by rising costs of medicines, employment costs, costs of utilities among others, the hospital has, over the years continuously raised user fees since government subsidies have stagnated in absolute terms (thus declining in real terms). The table below gives the picture over a 5 year period.

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Table 11: Trend of Income over the last 5 years

Description 2011-12 2012-13 2013-14 2014-15 2015-16

User Fees 917,158,414 916,804,540 952,498,810 1,158,337,700 1,328,883,891

PHC CG 262,253,305 284,815,815 282,644,108 (Hospital) 287,746,352 289,358,126

External 190,478,000 237,980,850 93,003,696 Donation 130,871,476 488,058,580

Credit Line

Both (Drugs & lab 74,215,322 - - Supplies) - -

Other Income 88,418,388 224,908,485 335,863,951 189,987,813 193,857,884

Total Income 1,532,523,429 1,664,509,690 1,664,010,565 1,766,943,341 2,300,158,481

From the table above, it is evident that the hospital has continuously attempted to raise more money in form of patient fees and this explains the gradual increase over the years and the higher proportionate contribution as compared to other income sources over a 5 year period. However, the proportion of patient fees in 2015-16 to total income, reduced because of increase in other source of income like external donations as it is observed in the figure below.

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Figure 2: Proportionate contribution of User fees to total income in 5 years

User fees collection as a proportion to the hospital income shows a slight decline in two consecutive years (2011-12 and 2012-13) followed by a slight increase in 2013-14 and 2014/15. Since the hospital serves the population with no discrimination and is performing duties that are a constitutional mandate of the government, it should be helped to subsidize costs by receiving higher support in form of PHC CG and essential drugs so that access for the poor can improve. This will eliminate the need for people to move long distances, often bypassing the hospital in search for free government health care. The hospital would further decongest the government health units that are overwhelmed by patients who fear the costs of the PNFP hospital and end up staying on floors of the government hospital in search of free health care. In addition the now increasing number of self- discharges/run away cases would be significantly reduced.

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Figure 3: Proportionate contribution of PHC conditional grant to total hospital income in 5 years

The graph shows PHC CG as percentage of total income over a 5 year period. Of importance to note is the stagnation in the relative contribution over a three period followed by a further decline in the year under report. It needs to be appreciated that such stagnation has occurred despite continued increase in the cost of doing business and the continued increase in costs of utilities and supplies.

Over the years, the gap between the main sources of income combined in comparison to the SUOop (User fees and PHC CG per SUOop) and total hospital recurrent costs per SUOop has continuously widened leaving funding gaps (see figure 4 below).

Fig 4: User fee and PHC CG per SUOop plotted against the total recurrent cost per SUOoop over a 5 year period. Notice the funding gap

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Such funding gaps are compensated by:

• Donations in kind

 Used equipment

 Donated sundries

 Personnel (expatriates) on short term placements

 Specific project support

 Staff secondment (1 doctor by MOH, 1 doctor under SDS, 1 orthopedic officer, 1 lab technician)

 Laboratory reagents

 Drugs in kind for specific diseases (ARVs, Septrin, vaccines

• Relatively fewer staff (both in numbers and skill mix)compared to work load

Hospital expenditure.

The budget expenditure performance was according to plan (i.e. 99%). There are no over-spent votes, which is a sign of financial discipline on the side of the management team.

Table 12: Hospital expenditure for FY 2015/16 compared with the previous year. 33

Budgeted %-ge of Actual Expenses FY Actual Expenses Expenditure Line Expenses FY Budgeted 2014-2015 FY 2015-2016 2015-2016 Expenditure

Employment Costs 945,962,483 991,001,000 987,418,803 100

Hospital Board Cost 6,382,600 7,000,000 5,867,000 84

Administration Costs 64,354,900 95,312,052 69,690,197 73

Property Costs 124,116,838 132,501,000 133,702,128 101

Transport &Plant Costs 24,453,320 52,500,000 45,736,630 87

Supplies & Services 4,283,500 8,000,000 5,353,000 67

Medical Goods & Sundries 364,201,712 431,800,000 500,292,526 116

Capital Development 181,026,106 528,005,000 490,049,889 93

Other Expenditures 20,455,350 19,018,000 11,850,400 62

TOTAL EXPENDITURE 1,735,236,809 2, 265,137,052 2,249,960,573 99

Employment costs continue to consume the bulk of the money generated. This is because of the increased desire to pay competitive salaries to the workers as a motivation strategy. The % contribution of the different expenditure lines is shown in the graph below.

Fig 5: Contribution of different expenditure lines to total hospital expenditure

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Employment costs and medical goods and services are responsible for 76% of the entire hospital expenditure. This trend of events has been maintained over the last 5 or so years (see graph below) and any intervention/assistance to the hospital would have to focus on the two areas if there is to be impact.

Fig 6: Main expenditure categories

Table 13: .Hospital expenditure categories over 5 years

Description 2011-12 2012-13 2013-14 2014-15 2015-16

Employment cost 768,803,577 752,377,168 885,023,697 945,962,483 987,418,803

Medical Goods & Services 355,953,469 282,199,576 298,672,855 364,201,712 500,292,526

Capital Development 166,355,900 220,903,108 181,251,814 181,026,106 490,049,889

Property costs 110,426,080 125,686,345 122,177,159 124,116,838 133,702,128

Other Expenditure 11,272,100 61,658,900 52,296,550 20,455,350 11,850,400

Administration cost 61,499,440 51,157,873 62,356,171 64,354,900 69,690,197

Transport & Plant Cost 32,860,100 43,944,300 43,698,900 24,453,320 45,736,630

Supplies & Services 3,755,000 6,231,000 3,447,000 4,283,500 5,353,000

Hospital Board Cost 5,676,700 5,282,000 6,163,000 6,382,600 5,867,000

Total 1,516,602,366 1,549,440,270 1,655,087,146 1,735,236,809 2,249,960,573

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Table 14: Average User Fee per SUO Op Comparisons from 2011/12 FY through to 2015/16 FY

YEAR 2011/12 2012/13 2013/14 2014/15 2015/16

USER FEES 917,158,414 916,804,540 952,498,810 1,158,337,700 1,328,883,891

SUOop 217161 170168 162849 153546 165913 Fees per 3513 5389 5629 6203 8010 SUOop

The table shows an increase in average user fee per SUO Op, which implies progressive “unaffordability (inequitable)” of hospital services. The average user fees per SUO Op are progressively going up over the years and this is a proxy indicator of unaffordability of hospital services. The general trend is upward which correspondingly infers progressive un-affordability of hospital services assuming the economic status of the catchment community, and costs for running the hospital remained the same like the years under review. This indicator is a trend indicator but will require a standard comparative indicator. At Ug.Shs . 8010 per SUO Op (compared to a similar setting facility—within an urban area, accessing the same markets for medicines and supplies etc), it is likely that the hospital is either greatly affordable or just un-affordable. The assessment of the hospital shows we are highly affordable. National statistics indicate that over the last 6 years there has been a progressive increase in the per capita Gross National Income, which may indicate the affordability of health care services with changes in hospital operational and other costs. The trends show, there is a progressive annual increase in the average user fees/SUO OP. The fees per SUOop has doubled in the last five years.

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Table 15: Average Expenditure per SUO Op Comparison from 2011/12 through to 2015/16

2011/12 2012/13 2013/14 2014/15 2015/16

Total 1,350,246,466 1,328,522,142 1,429,973,898 1,670,881,909 1,759,910,684 recurrent Expenditure 170168 162849 153546 161890 165913 SUO OP Avg. Cost per 7934 8158 9313 10321 10607 SUO OP

2011/12 2012/13 2013/14 2014/15 2015/16

170168 162849 153546 161890 165913 SUO OP Number of 155 156 158 170 156 Staff SUO OP per 1097 1043 971 952 1064 Staff

The table shows a progressive increase in average costs per SUOop which translates into decline in economic efficiency. Simply put the hospital has continued to become more expensive to run and strategies to contain this worrying trend are necessary.

Staff productivity showed some increase compared to the previous year.

Analysis of hospital liquidity shows some disturbing trends. The hospital continues to suffer the effects of bad and sundry debtors. We continue to see situations where people are treated and discharge themselves without paying. The insurance scheme appears to be getting bankrupt and yet its clients continue to receive services. User fees being the main source of income, there should be strategies to minimize losses otherwise the hospital will eventually fail to have the necessary supplies to provide quality services.

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CHAPTER SIX:

HOSPITAL ACTIVITIES In this chapter we give the activities of the year under report and make a comparison with the previous years. We shall give information on curative, preventive and promotive services.

Curative: A. OPD

The OPD is the first place of contact for majority of the patients. It runs daily, including public holidays, from 08 30 hours to 17 00 hours, with break tea and lunch interruption. On Saturday, it opens from 0900 hours to 13 00 hours and remains closed on Sundays. Staff who work on Public holidays are entitled to equal time compensation but this should occur in the month when the holiday fell.

The department is housed in the OPD complex with various rooms for clinical officer and doctor consultations. The same complex has a reception, a cash office for outpatients, eye clinic, dressing room, the laboratory and offices for the pre-payment scheme. Other rooms include the dental clinic, counseling rooms for HIV/AIDS, records office and cash office for outpatients.

Table 2 : Here below we give the OPD utilization for the year under report: Category 0-28 days 29 days-4 yrs 5 -59 yrs 60 yrs & above Male Female Male Female Male Female Male Female New attendance 25 20 1581 1431 4728 8979 977 1458 Re-attendance 0 0 19 8 66 123 13 31 Total Attendance 25 20 1600 1439 4794 9102 990 1489

From thetable, we notice the total OPD attendance (excluding ANC) for the year was 19459. This indicates a fall in OPD by -11% as compared to the previous year.

Overall there is a steady fall in OPD utilisation for the last 5 years (See figure….below). This fall in OPD utilisation coincides with the gradual reduction in the malaria cases reported here and in other GOU health units.

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Fig 7: OPD utilization over 5 years

Generally, the reduction in the numbers of persons accessing (or utilizing hospital services) may be due to two or three probable causes which could be existing either singly or in combination—either people are increasingly seeking health care services elsewhere—such as, especially government facilities or generally morbidity (ill health) has reduced among the population—due to extensive health preventive/promotive initiatives (e.g. increased access to safe drinking water, increased numbers sleeping under an ITN, VHT initiatives etc…) or possibly people are not seeking health services—perhaps due to financial barriers or other reasons. In our circumstances, OPD attendances’ fall may be due to increasing numbers and functionality of lower level government health facilities in the district. These have generally registered marked improvement in availability of the 6 trace medicines. At a national level, the percentage of facilities without stock out of any of the 6 indicator medicines has reportedly increased from 21% in 2009/10 to 43% in 2010/11 and 69.8% in 2011/12 (AHSPR 11/12).This means progressive increase in availability of medicines at the government units, therefore functionality. The 6 indicator medicines include CoartemR, Measles vaccine, ORS sachets, Cotrimoxazole, Fansidar and Depo-Provera. The Mutolere pre-payment scheme continues to register substantial reductions in the numbers of registered members and this too could account for a fall in OPD utilization as scheme members are previously known to over utilize hospital services because they are adversely selected. The main OPD diagnoses are shown in the HMIS extract below. (HMIS 107 for year 2015/16). From the table, the top causes of morbidity are malaria, respiratory tract infections, skin diseases, intestinal worms, sexually transmitted diseases, eye conditions, ear, nose and throat conditions and diarrheal diseases. A number of these can be controlled by public health interventions.

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Table 17: OPD diagnoses for the year under report

0-28 days 29 days-4 yrs 5 -59 yrs 60 yrs & above Diagnosis Male Female Male Female Male Female Male Female 1.3.1 Epidemic-Prone Diseases 1. Acute Flaccid Paralysis 2. Animal Bites (suspected rabies) 3. Cholera 4. Dysentery 0 0 1 0 4 5 1 1 5. Guinea Worm 6. Malaria Total 0 0 73 76 318 410 22 43

Confirmed (Microscopic & RDT 7. Measles 8. Bacterial Meningitis 9. Neonatal tetanus 10. Plague 11. Yellow Fever 12. Other Viral Hemorrhagic Fevers 13. Severe Acute Respiratory Infection (SARI)

14. Adverse Events Following Immunization (AEFI) 15. Typhoid Fever 0 0 2 4 47 51 3 3 Presumptive MDR TB cases 16. Other Emerging infectious Diseases specify e.g. Influenza like illness (ILI), SARS

1.3.2 Other Infectious/Communi cable Diseases 17. Diarrhoea- Acute 0 0 165 148 28 74 0 5 18. Diarrhoea- Persistent 19. Urethral discharges 20. Genital ulcers 21. Sexually Transmitted Infection due to (Sexual Gender Based Violence) 22. Other Sexually Transmitted Infections 0 0 2 6 94 239 4 5 23. Urinary Tract Infections (UTI) 14 15 237 705 25 69 24. Intestinal Worms 84 70 140 228 10 23 25. Hematological Meningitis 26. Other types of meningitis 0 0 4 3 5 6 27. No pneumonia - Cough or cold 18 15 466 422 487 806 69 93 28. Pneumonia 2 1 120 108 35 46 4 2 29. Skin Diseases 135 107 175 251 14 16 Bacteriologically confirmed 21 8 30. New TB cases Clinically Diagnosed 4 diagnosed EPTB 1 31. Leprosy 32. Tuberculosis MDR/XDR cases started on treatment 33. Tetanus (over 28 days ) 34. Sleeping sickness 35. Pelvic Inflammatory Disease (PID) 272 6 36. Brucellosis 29 31 4 3

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0-28 days 29 days-4 yrs 5 -59 yrs 60 yrs & above Diagnosis 1.3.3 Neonatal Male Female Male Female Male Female Male Female Diseases 37. Neonatal Sepsis (0-7days) 38. Neonatal Sepsis (8-28days) 1 39. Neonatal Pneumonia 40. Neonatal Meningitis 41. Neonatal Jaundice 42. Premature baby (as a condition for management) 43. Other Neonatal Conditions

1.3.4 Non Communicable Diseases/Conditions 44. Sickle Cell Anaemia 0 0 0 0 0 0 0 0 45. Other types of Anaemia 0 0 2 3 6 16 0 3 46. Gastro-Intestinal Disorders (non-Infective) 40 35 455 897 66 132 47. Pain Requiring Palliative Care Oral diseases 48. Dental Caries 0 0 7 6 122 175 13 33 49. Gingivitis 50. HIV-Oral lesions 51. Oral Cancers 52. Other Oral Conditions 0 0 3 7 9 1 0 ENT conditions 53. Otitis media 0 0 29 22 37 48 1 4 54. Hearing loss 55. Other ENT conditions 0 0 29 24 72 126 6 18 Eye conditions 56. Ophthalmia neonatorum 1 0 1 0 0 0 0 0 57. Cataracts 0 0 0 0 9 8 7 8 58. Refractive errors 59. Glaucoma 2 1 2 1 60. Trachoma 61. Tumors 62. Blindness 1 0 1 1 63. Diabetic Retinopathy 64. Other eye conditions 0 0 87 68 172 198 45 53 Mental Health 65. Bipolar disorders 0 0 0 0 0 0 0 0 66. Depression 1 5 0 1 67. Epilepsy 0 0 1 2 22 17 1 1 68. Dementia 69. Childhood Mental Disorders 70. Schizophrenia 0 0 0 0 1 0 0 0 71. HIV related psychosis 0 0 22 24 486 1465 46 42 72. Anxiety disorders 47 102 3 5 73. Alcohol abuse 11 2 0 1 74. Drug abuse 1 Chronic75. Other respiratory Mental Health Conditions 0 0 0 20 21 diseases 76. Asthma 0 3 19 39 14 29 77. Chronic Obstructive Pulmonary Disease (COPD) Cancers 78. Cancer Cervix 0 0 0 0 0 10 0 12 79. Cancer Prostate 2 0 1 80. Cancer Breast 6 5 81. Cancer Lung 82. Cancer Liver 83. Cancer Colon 84. Kaposis Sarcoma 85. Cancer Others 5 1 1 5 Cardiovascular diseases 86. Stroke/Cardiovascular Accident(CVA) 0 0 0 0 16 26 10 19 87. Hypertension 155 285 156 361 88. Heart failure 7 12 5 10 89. Ischemic Heart Diseases 88. Rheumatic Heart Diseases 90. Chronic Heart Diseases 41 91. Other Cardiovascular Diseases 13 19 9 33

0-28 days 29 days-4 yrs 5 -59 yrs 60 yrs & above Diagnosis Endocrine and Male Female Male Female Male Female Male Female Metabolic Disorders 92. Diabetes mellitus 0 0 0 0 62 73 85 54 93. Thyroid Disease 94. Other Endocrine and Metabolic Diseases Malnutrition 95. Severe With oedema 0 0 0 0 0 0 0 AcuteMalnutrition Without oedema 19 5 7 6 9 8 (SAM) 96. Mild Acute Malnutrition (MAM) 0 0 33 20 51 71 39 45 Injuries 97. Jaw injuries 98. Injuries- Road traffic Accidents 0 0 1 1 43 15 0 0 99. Injuries due to motorcycle(boda-boda) 100. Injuries due to Gender based violence 2 2 101. Injuries (Trauma due to other causes) 13 8 102 55 5 3 Domestic 1 102. Animal bites Wild Insects 103. Snake bites 1.3.5 Minor Operations in OPD 104. Tooth extractions 0 0 1 0 38 80 5 10 105. Dental Fillings 106. Other Minor Operations 0 0 0 0 0 1 1.3.6 Neglected Tropical Diseases (NTDs) 107. Leishmaniasis 108. Lymphatic Filariasis (hydrocele) 109. Lymphatic Filariasis (Lympoedema) 110. Urinary Schistosomiasis 111. Intestinal Schistosomiasis 112. Onchocerciasis 1.3.7 Maternal conditions 113. Abortions due to Gender-Based Violence (GBV) 114. Abortions due to other causes 0 0 0 0 0 87 0 0 115. Malaria in pregnancy 7 116. High blood pressure in pregnancy 117. Obstructed labour 118. Puerperal sepsis 1 1.3.8119. HaemorrhageOther OPD related to pregnancy (APH or PPH) 2 conditions 120. Other diagnoses (specify priority diseases for District). 121. Deaths in OPD 122. All others 6 5 480 449 1917 2552 409 476 Total Diagnoses

Analysis of the leading causes for OPD consultations over a 3 year period shows an interesting trend (See graph below):

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Fig 8: Selected OPD diagnoses over 3 year period

An obvious observation from the graph is that Malaria is the least cause for OPD consultations and this has been observed over a 3 year period. Another observation is the increasing burden of the non-communicable diseases. Cardiovascular diseases are the leading cause for OPD consultations followed by respiratory infections. There is thus a definite need to improve capacity to diagnose and manage the emerging non communicable disease burden.

SPECIAL CLINICS.

PALLIATIVE CARE ANNUAL REPORT 2015 – 2016

Palliative care is the care given to patients and families with chronic and life threatening conditions through early detection, assessment, diagnosis, effective management of pain and other distressing symptoms holistically i.e physically, psychologically, socially and spiritually by a multi-disciplinary team.

The hospital has always provided palliative care services but the active and consistent palliative care services started in 2008 with the introduction of oral morphine which is the drug of choice used in palliative care to manage severe debilitating chronic pain.

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Palliative care services are consistently offered in the hospital with the help of the doctors, clinical officers, counsellors, pastoral care staff who partly manage and refer to the specialist where necessary.

Table 18: PATIENTS SEEN WITHIN THE FINANCIAL YEAR 2015-2016

DIAGNOSIS NO

1 Ca cervix 07

2 HCC 07

3 Ca Breast 05

4 Osteosarcoma 02

5 Intra-abdominal tumours 02

6 Ca rectum 02

7 HIV AIDS 01

8 Ca vulva 01

9 Retinalblastoma 01

10 Ca thyroid 01

11 Ca stomach 01

12 Ca Brain 01

13 Gangrene 01

14 Angina 01

15 Athritis 01

TOTAL NUMBER OF CANCER/HIV

CANCER 31

HIV 02

OTHERS 03

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During the Financial year, 4 were referred to other facilities with Palliative care services. Also 6 clients died.

Challenges

Few palliative care health providers.

NB: The provider who had been trained already left.

RECOMMENDATIONS

There is need for one or more other health workers to be trained in Palliative care so that all patients who need this care can always access it even when the trained one is not present.

“Palliative care should be available as air” Dr. Amandua Jacinta.

We look forward to seeing other staffs being sent for palliative care training to ensure constant availability of palliative care services like “air”.

DEPARTMENT OF OPTHALMOLOGY The hospital has a principal ophthalmic clinical officer (PCO)/Cataract Surgeon who does most of the work assisted by an ophthalmic assistant. Most of the work is done at the static unit with few outreach activities due to limited resources.

Globally, blindness and vision loss are common and will increase with the ageing population. Yet ¾ of blindness and vision loss can be prevented or treated. The major preventable causes of childhood blindness are vitamin A deficiency, measles, ophthalmia neonatrum and cataract surgery is one of the most effective of all health interventions.

The mission of 2020 is to eliminate the main causes of avoidable blindness in order to give all people in the world, particularly the millions of needlessly blind the right to sight.

The hospital has finalised a proposal to find children with blindness and assist them to access health care and education. It will be supported by Sustain for Life with close collaboration with Kisoro Demo. This is premised on the observation that there are not many opportunities for the visually impaired children, a group that is even ostracised by the parents who consider them curses in the families. As such they are not allowed any education opportunities; there are few schools capable of handling children with special needs. Besides, these children are often left at home for nature. The project is also expected to have a component to deal with children with hearing impairment so that they too can have education opportunities.

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For the year under report, the following cases were handled:

Table 19: Eye conditions seen during the year 2015/16 CONDITION TOTAL

Normal eyes 20

Retractive error 15

Presbyopia 20

Aphakia 38

Allergic conjuctivities 118

Other conjuctivities 47

Trachoma 1

Corneal diseases 10

Cataracts 69

Leprosy Lesians --

Glaucoma 11

Onchocerciasis ---

Trauma 28

Uveitis 10

F.B 10

Squint 14

Lidsfalaluv app ---

Xerophthalmin 05

Others 36

Optic nerve + retina 05

Monthly total

Of the total, indicate those seen on mobile Clinics 437

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SURGICAL OPERATIONS

Major Procedures: In Base Hospital

Cataract 35

Glaucoma 05

Others 11

Minor Procedures:

Entropion 1

Other 19

ORTHOPAEDIC SERVICES Common Orthopedic conditions in Mutolere are:

 Trauma related

 Infection related

 Congenital malformations of the limbs

Trauma related cases account for 80% of the total number of patients admitted on the surgical ward. The commonest cause of trauma are motor accidents followed by physical assault.

Motorbikes, commonly referred to as boda boda are the leading cause of motor accidents. Boda boda riders are young Macho guys earning a living by carrying passengers and their merchandise to survive. More often than not, these rather economically disadvantaged people carry more than the recommended number of passengers.

Boda boda riders sustain injuries ranging from simple abrasions to fatal and multiple injuries of different parts of the body. These injuries, like head injuries often necessitate referral for complicated care. For fractures of long bones, we now use intramedullary nailing system in addition to other treatment modalities. This has replaced use of traction that inevitably led to long hospital stay with its attendant soio-economic complications in addition to prolonged bed occupancy.

Table 20: Number of cases seen in FY 2015-16

Procedures Nummbers

IM nailing 12

External fixation 23

Plaster casing

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Infection related cases include Osteomyelitis. Majority of these cases originate from Rwanda and already have had the condition for long time. Treatment is also very costly, sometimes resulting into loss of limbs by amputation. Other conditions include septic arthritis among others.

Club foot (Talipes equinovarus) is the commonest congenital abnormality seen here. When received in time, the condition is successfully managed with no residual complication. However on account of delay to come to hospital (either because mothers or even health workers could not detect in time), some children present when it is relatively late and the condition (which is managed by simple application of plaster cast) results into disability. In view of this, Africa Fund EMMEN started a project to offer free treatment for these patients in February 2016. Under this project, the following activitie are undertaken:

 Sensitization to communities through radio talk shows about club foot presentation and early treatment.

 Free treatment when children are brought in early enough i.e 2-6 weeks after birth. Treatment takes about 4 years.

So far 21 children are in the program.

HIV/AIDS SERVICES.

The Hospital runs an HIV clinic, which has been operational since the late 1990’s initially providing Counseling and testing services with support from CORDAID. ART services were started at the hospital in 2003/04 by the hospital management with support from the Ministry of Health. Currently HIV/AIDS activities are funded by EGPAF under the RHITES-SW project starting with FY 2016/17. Previously the activities were funded by the STAR-SW project and the hospital before the new project came on board at the beginning of this financial year. The objectives are to increase the uptake of comprehensive HIV/AIDS and TB services at the hospital, strengthen linkages and referral systems within and between health facilities and the catchment community, increase demand for comprehensive HIV/AIDS and TB prevention, care and treatment services to the hospital, and finally increase the demand and uptake of PMTCT/EID services at the hospital. The clinic has been run by two clinical officers, a counselor, a nurse, two lab technicians, and a number of volunteers. Due to the pressure exerted on the thin human resource at Mutolere hospital, it was decided that HIV/AIDS patients coming for drug refills (ARVS and/Cotrimoxazole) should have a clinic day on Mondays and Thursdays.

Table20: HIV/AIDS COUNSELING AND TESTING (HCT), FY 2015/16.

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< 2years (24months) 2-< 5years 5-14years 15years and above Category TOTAL Male Female Male Female Male Female Male Female Cumulative No. of clients ever enrolled in HIV care at this facility at the end of the previous quarter 0 2 5 5 11 17 284 493 817 No. of new patients enrolled in HIV care at this facility during the reporting quarter (Exclude transfer In) 1 5 6 No. of pregnant & lactating women enrolled into care during the reporting quarter. (Subset of row 2 above) 0 4 4 No. of clients started on INH Prophylaxis during the reporting quarter (Subset of row 2 above) 1 Cumulative Number of clients ever enrolled in HIV care at this facility at the end of the reporting 0 2 5 5 11 17 285 498 quarter(row 1+ row 2) No. of persons already enrolled in HIV care who transferred in from another facility during the quarter. 1 No. of active clients on pre-ART Care in the quarter 0 0 0 0 0 0 4 4 8 No. active on pre-ART Care who received CPT/Dapsone at their last visit in the quarter 4 4 8 No. active on pre-ART Care assessed for TB at last visit in the quarter 8 No. active on pre-ART Care diagnosed with TB in the quarter 0 No. active on pre-ART Care started on anti -TB treatment during the quarter 0 No. Active on pre-ART Care assessed for Malnutrition at their visit in quarter 0 No. active on pre-ART who are Malnourished at their last visit in the quarter 0 No. active on pre-ART Care eligible and ready but not started on ART by end of the quarter 0 Cumulative No. of clients ever enrolled on ART at this facility at the end of the previous quarter 4 8 5 2 10 11 194 403 No. of new clients started on ART at this facility during the quarter 0 0 0 0 0 0 1 6 No. Of new clients started on ART at this facility during the quarter based on CD4 count 5 No. of pregnant & Lactating women started on ART at this facility during the quarter (Subset of row 16 0 4 4 above)Cumulative No. of individuals ever started on ART (row 15 + row 16) 4 8 5 2 10 11 195 408 37 No. active on ART on 1st line ARV regimen 1 0 2 2 6 14 84 265 374 No. active on ART on 2nd line ARV regimen 0 1 0 0 1 0 2 9 13 No. active on ART on 3rd line or higher ARV regimen No. active on ART who received CPT/Dapsone at the last visit in the quarter 1 1 2 2 7 14 86 274 387 No. active on ART assessed for TB at last visit in the quarter 387 No. active on ART diagnosed with TB during the quarter 0 No. active on ART started on TB treatment during the quarter(New TB cases) 0 Total No. active on ART and on TB treatment during the quarter 0 No. active on ART with Good adherence(>95%) during the quarter 387 No. active on ART assessed for Malnutrition at their visit in quarter 387 No. active on ART who are Malnourished at their last visit in the quarter 3

1A - HIV CARE/ART - CROSS SECTIONAL REPORT

BASELINE FOLLOW UP No of Months Record Record Started ART in Fraction of Median Transfers Transfers Net Stopped Died Lost Lost to No. of Percent Fraction of Median completed on ARV by Month when cohort Year when this clinic- clients 5 yrs CD4 (for 5 In (TI) Add Out (TO) Current co (missed Follow-up Cohort of clients CD4 (for 5 various quarterly started(3 months cohort original cohort above with years and + Subtract - hort appointm (DROP) Alive and cohort 5yrs & yrs and cohorts period) started(3 CD4<500 above with (N) Column ent) on ART alive above with above with months available 3+TI-TO) (On Rx) and on CD4 <500 available period) CD4- ART [ CD4- optional) (On Rx) optional) / N * 100 ]

1 2M 2Y 3 4 5 6 7 8 9 10 11 12 13 14 15 16 All patients 6 months Oct. 15 2015 10 252 1 1 10 0 0 2 0 8 80 eMTCT Mothers 6 months 15-Dec 2 544 1 0 3 0 0 1 0 2 67

All patients 12 months April 2015 23 234 0 1 22 0 1 0 2 19 86 eMTCT Mothers 12 months Jun-15 9 264 0 0 9 0 0 0 0 9 100

All patients 24 months April 2014 21 260 1 1 21 0 2 0 2 17 81 eMTCT Mothers 24 months Jun-14 5 264 1/2 0 0 5 0 0 0 0 5 100

All patients 36 months April 2013 32 294 0 4 28 0 1 0 3 24 86 eMTCT Mothers 36 months Jun-13 6 358 0 1 5 0 0 0 0 5 100

All patients 48 months April 2012 22 289 0 5 17 0 2 0 2 13 76 eMTCT Mothers 48 months Jun-12 0 0 0 0 0 0 0 0 0 0 0

All patients 60 months April 14 14/14 161 1/2 0 1 13 0 3 0 1 9 69 eMTCT Mothers 60 months Jun-11 2011 0 0 0 0 0 0 0 0 0 0 0 0

All patients 72 months April 6 65 1/2 0 3 3 0 0 0 1 2 67 eMTCT Mothers 72 months Jun-10 2010 0 0 0 0 0 0 0 6

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62.4 EXPOSED INFANT DIAGNOSIS (EID) SERVICES NUMBER 1st PCR 32 E1: Exposed infants tested for HIV below 18 2nd PCR 16 months of age < 2 months old 12 E2: 1st DNA PCR result returned Total 21 HIV+ E3: 2nd DNA PCR result returned Total 17 HIV+ Total 29 E4: Number of DNA PCR results returned Within 2 weeks 29 from the lab Given to caregiver 26 E5: Number of HIV Exposed infants tested Total 17 by serology/rapid HIV test at ≥18 months Positive

E6: Number of HIV+ infants from EID enrolled in care E7: HIV exposed infants started on CPT Total 25 Within 2 months 25

IN-PATIENTS WARDS

ORGANISATION AND MANAGEMENT OF THE WARDS.

Procedure for admission and discharge. All patients go through OPD during the day, where they are assigned OPD numbers. Critically ill and trauma patients are triaged, given preferential treatment and then sent directly to the wards from where vitals are taken, investigations done and the treatment given by the nurses and ward doctors. The non-critically ill patients are examined by the OPD clinicians and sent to the respective ward if admission is warranted. On the ward they are received by a nurse on duty who assigns an inpatient number and treats the patient as per the instructions by the admitting clinician. Mothers in labor and other obstetric emergencies are directly admitted to maternity ward without having to go through OPD but the same process is followed. The patients who come when the OPD is closed (usually after 5.00 p.m, Saturdays after 1.00 p.m, and on Sundays) go straight to the wards for admission and clinician on call is asked to come and review the patients and institute appropriate treatment. The assumption is that such patients coming after closure of business will usually be admitted. Discharge of patients is done by the ward Doctor after the ward rounds. Discharge instructions, medicines and appointments for review are indicated on the patient’s discharge note and are explained to the patient by the nurse. Upon discharge, the patient file is analyzed by the nurses and information necessary for billing the patient extracted and put on a chargeable form that is forwarded to the cash office. The patient/attendants then follow the file in the cash office for payment of medical bills. There is

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hope that all this process will be computerized when all departments are connected to the computerized system in the OPD/Cash office. Ward rounds are done on Mondays, Wednesdays and Fridays on all wards though ward doctors are encouraged to regularly check on their wards to ensure very sick patients and those whose condition may change are attended to on other days. Over the weekend it is only the critically ill that are seen by the doctor-on-call. Appropriate prescription practices.

Our standing order is that prescription of medicines is done by only clinical officers and doctors. However, nurses on the wards are allowed to give some first aid treatment (including the institution of I.V. lines) awaiting arrival of the clinicians on call. Prescriptions are based on a working diagnosis and guided by the Uganda Clinical Guidelines (2006—or as revised), and the British National Formulary. Prescriptions in OPD are only limited to oral or topically applied medicines. Parenteral medicines are reserved for the in-patients. Prescription surveys are done annually and the findings used to guide us in areas we need to improve.

Table 21: IPD utilization for the year 2015/16

(A) (B) (C) (D) (E) (F) (G) (H)

List of wards No. of Admissions Deaths Patient Average Average Bed Beds days length of Occupancy = Occupancy = stay = E/No. of days GX100/B E/C in month

Male Medical 27 970 59 5333 5.5 15 56 Ward

Female Medical 27 1501 56 6632 4.4 18.2 67 Ward

Pediatic Ward 27 1381 13 5990 4.3 16.4 61

Maternity/ 46 2508 3 14050 5.6 38.5 84 Obsteric ward

Male Surgical 29 1491 37 11536 7.7 32 110

Female Surgical 21 797 11 6391 8 18 86

Gyn Ward 23 908 0 3340 3.6 9.2 40

Totals 200 9555 179 49932 6.0 146 73

There has been gradual increase in the BOR from 59% in 2012/13 to 64% in 2013/14 and 66% in the FY 2014/15 and 73% in FY 2015/16 indicating an increase of fourteen percentage points over a 5-year period. 51

The leading cause of morbidity and mortality are shown in the table below:

Table 22: Morbidity patterns 2015/16

# of new Diagnoses TOP 5 Causes of Morbidity during the Financial Year for persons 5 years TOP +A1125:O11465 Causes of Morbidity during the Financial Year for Children under 5 previous Financial # of new diagnoses and older previous Financial Year Year Disease/Condition # of new Diagnoses Disease/Condition # of new Diagnoses

1. PNEUMONIA 446 523 1. ABORTIONS 380 321

2. DIARRHOEA 376 438 2. MALARIA 367 451

3. RTI 347 339 3. INJURIES 319 253

4. IINJURIES 157 111 4. UTI 308 166 GASTRO INTESTINAL 5. SEPTICAEMIA 96 47 5. 291 319 DISORDERS Total rest of Diagnoses 1319 1273 7370 7037 Total all Diagnoses 2794 2897 9035 8470

(c) TOP 5 Causes of Mortality during the Financial Year for persons 5 (F) TOP 5 Causes of Mortality during the Financial Year for Children under 5 (C)=(B)/(A)x100 years and older (F)=(E)/(D)x100

(A) (B) (D) (E) Case Fatality Rate Disease/ Condition Case Fatality Rate (CFR) Disease/ Condition # of new (CFR) # of new cases # of new Deaths # of new cases Deaths PNEUMONIA 446 6 1% CARDIOVASCULAR DISEASES 119 19 16% INJURIES 157 5 3% RTA 226 10 4% ANAEMIA 17 2 12% INJURIES 319 9 3% SEPTICAEMIA 96 2 2% T.B 65 9 14% DIARRHOEA 376 1 0.20% HIV 79 7 9% Total rest of Diagnoses 1391 1 Total rest of Diagnoses 7370 107 1.40%

The table shows that pneumonia, diarrhea, RTIs and malaria are the leading cause of admission among the under 5’s. Among those with 5 years and above, the leading causes of morbidity are abortions, malaria, injuries, UTI and gastro-intestinal disorders.

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The table shows high CFR of anemia in the under 5’s because of late presentation mainly because anemia is a complication of other conditions that are usually initially treated locally by local tonsillar mutilation (“gapfura” in local lingua). Among those above 5 years, cardiovascular conditions appear to be increasingly causing significant mortality mainly due to late diagnosis and lack of compliance when on long term medications.

Road accidents are on the increase and they have a preventable high case fatality rate if safe driving practices are applied. The accidents have been attributed to the upgrading of the Kabale-Kisoro- Chanika-Bunagana road as well as the road from Kisoro town to Mutolere hospital. The detailed admissions and deaths per cause are indicated in the following tables (source:HMIS).

Table 23: Admissions and deaths per cause FY 2015/16

under five years Five years and above Diagnosis Cases Deaths Cases Deaths M F M F M F M F Non communicable diseases 13 12 01 02 19 20 4 4 46 Anaemia 5 5 13 36 1 1 47 Asthma 48 Oral cancers 49 Jaw injuries 50 Other oral diseases and conditions 51 Periodontal conditions 52 Diabetes mellitus (newly diagnosed cases) 02 01 53 Diabetes mellitus (re-attendances) 16 49 02 54 Endocrine and metabolic disorders (other) 55 Gastro-Intestinal disorders (non Infective) 02 01 84 148 01 56 Hypertension (newly diagnosed cases) 57 Hypertension (old cases) 49 94 02 01 58 Stroke 05 16 01 04 59 Cardiovascular diseases (other) 02 01 35 53 01 04 60 Anxiety disorders 02 18 61 Bipolar disorders 62 Depression 02 08 63 Schizophrenia 03 64 Alcohol abuse 45 03 06 65 Drug Abuse 01 02 01 01 66 Dementia 04 05 67 Childhood Mental Disorders 1 68 Epilepsy 3 3 0 0 10 5 69 HIV related Psychosis 02 0 1 33 37 6 0 53

70 Other forms of Mental illness 14 12 0 0 71 Nervous system disorders 72 Severe Malnutrition (Kwashiorkor) 42 38 2 1 17 11 1 2 73 Severe Malnutrition (Marasmus) 15 20 74 Severe Malnutrition (Marasmic-kwash) 751niuries - Road traffic Accidents 14 12 2 2 108 50 9 3 761niuries - (Trauma due to other causes\ 71 44 2 134 88 3 0 77 Animal bites 1 78 Snakes bites 1 1 3

79 Poisoning 4 3 30

80 Liver Cirrhosis 10 0 1 81 Liver diseases (other) 19 2 6 82 Hepatocellular carcinoma 83 Hernias 8 1 27 8 84 Diseases of the appendix 1 2 85 Diseases of the skin 18 9 14 15 86 Musculo skeletal and connective tissue diseases 87 Genito urinary system diseases (non infective) 88 Congenital malformations and chromosome abnormalities 89 Complications of medical and surgical care 90 Benign neoplasm's (all types) 91 Cancer of the cervix(newly diagnosed cases) 1 92 Cancer of the cervix (re-attendance) 18 1 93 Cancer of the breast 2 1 94 Cancer of the prostate 1 1 95 Malignant neoplasm of the digestive organs 96 Malignant neoplasm of the lungs 97 Kaposis and other skin cancers 98 Malignant neoplasm of Haemopoetic tissue 99 Other malignant neoplasm 100 Cutaneous ulcers

SUPPORT SERVICES.

PHARMACY DEPARTMENT

During this financial year the total expenditure on both drugs and sundries was 386,927,490.87. The main source of medical drugs and sundries w JMS (Joint Medical Store) where total annual purchase was worth UGX 296,167,700.92 accounting for 76.5% of total expenditure on drugs and sundries. The remaining 23.5% (UGX 90,759,789.95 worth of medical supplies) were purchased from local pharmacies. The value of medical goods and sundries from donations (largely Humedica) is not computed.

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As usual ARVs, Anti TB drugs, HIV test kit plus some other laboratory reagents and Cotrimoxazole tabs were got free through different government projects and were dispensed to patients at no cost save for consultations. Their value too is not indicated.

During the year we tried to minimize stock outs by stocking most of the essential items. Those items that were out stock at JMS were purchased locally as soon as the packing list of the expected consignment was available to us in soft copy.

Below is the list of the Fast Moving items which made 40% of the total annual cost.

Table 24: Fast moving items at Mutolere hospital FY 2015/16

NO ITEM DESCRIPTION TOTAL UNITS UNIT COST TOTAL COST

1 Gauze Hydrophyllic 90 x 91 820 61930 50,782,600

2 Gloves surgical 71/2 and 7 900 35500 31,950000

3 Gloves Non-sterile 2150 13,357 28,717,550

4 Syringes 2ml 260 14500 3,770,000

5 Syringes 5ml 225 19455 4,377,375

6 Syringes 10ml 246 246 3,313,374

7 Dextrose 5% IV 500mls 4010 1102 4,419,020

8 Normal saline 0.9% 500mls 15075 1259 18,979,425

9 Ringers lactate 500ml 13095 1252 16,394940

10 IV Giving sets 5800 690 4,002,000

11 Theatre sutures PGA(2)32240TH 122*112 53660 6,546,520

12 Theatre sutures PGA(2) 3224RC 892x 12 52500 4,830,000

Total 170,061,984

This total makes 44% of the total annual cost. Most of these items are medical sundries used in theatre and wards; with higher consumption being reported in maternity and surgical wards.

Below is the list of drugs that got expired during the year.

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Table 25: Expiries for FY 2015/16

NO ITEM DESCRIPTION TOTAL UNITS UNIT COST TOTAL COST

1 Calcium lactate tabs 4*100 2700 10800

2 Hydralazine tabs 2*100 12012 26024

3 Hydralazine inj 1*5 41984 41984

4 Digoxin tabs 4*100 7176 28704

5 Quinine tabs 5*100 15129 75645

6 Chlorpromazine inj 2*100 31200 62400

7 Ephedrine nasal drops 20*1 2640 52800

Total 298357

AVAILABILITY OF DRUGS AND SUNDRIES

All the essential items did not run out of stock during the year.

STOCK OUT MONITORING

We managed to avoid stock outs by maintaining all stock levels ie

Maximum stock level at 5 months consumption.

Minimum stock level at 2 months consumption.

All orders were prepared in time considering VEN analysis. JMS made it possible for us to get our orders in time by delivering for us.

CONTROL OF EXPIRIES

This was successful due to the following;

1. By determining the quantity to order using average monthly consumption to avoid stock out and over stocking. 2. By arranging items on shelves in FEFO order to minimise losses. 3. By constant checking the stocks so that those nearly to expire to exchange them with nearby health units.

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ECONOMISING ON DRUG EXPENDITURE

This was managed by the following.

1. Weekly clinical audit meetings. 2. Monthly staff conference meetings. 3. Departmental regular meetings. 4. Constant notices to clinicians and doctors. All the mentioned meetings were aiming at proper use of medicines and supplies.

REDUCTION OF LOSSES

This was successful due to effective control of the following.

1. Misuse 2. Expiries 3. Theft 4. Breakages 5. Pilferages Nevertheless, greater control/regulation of use of medical goods is required because this expenditure item has drastically increased at a rate not commensurate with the rise in the hospital’s SUOop.

INFORMATION TO PATIENTS

During dispensing the patients received adequate information about proper use, storage of dispensed medicines. They also received adequate information about possible side effects, prevention of their illness also dietary advice to help them improve on their immunity.

STORAGE CONDITION OF DRUGS

All drugs and sundries were stored according to the recommended storage conditions by the manufacturers i.e.

- External preparations kept separate from internal preparations to avoid cross contamination. - Heat sensitive kept in a fridge. - Flammables kept in a special fireproof room. - Heavy items kept on the lower shelves and the light ones on the upper shelves to avoid physical damage. - Flammables kept in a special fireproof rom. - Heavy items kept on the lower shelves to avoid physical damage. - The store room was kept clean throughout the year to avoid rats, dust, pests etc which may interfere with our drug safety. OVER ALL COMMENTS

Compared to the previous year there is an increase in expenditure due to the following reasons.

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1. The school of nursing and midwifery has been increasingly admitted many students. Thus increase on consumption of sundries mainly gloves. 2. During the year we did so many operations both from maternity and surgical wards due to increased number of accidents. This increased the number of IV fluids and gloves used. 3. However we managed all unusual challenges due to JMS delivery all the needed items as soon as we needed them. 4. The prices of drugs and sundries from the main suppliers have gone up.

LABORATORY

The laboratory is one of the support services frequently used by both outpatients and inpatients. Consequently it is staffed with a laboratory technologist (graduate BLT), 1 laboratory technician deployed by the district, 2 laboratory assistants and 2 laboratory attendants. The laboratory department is housed in the OPD complex and consists of the parasitology/clinical section room where investigations like hematological tests, serology, clinical chemistry and parasitology among others are performed. Then there is a room for bacteriology/culture and sensitivity where the in charge also sits. In this same room, CD4 T-cell counts are performed. The activities for FY 2015/16 are tabulated below:

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Table 26: Activities of the laboratory for FY 2015/16

10.LABORATORY LABORATORY TESTS TESTS NUMBER DONE NUMBER POSITIVE LABORATORY TESTS NUMBER DONE NUMBER POSITIVE 10.1 HEMATOLOGY (BLOOD) 38. Hepatitis B 42 6 01. Hb 399 39. Brucella 1452 214 02. HBG<8 161 40. Pregnancy Test 904 428 03. HBG≥8 2608 41. Rheumatoid Factor 491 50 04. WBC Total 3907 Widal 2299 05. WBC Differential 3889 42. Others 06. Film Comment 33 07. ESR 267 PSA 41 7 08. Semenalysis 34 10.5 IMMUNOLOGY 09. Bleeding time 18 43. CD4 tests 10 CSF 14 44. Viral Load Tests 11. Clotting Time 18 45. Others 124 10.6 MICROBIOLOGY (CSF URINE, STOOL, BLOOD, SPUTUM, SWABS) 12. Others 156 35 46. ZN for AFBs 429 20 930 47.Routine Cultures & Sensitivities 10.2 BLOOD TRANSFUSION 48. Gram 13. ABO Grouping 469 49. India Ink 14. Combs 4 50. Wet Preps 15. Cross Matching 320 51. Urine Microscopy 3761 1776 16. Blood Collected WB 189 10.7 CLINICAL CHEMISTRY 17. Blood Transfusion PC 209 Renal Profile 10.3 52. Urea 226 CATEGORY 0-4 years 5 and over 0-4 years 5 &over 53. Calcium 18. Malaria Microscopy 704 1800 53 349 54. Potassium 52 19. Malaria RDTs 715 1663 39 229 55. Sodium 14 20. Trypanosoma 56. Creatinine 297 21. Microfilaria Liver Profile 22. Leishmania 57. ALT 177 23. Trichinella 58. AST 175 24. Borrella 59. Albumin 39 Stool Microscopy 60. Total Protein 16 25. Entamoeba Lipid/Cardiac Profile 26. Glardia Lamblia 947 8 61. Triglycerides 3 27. Trichomonas 947 30 62. Cholesterol 3 28. Stronyloides 63. CK 1 29. Shistosoma 64. LDH 30. Taenia 947 2 65. HDL 31. Askaris 947 63 Other Clinical Chemistry Tests 32. Hookworm 947 7 66. Alkaline Phos 133 33. Trichuris 947 5 67. Amylase 7 34. Other Parasites 947 49 68. Glucose 18 10.4 SEROLOGY 69. Total Birubin 37 35. VDRL/RPR 4901 139 70. Direct Birubin 16 36. TPHA 26 10 44 1 37. Shigella Dysentery 947 104 71. Others 31 0

HMIS FORM 107: HEALTH UNIT ANNUAL REPORT Page 16

10.8 SUMMARY OF HIV TEST BY PURPOSE CATEGORY HCT PMTCT CLINICAL QUALITY CONTROL SMC TOTAL 72. DETERMINE 746 3021 1756 346 0 5899 73. STAT PAK 30 49 77 70 0 226 74. UNIGOLD 12 33 32 61 0 138

Laboratory investigations for the inpatients entail collection of the samples by the nurses, labeling them and manually delivering them to the laboratory. The reports are also manually delivered to the wards. Some few tests like Random blood sugar are carried out on the ward using glucose test strips. There is a request that nurses on the wards carry out HIV-testing as precaution to minimize accidental HIV transmission to the staff during procedures on the wards.

The biggest reason for transfusion is anemia due to HIV related illnesses and the others include anemia due to; Obstetric/Gynecological hemorrhage—not surprisingly transfusions for female 5years and above account for the bulk of all the transfusions, Malaria and trauma (many motorcycle accidents following the completion of the Kabale-Kisoro-Bunagana-Chanika highway and the road linking the hospital to Kisoro town).

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CHAPTER SEVEN

HOSPITAL SUPPORT SERVICES ADMINISTRATION AND MEDICAL RECORDS

The Hospital has an Administration department that encompasses human resource, finance and administration units. The Hospital Administrator is the overall in-charge of administration department with Human Resource Officer and Accountant as being in-charges of Human Resource and Finances respectively and reporting directly to the Hospital Administrator. The other staff that are under administration department are: three (3) Accounts Assistants, Bursar, three (4) cashiers, one administration secretary, one (1) Records Officer, Main Stores In-charge, three (4) laundry attendants, one (1) gatekeeper, two (2) Drivers, Electrician, Tailor, two (2) Carpenters employed on contract subject to availability of work, and five night watchmen. Recently, a job of documentation, information and communication officer has been approved and filled to improve on the flow of information in the hospital. More recently, the hospital enlisted the services of a private security firm to take charge of the security of the hospital throughout the day. These deploy armed guards who support the regular watchmen to ensure tight security of person and property in the hospital. All general administrative staff report to the Hospital Administrator. By the nature of the complexity of Hospital activities, the Hospital Administrator delegates the Human Resource Officer to act on his behalf in receiving reports from the general administrative staff and acting on his behalf. The financial staff (accounts assistants, bursar, and cashiers) report to the Accountant. The Accountant and the Human Resource Officer report to the Hospital Administrator. Inventories / Stocks Inventories are stated at cost value, not at the net realizable value. The cost is calculated on the basis of the average price paid for the items remaining in stock. The distribution of items follows the first in first out (FIFO) method. The cost of the items in stock comprises only of the direct cost of purchase and excludes trip and transportation costs made to enable the purchase. Debtors / Receivables Debtors are carried at anticipated realisable value. At the balance sheet date an estimate is made for doubtful debtors based on a review of all outstanding amounts. Bad debts are written off in the year in which they are identified as bad debts.

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Capital grant / donation Grants and donations for the purchase of fixed assets are included in the accounts as deferred income (on an equalization account) and credited to the income statement on a straight-line basis over the expected economic life of the assets, to offset the depreciation costs of the donated property. Savings & Reserve Savings are amounts included in the costs (therefore also included in the ‘benefit & cost statement’), but not spent. This way they are excluded from the surplus. The Savings are kept on a Savings-account and withdrawn only to pay for the purposes for which they are saved for. This is what was done in order to purchase the hospital truck recently. Reserves are built up as the accumulation of annual surpluses and deficits. The surplus or deficit is what is left after deducting all costs from the benefits. Generally the Hospital applies internationally acceptable accounting procedures as guided by the Hospital Financial management manual.

Health Management Information System (HMIS): The Hospital records officers gather medical data regularly; from various wards and departments and completes the HMIS 105 and 108 forms monthly with the help of an automated computer database. Based on the data collected and analyzed on the four performance indicators of faithfulness to the Mission of the Roman Catholic Church, Management discusses and suggests ways forward on better performance. Then annually we complete the HMIS 107 which is also discussed at Management level and copies of reports submitted to the District and Uganda Catholic Medical Bureau. Each ward/department has independent records that are compiled by respective staff and students and manually collected by records officers for computation and analysis.

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The Hospital has one Records Officer. The Medical records are reviewed by Medical Superintendent and Hospital Administrator used for the quarterly analysis reporting on performance by Hospital Management as well as for making decisions for quality improvements. Information analyzed is then disseminated to staff, with each ward getting a copy and to Uganda Catholic Medical Bureau Domestic Services The Hospital gets a lot of visitors both international and local and as such it employs two guest house attendants on full time basis. The same employees are responsible for preparing staff break Tea. Otherwise all staffs are responsible for the rest of their meals. The Hospital has a kitchen for patients’ attendants from where they prepare their meals. The Hospital employs cleaners to keep the wards and compound clean while slashing of the compound is done using a machine. The Hospital does not provide meals to patients, except for the Batwa who obviously are in desperate need. The Hospital has a nutritional unit where mothers come with malnourished children in the Hospital and have to attend to them until the children finish treatment and a nutritional course. Today, the hospital has a vegetable gardens project whose mission is to provide, on a sustainable basis, nutritious vegetables to the patients and staff. The project is funded by Sustain For Life. It is under the sustainable agriculture project with support from Sustain for Life that the hospital has completed constructing a canteen. The canteen is expected to provide ready market for the vegetables while at the same time acting as a source of ready paid-for food for staff who have hitherto been having long lunch breaks as they prepare their meals in their respective places of abode.

As far as Laundry is concerned, the Hospital’s dirty linen (usually bed-sheets and blankets) are collected daily from the wards and thoroughly hand washed. We do not provide laundry services for patients but rain water is provided for the attendants to wash the linen. Patient attendants are required to clean patients’ personal belonging. We have indoor toilet and bathroom facilities in all of our inpatient wards. For the Outpatient departments we have an outdoor pit-latrine. We have large rubbish bins scattered around the hospital for collection of both bio-degradable and non-biodegradable wastes. All medical waste is disposed of at our incinerator.

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Ambulance Services The Hospital has a Toyota Land Cruiser Ambulance. The Hospital provides ambulance services for referred patients out of the Hospital. The patients are required to pay UGX 1,000 per kilometer covered. For expectant mothers needing emergency attention including caesarean section, we informed lower level health units that they can alert us in case of need for ambulance services but the response has not been good because many people prefer the cheaper, smaller cars (taxis) distributed in the communities. Apart from the Ambulance, the Hospital has other vehicles (a double cabin Hilux, a Toyota Land cruiser hard top used for outreaches, Minibus Hiace for the nurse training school, a Tata Lorry for transporting medicines,). The lorry is seldom used for transportation of medicines as Joint Medical Stores, the main supplier of medicines now transports them up to the hospital. Usage of Hospital vehicles is monitored and regulated by the Hospital Administrator who is responsible for them. Quarterly, analysis on each vehicle is done to determine costs on each, their conditions and mileage travelled and to make informed decisions regarding these vehicles e.g. whether to dispose off or retain a certain vehicle. Technical services The Hospital has electrical and water supply from UMEME and NWSC, respectively. We have electricity about 95 percent of the time. For the times we do not have UMEME (hydro-generated) electrical power, the hospital utilizes either of the two (2) standby generators. Also at night time, when there is not UMEME and no need for the generator we can utilize solar power in some places. The Hospital has an Electrician. This person does routine electrical maintenance and installations. He also advises on electrical installations for the new projects. Under the supervision of our Human Resource Officer, who acts as our supervisor of works, we attempt to take care of general maintenance issues as they arise to avoid major repairs. Major renovations/Hospital refurbishments are discussed at management level and undertaken subject to availability of funds. PASTORAL CARE The Hospital Chaplain spearheads pastoral care issues. Initially, the Hospital Chaplain was handling every pastoral care issue, but with introduction of Clinical pastoral care givers in 2007, pastoral care givers have been trained to provide pastoral care in the Hospital. These pastoral care givers offer a number of services including spiritual counseling, sharing the word of God, call to sacraments, organizing communal prayers, and bed-visits to the sick. Pastoral care givers work with the hospital chaplain but sometimes involve students and members of catholic charismatic group for certain activities. The Hospital Chaplain together with Clinical Pastoral Care givers visits the sick irrespective of religion or tribe, shares a word of God and prays with them. For those who are willing to receive sacraments, the Chaplain gives them sacraments especially the anointing of the sick, Holy Eucharist and Penance. 63

The hospital has greatly improved on its care to the patients who in turn appreciate the CPC services. The clinicians and nurses have also picked interest in getting to know more about the patients and providing care beyond medication.

Above: The Holy Eucharist is delivered to the patients in the wards.

CHAPTER EIGHT QUALITY AND PATIENT SAFETY IMPROVEMENT

The provision of quality health care is a key mission to St. Francis Hospital Mutolere and this is clearly indicated in the hospital strategic plan 2011/12-2015/16.

Patients are said to be having quality health care if:

• The health care fits their needs and preferences.

• The health care does not cause harm.

• The treatment is right for their illness.

• Access to health care is without unnecessary delays.

• The health care includes only the medical tests and procedures they need.

There are several other ingredients to quality but they all focus on a definition that is simply put: “quality health care is getting the right care to the right patient at the right time—every time”. The focus is to ensure that the services we offer fit the needs of the patient, who occupies center stage of our activities, to the extent possible.

The senior staff involved in patient care have a weekly meeting on Monday morning to examine the previous week’s performance and jointly address challenging situations. Further, plans for the coming

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week are drawn. This team work ensures that real time patient management and consultations are made. In addition, joint decision making in difficult circumstances ensures ownership of outcomes on the wards.

Other initiatives to ensure quality and safety:

1. Issues relating to the adverse outcomes in other hospitals are circulated as they appear in the media. The aim is to sensitize the staff about what is happening in the health sector with emphasis on dangers of our professional practice.

2. Staffs have been sensitized on some medico-legal aspects because this is an emerging threat and we observed that a number of cases of professional negligence are avoidable.

Table 27: Outcome/quality indicators.

This year (1/7/15- Last Year Outcome/Quality indicators % Difference 30/6/16) (1/7/14-30/6/15) Number of babies born dead (but known to be alive on arrival in 16 17 -5.8% hospital) by spontaneous vaginal delivery or caesarean section Number of deliveries in the hospital in the year 2123 2137 -0.6

Hospital Fresh Stillbirth Rate % (see definition) 1.0 1.0 0

Number of mothers dying in one year in the hospital while pregnant 03 2 75

Number of obstetric admissions in the hospital in the year 2508 2486 0.8

Maternal Death Rates % (see definition) 0.1 0.1 0

Number of patients in one year discharged as clinically recovered 9198 8960 2.6

Number of discharges (from all wards) in the year 9485 9124 4.0

Recovery rates on discharge % (see definition) 98%

Number of SELF-discharged patients in one year 107 96 11.4

Number of discharges (from all wards) in the year 9484 9124 4.0

Self-Discharge Rate % (see definition) 1.1 1.1 0

Number of caesarean section wounds in one year that get infected 32 21 52

Number of caesarean sections in the year 714 780 -8.4

Infection rates for caesarean section % (see definition) 4.8 2.7 77 Number of babies who died within 7th day from birth (early-neo natal 23 29 -20 deaths) Total number of deliveries in the hospital in the year 2123 2134 -0.5

Early neo-natal deaths rate (see definition) 1.0 1.4 -28.5

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The table shows that there has been progressive decline in hospital FSB rate, hospital maternal deaths rate, and improvement on recovery rate at discharge. There is an increase in neonatal deaths rates infection rates after caesarean section because of late referrals (either self referrals or delays in various health units). We carry out patient satisfaction surveys on an annual basis to track and get feedback from the patients who are the primary targets of our services.

CHAPTER 9

THE TRAINING SCHOOL:

Mutolere school of Nursing and Midwifery is a private not for profit training school, which is under the legal ownership of the Board of trustees of Kabale Diocese. It started in 1984 and is affiliated to Uganda Catholic Medical Bureau.

It is located on Mutolere - Kisoro road, Mutolere village Nyakabande Sub-county, in Bufumbira` East Constituency, Kisoro District, in South Western of Uganda. It is 500kms away from Kampala, the Capital City of Uganda and 17kms from both boarders of the Republics of Congo and of Rwanda respectively. It is in a valley surrounded by hills, which makes it hard to reach.

The school is registered by the Ministry of education and Sports, Classified under Vocational Training with registration number ME/TVET/097.

It offers four disciplines running concurrently, i.e Diploma Midwifery and Diploma Nursing course (extension) for 1½ years. In 1994 Direct Entry Diploma Nursing course was started taking 3 years. In addition, we also train Certificate in Nursing and certificate Midwifery for 2 ½ years.

The total enrollment for all courses is 235 students.

3.0 PERFORMANCE OF THE SCHOOL FOR THE PERIOD 2015-2016:

The school is generally making steady progress in size and performance. Its enrollment has for years been small but it is now increasing steadily.

Table 1: Enrollment and Performance of Mutolere school of Nursing and Midwifery 66

Table 28: The composition of intakes and last performance per course is as in the table below.

Courses No. of students No. of No. of No. of No. of Success enrolled in the students students 3rd students sat students rate year (new intake) 2nd year year for final exams passed final exams

Registered Nursing(Extension) 8 6 3 3 100%

Enrolled comprehensive Nursing - 0 0 0%

Certificate midwifery 43 34 33 46 43 93%

Certificate nursing

41 30 11 17 17 100%

Registered Midwifery( Extension 7 5 2 2 100%

Registered Nursing (direct) 0

6 11 0 0 0%

HTI progress in Faithfulness to the Mission compared to the years

There has always been a progress in faithfulness to the Mission in some aspects like Access, fluctuations in Equity as well as Success rate and efficiency due to different factors as will be mentioned below. Here below is its performance in the last four Years.

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Table 29: Performance in the last Four years

Indicator 2012/2013 2013/2014 2014/2015 2015/2016

Access (percentage of total 122 85% 85% 92 % capacity used)

Equity (average student fee) 1,880,813 2,338,096 2,277,928 2,456,240/=

Efficiency( average recurrent cost per student) 1,720,306 2,353,696 1,851,942 1,828,483/=

Quality (average rate of students passing their final exams = success 100% 98% 98% 96% rate).

Hindrances affecting the performance of the school on faithfulness to the mission

Access:

Few students are admitted for Registered Nursing course because the entry requirements are the same as those of the University. As such students prefer going to the many mushrooming universities instead of pursuing diploma nursing.

Some students do not turn up due to failure to raise school fees and due to limited number of bursaries available.

Equity:

The average students fees is low due to the fact that students come from peasant families and increasing fees will lead to low access hence the fees tend to change slightly. In addition the bursary scheme pay less compared to self-sponsored students.

Efficiency:

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Income that is collected is used to finance recurrent expenditures and prices are unstable due to increasing prices of commodities over time and as a result the income is not enough to finance the capital developments.

Success rate (quality) the schools performance academically is good. The tutors have worked hard to ensure the syllabus is covered in time and have tried to involve a good number of part-time teachers. However there is shortage of staff and this strain the available staff.

Achievements

 The construction of the double storey Girl’s hostel was completed and blessed /officially opened on 28th May 2016.  Graduation ceremony for 135 health workers on 28th May 2016,  Official hand over from previous Principal Tutor Sr. Inviolate Baganizi who handed over her responsibilities to our new Principal Tutor Sr. Agnes Agaba on the 28th May 2016  Good performance of students  Clinical placement for Diploma nurses was conducted successfully at Mulago and Butabika National Referral Hospitals.  Some of the midwifery students got bursary from Baylor Uganda and Uganda health systems strengthening Project through Uganda Catholic Medical Bureau and Ministry of Health.  The school was accredited by Ministry of Education and Sports and Uganda Catholic Medical Bureau  The school managed to send a candidate to Tutors College Mulago for Bachelor’s Degree in Tutorship and he will complete his course in July 2016.

Major constraints

 Understaffing especially midwifery tutors.  Inadequate funding leading to financial constraints.  Lack of accommodation for school staff.  Lack of enough computers compared to the number of students.  Lack of a good sewerage system. 69

 Failure of students to pay school fees in time yet it is the main source of income for the school.  Lack of transport means for students going for field experience, purchasing materials and food. Hence the need for a costa for field experience and a pick up for food and other materials.

Future plans

 To recruit more qualified Tutors  To buy more computers.  To train more tutors.  To train more clinical Instructors and Mentors  To solicit funds for constructing Tutor’s houses  To buy a Costa for taking students for field work and study trips and pick up for shopping other things for the smooth running of the school.  To renovate the old school.

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CHAPTER 10: PROJECTS 2015/16

The following projects were carried out with the help of our external development partners;

1. Completion of the girl’s dormitory which has 66 rooms 18 toilets, 18 Barth rooms and ironing places .It was co funded by Mutolere hospital and Franciscan sisters of Breda. 2. Procurement of two auto claves from joint medical stores, shs 98,000,000/= (ninety eight million only) was got from Franciscan sisters of Breda. 3. Construction of enrolled nurses /midwives accommodation ,the 1st phase of 12 unit were completed and are occupied and the other 12 units are under construction, this project worth 300,000,000 /=(Three hundred million ) was funded by Franciscan sisters of Breda . 4. Medical equipment that included, one theatre operating table, oxygen concentrators theatre instruments sets, theatre linen, suction pump and many others, was funded by Franciscan sisters of Breda at acost of shs 70,000,000/=( seventy million shillings only) 5. Second doctor’s residence (coda house) was reroofed and rain water is harvested from the roof. Sponsored by together for Uganda Germany. 6. Sustainable Agriculture and Nutrition project, this, project involves provision of nutritious, affordable high quality, organic vegetables and agricultural skills to clients within and around the hospital catchement area. It is funded by Sustain For Life. 7. Hospital Canteen ,also funded by sustain for life ,started as a result of a need to improve the marketing and sales for farm products ,the project comprised of canteen and vegetable shop. in the canteen nutrious meals ( all vegetables bought from the farm) will be sold to staff ,patients ,patient attendants ,students and others .vegetable shop with a cold store room provides proper out let to market, the surplus vegetables from the farm.

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UP COMING PROJECTS ( 2016/17)

1. Renovation and extension of Medical department, this will include, creation of intensive care units for the critically ill patients for proper management. Also two doctors rooms will be put and nurses duty room. At least four side rooms will be put for patients who need extra privacy. All this will be done at a cost of ug.shs. 175 million and is funded by Franciscan sisters of Breda, Holland. 2. Renovation and extension of Surgical department , an Intensive care Unit , a nurses duty room and a teaching room will be added in addition to the expansion of the female and male surgical wards. This project is co funded by Friends of Mutolere Holland and Franciscan Sisters of Breda and will cost shs. 145 million. 3. Renovation of CBHC building , expansion and construction of outside ventilated Improved Pit latrines. This is being funded by Friend of Uganda, Germany at a cost of Ug.x. 75 million.

FUTURE PROJECT 2017/18

1. Solar electrification , this will entail, the use of solar panels, batteries and power inverters to generate power to be used in the whole hospital. The hospital intends to generate at least 50% of its needed power. The total cost will be above ug. Shs. 300 million. Funding has been requested from Franciscan Sisters in Breda. 2. Storm /Rain water harvesting project. Tanks will be constructed, and connected to top tanks that will distribute the harvested water to different user areas. Water pumps will be used to take water from underground tanks to higher tanks. It is anticipated that 60 % of the needed water will be collected through harvesting. This project which will cost shs. 300 million has been sent to Breda Sister for financial support.

Financial savings from the above two projects( solar and water) will be used in the comprehensive maintenances of the hospital. That is , building maintenance, plumbing,

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electrical, sanitation and compound. This in the end will ensure sustainability in as far as hospital maintenance program is concerned.

3. Procurement of an x-ray machine complete with a development unit . To be financed by the hospital and Sisters of Breda, at a cost of ug.shs. 150 million 4. General maintenance of the hospital buildings, both wards and staff accommodation. This project will be funded by the hospital and Sisters of Breda. 5. Construction of new senior staff quarters, to accommodate 12 families of the senior staffs of Mutolere Hospital. This project, when finished, will house all the people currently in Mubano village, which is beyond repair.

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