THE REPUBLIC OF UGANDA
Annual Health Sector Performance Report
Financial Year 2004/2005
October 2005
Foreword
This Annual Health Sector Performance Report FY 2004/05 marks the end of the final and fifth year in the implementation of the first Health Sector Strategic Plan (HSSP I) 2000/01-2004/05. It, therefore provides a proxy evaluation of the achievements of the sector against the HSSPI targets. It is gratifying to note that, in terms of outputs, most targets have been attained. I salute every stakeholder and actor who has contributed to this success.
The second five-year Health Sector Strategic Plan (HSSP II) 2005/06-2009/10 represents a consolidation and extension of these achievements. Furthermore the Government of Uganda has reaffirmed its commitment to achieving the Millennium Development Goals (MDGs) within the framework of the National Poverty Eradication Plan (PEAP). This commitment poses a great challenge for the sector because there is a big resource gap to finance health services that would most likely result in maximum progress towards achievement of PEAP and MDG targets. This reality calls for paying closer attention to prioritization and intensive search for strategies to close the financial gap.
The functionality of Health Centre IVs is critical in timely management of birth-related emergencies and in averting unnecessary maternal deaths. At the same time, the preparedness and responsiveness of the supportive referral system have to be augmented in order to handle effectively those cases which the lower levels of care cannot manage. This report indicated that positive progress has been on both fronts, but that a lot more has yet to be accomplished. I appeal to all partners in health development to accord this component and other elements of reproductive health maximum effort.
One of the lessons we have learned during the implementation of HSSP I and over the year under review is that deliberate efforts need to be directed at harnessing the contribution of health related sectors and involvement of communities in planning and implementing strategic activities that will improve the health of the population and thereby enhance human development. This underscores the fact that improving health outcomes requires inputs from several sectors and the community itself.
In conclusion, I wish to extend my appreciation to all those who have contributed to the achievements recorded in the report of the final and fifth year of HSSP I. The strong partnership, which has bonded us together, gives me the confidence that we shall all collectively and boldly face the even more challenging future. Let us all aspire for more success and achievements in the health sector during the year 2005/06.
Major General (Rtd) Jim K. Muhwezi, MP MINISTER OF HEALTH
i
ii Picture Delegated at the 2nd National Health Assembly October 2004
iii Three Pictures
Picture NHA Opening Ceremony 2004
DGHS Zaramba with Amandua at NHA 2004
Omaswa with Lise at Technical Review Meeting April 2005 – Dates for Grace
iv Table of Contents
Foreword...... i Acronyms...... vii Illustrations ...... ix Executive Summary...... xii
Chapter 1 Introduction...... 1
1.1 Background ...... 1 1.2 The framework for achieving sector goals & objectives ...... 1 1.3 The Annual Health Sector Performance Report FY 2004/05...... 4 1.4 Sources of Information...... 4 1.5 Outline of the Report ...... 5
Chapter 2 Overview of Health Sector Performance FY 2004/05...... 6
2.1 Performance Against HSSP Indicators...... 6 2.2 Summary Financial Report - HSSP I trends with focus on the FY 2004/05 ...... 7 2.3 Measuring District Performance against the HSSP Indicators ...... 9 2.4 Factors Influencing District Performance ...... 12
Chapter 3 Delivery of the Uganda National Minimum Health Care Package ...... 16
3.1 Health Promotion, Disease Prevention and Community Health Initiatives ...... 16 3.2 Maternal and Child Health...... 21 3.3 Control of Communicable Diseases...... 33 3.4 Control of Non-Communicable Diseases ...... 52
Chapter 4 Integrated Health Sector Support Systems ...... 65
4.1 Health Care financing ...... 65 4.2 Human Resources for Health ...... 84 4.3 Health Infrastructure Development and Management ...... 87 4.4 Management of Medicines and Health Supplies ...... 89 4.5 Blood Transfusion Services ...... 96 4.6 Information for Decision Making ...... 97 4.7 Health Research and Development...... 101 4.8 Legal and regulatory framework...... 102
Chapter 5 Monitoring Implementation of HSSP I: Trends and Highlights ...... 107
5.1 Monitoring the performance of HSSP I...... 107 5.2 Monitoring GoU/DPs Memorandum of Understanding ...... 107 5.3 Health Centre IV functionality...... 109 5.4 Health situation in Northern Uganda...... 114 5.5 Health Sector Accountability: Client Satisfaction ...... 119 5.6 Progress on the Resolutions of the October 2004 National Health Assembly ...... 122
v 5.7 Progress on the Undertakings of the October 2004 Joint Review Mission...... 128 5.8 Future Annual Health Sector Performance Reports and Monitoring for HSSP II ...... 132
Annexes
Annex I: The District League Table FY 2004/05 ...... 133 Annex II: Staffing Situation in General Hospitals ...... 134 Annex III: General Hospital (Facility) Outputs ...... 136 Annex IV: Facility Care Outcomes...... 138 Annex Va: Mulago Hospital Service Outputs FY 2004/05 ...... 140 Annex Vb: Butabika Hospital Service Outputs FY 2004/05 ...... 140 Annex VI: Detailed analysis of health sector projects. (Ugshs millions)...... 141 Annex VII: Programme 9 allocation, releases and expenditure:...... 142 Annex VIII: Proposed Recruitment Ceilings for District PHC Health Facilities...... 143 Annex IX: Budget Performance FY 2004/05...... 146 Annex X: Financial Contribution by different sources at district level...... 147
vi Acronyms
ABC Abstinence, Be faithful, Condom use AFP Acute Flaccid Paralysis AHSPR Annual Health Sector Performance Report AIM AIDS Integrated Management ANC Ante Natal Care ARV Antiretroviral BCC Behaviour Change Communication BEmOC Basic Emergency Obstetric Care CB-DOTS Community based Directly Observed Treatment CDC Centre for Disease Control CDD Community based Drug Distributors CEmOC Comprehensive Emergency Obstetric Care CME Continuing Medical Education CYP Couple Years of Protection DDHS District Director of Health Services DOTS Directly Observed Treatment DPs Development Partners ENT Ear, Nose and Throat EPI Expanded Programme for Immunisation ESD Epidemiology and Surveillance Division FP Family Planning GFATM Global Fund for AIDS, TB and Malaria GoU Government of Uganda GTZ German Technical Cooperation HC Health Centre HDP Health Development Partners HMIS Health Management Information System HPAC Health Policy Advisory Committee HRD Human Resource Division HSSP Health Sector Strategic Plan HUMC Health Unit Management Committee IDSR Integrated Disease Surveillance and Response IEC Information, Education and Communication IMCI Integrated Management of Childhood Illnesses IPT Intermittent Presumptive Treatment IRS Indoor Residual Spraying IST In-service Training Strategy ITN Insecticide Treated Nets JRM Joint Review Mission KABP Knowledge, Attitude, Behaviour change, Practice KDS Kampala Declaration on Sanitation KPI Kampala Pharmaceutical Industries LLIN Long Lasting Insecticide Nets LSS Life Saving Skills LTPM Long Term Permanent Methods MAAIF Ministry of Agriculture, Animal Industries and Fisheries MCP Malaria Control Programme MDGs Millennium Development Goals MIP Malaria in Pregnancy
vii MNT Maternal and Neonatal Tetanus MoES Ministry of Education and Sports MoH Ministry of Health MoU Memorandum of Understanding MRC Medical Research Council MTR Mid-Term Review NCD Non Communicable Diseases NCRL Natural Chemotherapeutics Research Laboratory NGO Non Government Organisation NHA National Health Assembly NHP National Health Policy NIDs National Immunisation Days NMS National Medical Stores NVS National Voucher Scheme OPD Outpatient Department OPV Oral Polio Virus PC Palliative Care PEAP Poverty Eradication Action Plan PEPFAR President’s (Bush) Emergency Plan for AIDS Relief PET Post Exposure Treatment PHC Primary Health Care PHC-CG Primary Health Care Conditional Grant PHP Private Health Practitioners PMTCT Prevention of Mother to Child Transmission PNFP Private Not-For Profit PPPH Public Private Partnership for Health PSI Population Services I QA Quality Assurance RIDs Rabies Immunisation Days SHI Social Health Insurance SHSSP Support to the Health Sector Strategic Plan SOP Standard Operating Procedures SRH Sexual and Reproductive Health and Rights SWAp Sector Wide Approach TASO The AIDS Support Organisation TBL TB and Leprosy TCMP Traditional and Complementary Medicine Practitioners TOT Training of Trainers TT Tetanus Toxoid UBTS Uganda Blood Transfusion Services UDHS Uganda Demographic and Health Survey UNBS Uganda National Bureau of Standards UNHCO Uganda National Health Consumers Organisation UNHRO Uganda National Health Research Organisation UNMHCP Uganda National Minimum Health Care Package UPHOLD Uganda Programme for Human and Holistic Development UVRI Uganda Virus Research Institute VACS Vitamin A Capsule Supplementation VCT Voluntary Counselling and Testing VPH Veterinary Public Health WHO World Health Organization WP Wettable Powder Formulation
viii Illustrations
Figures
ix Tables
x Boxes
xi Executive Summary
This is the fifth and final health sector performance report in the implementation of HSSP I. The report also denotes the baseline situation in the sector at the transition into operationalizing the second Health Sector Strategic Plan (HSSPII 2005/06 – 2009/10). The report depicts achievements and constraints and reasons for both; and specifically provides the following:-
Overall health sector performance against 18 HSSPI indicators and that of individual district against 10 indicators; Progress on delivery of the Uganda National Minimum Health Care Package at the various levels; The performance of Integrated Support Systems, incorporating health care financing; Trends and highlights in monitoring implementation over the period of HSSPI; Progress in the implementation of the resolutions of the second National Health Assembly and undertaking of the 10th Joint Review Mission
Overall Health Sector Performance
The performance of the health sector has improved markedly over the HSSP priod. Performance of most HSSP I indicators was good and in some cases surpassed the targets set for HSSP I period. Five indicators provide a global overview of sector performance and measure sector progress in the Poverty Eradication Action Plan (PEAP). Three indicators have surpassed the targets for 2004/05, one indicator shows an improvement over the value for the last year and one was below target:-
New Outpatient (OPD) attendance per person per year has risen from 0.4 in 1999/00 to 0.9 in 2004/05, thus surpassing the year target of 0.7; The DPT3/Pentavalent Vaccine coverage, a proxy indicator to overall immunization and general health sector performance, at 89% far exceeded the target of 85%; Proportion of approved posts filled by trained health workers registered 68% against the target of 52%; Percentage of deliveries taking place in health units has improved from 24.4% to 25% against the target of 35%; National average HIV sero-prevalence as captured from Antenatal Care (ANC) at 7.1% was below the target of 5%;
Funding for the sector remained below the estimated minimum requirement of USD 28 per capita for delivering the Minimum Health Care package (Health Financing Strategy). GoU expenditure (Local Government and Central level) and donor projects amounted to a per capita expenditure of USD 10.5 in FY 2004/05. The GoU expenditure on health was UgShs. 219.56 billion representing 92.8% of the budgeted figure and 9.6% of total government expenditure. This amounted to a per capita expenditure of USD 4.78 This represents 9.7% of the total GoU budget 8.0. The increase over the previous year was only 5%.
xii Total inputs for medicines and health supplies availed to government and PNFP providers from all sources amounted to almost USD3.00 per capita. The escalating cost of treating malaria and the relatively high-cost interventions in HIV/AIDS further underpins the need to vigorously search and invest in preventive measures.
District Performance
For the third year running the same indicators for the League Table as for FY2002/03 and 2003/04 have been used to permit fair comparison between the years. These include information, management and service delivery output indicators. This year’s League Table is meant to facilitate the following:-
Compare sector performance between districts and determine good and poor performers; Provide information to facilitate analysis of circumstances behind good and poor performance at district level, and thus enable appropriate corrective measures which may range from increasing the amount of resources to the local government to more support supervision; Increase Local Government ownership for achievements; Encourage good practices i.e. good management, innovations and timely reporting.
The top 10 districts, from the first to the tenth are; Gulu, Bushenyi, Jinja, Mpigi, Kampala, Masaka, Rakai, Ntungamo, Kyenjojo and Rukungiri. The bottom 10 districts from the last are; Kotido, Nakapiripirit, Masindi, KIbaale, Kiboga, Moroto, Kamuli, Lira, Yumbe and Kitgum. There are some peculiar circumstances that influence the performance of some districts. These include districts with insecurity in 2004/05, limited capacity in new districts since 2000 and the nomadic culture in the Karamoja region.
The three years running, Jinja and Rukungiri districts have been in the best 10 performing districts, while Kotido, Masindi and Yumbe have remained in the worst 10 performing districts.
Delivery of the Uganda National Minimum Health Care Package
The report has regrouped the elements of the package in four clusters of HSSPII to emphasize the desired integrated approach and to foster increased complementality and coordination in planning, budgeting and implementation at the various levels. Within the clusters, performance of the elements has been assessed with particular emphasis on HSSP indicators and targets. Hospital services, being an integral actor in the delivery of the package, are also assessed under this chapter.
Health Promotion and Education
Health Education and promotion received priority attention during HSSP I in order to increase community awareness and health literacy so as promote healthy life style and prevent diseases. Village Health Teams strategy for empowering communities to take responsibility for their own health was initiated and has now been institutionalized fully in 11
xiii Districts of Northern Uganda where coverage stands at 100%. For the rest of the country the process has not moved beyond sensitization of District Councilors.
Sexual and Reproductive Health and Rights
Reproductive Health has been maintained as a sector priority for the last three years and will continue to be a priority in HSSPII. The proportion of women delivering in health facilities marginally increased from 24.40% in 2003/04 to 25% in 2004/05. Couple Years of Protection, a measure of effectiveness of family planning, increased by 10% due to improved availability of contraceptives and intensification of outreaches. Emergency Obstetric Care services were improved in 20 hospitals. The level of unsafe abortions has remained high in Uganda. A study estimated that over 300,000 unsafe abortions occur and annually 110,000 women seek post abortion care. There is therefore an urgent need for improving Family Planning services and post abortion care.
Management of Common Childhood Illness
Bi-annual Child Days were successfully conducted throughout the country. Home-base care programmed for treating malaria, pneumonia and diarrhoea at the community level was introduced. Over 1000 community resource persons were trained for this purpose. This has facilitated to avail services to children, and especially so in war-torn districts.
Immunization
The performance of immunization services has been good with coverage improving from 41% in FY 1999/00 to 89% in FY 2004/05 exceeding the HSSP I target of 85%. The marked improvement of performance in immunisation has been attributed to the general improvement in the health services delivery system and a comprehensive revitalization of EPI services since FY 2000/01. Sub-National Immunization Days (SNIDs) were implemented in the 15 high-risk districts of Northern Uganda, following isolation of the wild poliovirus in Southern Sudan in 2004. Measles is no longer among the top ten causes of childhood Illness and death.
STI/HIV/AIDS
HIV national serosurvey reported a prevalence rate of 7.1% with marked variation across the country. The HIV/AIDS programme has experienced expansion and increase in range of services during the HSSP I period. The prevention of mother to child transmission of HIV, access to services increased from 140 sites in 49 districts to 224 sites in all districts. 173 health facilities in the 56 districts have been accredited to provide antiretroviral drugs. An estimated 67,000 patients are currently accessing ART from the different outlets.
Malaria
The problem of Malaria has been compounded by the parasite resistance to cheaper drugs. A new treatment policy of using Artemether/Lumefantine (Coartem) as first line treatment was adopted. The target for children under five years of age receiving malaria treatment
xiv within 24 hours of onset of symptoms was achieved. The average proportion of households with at least one insecticide treated nets (ITN) rose from 15% (2003 survey) to 25.8%.
Mental Health
Rehabilitation of Butabika National Referral Hospital is nearing completion and 6 Regional Referral Mental Health units have been constructed at Gulu, Arua, Soroti, Hoima, Fort Portal and Kabale hospitals.
Hospital Services
Using the Standard Unit of Outputs (SUO), as a measure of performance at the Regional Referral Hospitals, the majority of these hospitals have increased the overall amount of Services produced. General hospitals increased to 42 with the completion of Kamuli Hospital. Data from a sample of 65% of PNFP hospital shows that outpatient and Inpatient attendances have increased by 21.78% and 12.32% respectively.
Integrated Health Sector Support Systems
The provisional budget out-turns for Primary Health Care were 97.8% for recurrent and 93.8% for domestic development budget. District and Referral hospitals achieved 100% performance on the recurrent budget. The Medicines and health supplies underwent major reforms during HSSP I with impressive results. The Pull System initiated in early years of HSSP I continued to be consolidated. The credit line established at the two major supply stores (NMS and JMS) markedly improved medicines procurement and management. Utilization on the credit line continued to be high with an average of more than 90%, while utilization on the PHC CG remained low. Human Resources for Health reforms implemented under HSSP I resulted in marked improvements. The proportion of approved post filled with qualified health workers increased from 33% in 1999/00 to 69% in 2004/05. Pay reforms results in modest increase in salaries for health workers and markedly improved access to the pay roll by health workers. Access of the population residing within 5 kilometres of health facility has improved from the baseline value of 49% in 2000 to 72% in 2005. Information management maintained improvement with timeliness and completeness of reporting of HMIS reports at 85% and 90% respectively. HMIS tools have been reviewed and revised to incorporate the information requirements for HSSP II. At central level there has been an improvement in IDSR performance in all indicators. At the District and HSD level there is improvement in most core functions.
Monitoring the implementation of HSSP I
xv Implementation of HSSP I brought a number of key innovations but also met challenges. Special highlights on the key innovations and major challenges of HSSP I implementation are provided in the report. Functionality of HC IV, one of the key innovation of HSSP I to improve health service delivery, is highlighted. An assessment of functionality of HC IV shows level of functionality of HC IV varies across and within districtis low in the country. District with serious and committed leadership have high levels of HC IV functionality. The deteriorating health situation in the Northern Region, a major challenge to health service faced under HSSP I, is also given special highlight in the report, taking into account consideration the results of the Mortality and Health Survey report.
Resolutions of the National Health Assembly and Undertakings of the 10th Joint Review Mission
Most of the resolutions were adequately addressed and fed into HSSP II; and significant progress was made towards the achievement of the undertakings.
xvi Chapter 1 Introduction
1.1 Background
Good health is an essential resource for social and economic development and an important dimension of quality of life. For development to be sustainable, health and economic growth must be mutually reinforcing. Without good health, individuals, families, communities and nations cannot hope to achieve their social and economic goals.
The National Health Policy (NHP) and Health Sector Strategic Plan (HSSP 2000/01 – 2004/05) were developed within the framework of the Poverty Eradication Action Plan (PEAP). In the revised PEAP, FY 2004/05 – 2007/08, health development is a component of Pillar 5 which addresses Human Development. The PEAP is Uganda’s comprehensive development framework and aligns with other development initiatives such as New Partnership for Africa’s Development (NEPAD) and the Millennium Development Goals (MDGs). The PEAP is also Uganda’s Poverty Reduction Strategy Paper (PRSP).
The long consultative process, with various health stakeholders and actors within and outside the government, in preparation of the National Health Policy and Health Sector Strategic Plan, (HSSP 2000/01 – 2004/05) laid a strong foundation for collective action in Uganda’s health development. The Sector Wide Approach was to galvanise effective coordination of efforts among all partners in Uganda’s national health development, increase efficiency in resource application and achieve equity in the distribution of available resources for health and effective access by all Ugandans to essential health care.
1.2 The framework for achieving sector goals & objectives
The vision of the health sector in Uganda is to make a contribution to the wellbeing of the people in terms of expanded economic growth, increased social development and poverty eradication. Consequently the mission of the health sector is the attainment of a good standard of health by all the people in Uganda, in order to promote a healthy and productive life. In tandem, the overall objective of the health sector policy is to reduce mortality, morbidity and fertility, and the disparities therein. In order to achieve this objective, HSSP I operated under the framework described in Figures 1.1 with five Programme outputs.
HSSP II aims to increase the efficiency and effectiveness of the health sector programme Compared to HSSP I, the new strategic plan document has been constructed to reflect more clearly, the maxim that the primary purpose of the National Health System (NHS) is to achieve improved health of the people (Figure 1.2). The programme objectives (1-4) are seen as the means to achieving the desired health outputs and outcomes but not as an end in themselves.
1 Figure 1.1: Framework for the Sector Programme HSSP I 2000/01 – 2004/05
Programme Goal Expanded Economic Growth Increased Social Development Poverty Eradication
Programme Development Objective Reduced Morbidity and Mortality from major causes of ill health and reduced disparity therein
Program output 1 Program output 2 Program output 3 Program output 4 Program output 5 Minimum Health Care Health Care Delivery Legal and regulatory Integrated support Policy, planning & Package implemented, system strengthened framework systems strengthened information management strengthened and and operational system operational; operational Research & development implemented Elements Elements Elements Elements Elements 1. Control of Restructured Ministry Health Acts 1. Human 1. Policy & Planning Communicable of Health and support Resources for Diseases institutions Professional Councils Health 2. Quality Assurance - Malaria - STD/HIV/AIDS Decentralised health Private sector 2. Health Care 3. Health Information - TB care delivery system regulated Financing System 2. Integrated Management of Partnership with Traditional 4. Research and Childhood Illness private sector. practitioners regulated 3. Health Development 3. Sexual and Infrastructure Reproductive Health Inter-sectoral linkages & Rights strengthened 4. Laboratory 4. Immunisation Services 5. Environmental Health 6. Health Education and 5. Procurement and Promotion management of 7. School Health drugs, medical 8. Epidemics and supplies and Disaster Preparedness logistics & Response 9. Nutrition 10. Interventions against Diseases Targeted for Elimination or Eradication 11. Mental Health 12. Essential Clinical Care
2 Figure 1.2: Framework for the Sector Programme HSSP II 2005/06-2009/10
Development Goal Expanded Economic Growth Increased Social Development Poverty Eradication
Programme Goal Reduced Morbidity and Mortality from the major causes of ill health and premature death and reduced disparity therein
Health Service Strategy Effective delivery of an integrated Uganda National Minimum Health Care Package
Programme Objective 1 Programme Objective 2 Programme Objective 3 Programme Objective 4
A Health Care Delivery To strengthen the To reform and enforce An Evidence-based Policy, System that is effective, Integrated support systems the Legal and Regulatory Programme, Planning and equitable and responsive Framework Development in place
Components Components Components Components 1. Central level 1. Human Resources for 1. Health Acts 1. Health Policy and organization and Health Planning management 2. Professional Councils 2. Decentralized heath 2. Health Financing and Associations 2. Health Management care delivery system Information System 3. Public/Private 3. Health Infrastructure 3. Private Sector Partnerships in Regulation 3. Integrated Disease Health 4. Essential Medicines and Surveillance health supplies 4. Traditional and 4. Intersectoral action Complementary 4. Quality Assurance for health 5. Diagnostic and Blood Medicine Practitioners transfusion services Regulation 5. Support and 5. Effective Community Supervision Participation 6. Research and Development
3 The programme overview has therefore been amended to show that implementing the Uganda National Minimum Health Care Package (UNMHCP) is the main approach for achieving the sector programme goal and development goal. This will be accompanied by a stronger focus on health promotion and disease prevention. The elements of the UNMHCP in HSSP II have been restructured into clusters, to illustrate more clearly the contribution to the HSSP II key programme outputs, as well as fostering improved operational coordination and integration.
1.3 The Annual Health Sector Performance Report FY 2004/05
For each HSSP implementation year, and as part of the strategic thinking and planning process, the GoU and stakeholders in the sector, examine the performance of the health sector against set targets and for the different levels against their responsibilities. The analysis also takes into consideration the contributions of the sector in the overall context of poverty eradication and national development. The Annual Health Sector Performance for the FY 2004/05 forms the subject content for this report. This Annual Health Sector Performance Report also reflects progress of the sector in the first year of the revised PEAP (2004). The objectives of the report are the following
To review the performance of the sector for FY 2004/05, identifying achievements and constraints To assess progress towards achieving the HSSP I targets examining the trends over the past five years
The process of compiling this report has greatly benefited from the experiences of the previous years of HSSP implementation. As in the other preceding reports, the emphasis remains on assessing the implementation of the HSSP both in the perspective of the period under report and in relation to the overall sector achievements and strategic planning. Within this framework, efforts have been made to:
Maintain the focus on performance at the district level and making comparisons among the districts by use of a League Table Highlight the individual and collective contribution of the National and Regional Referral Hospitals as well as the PNFP hospitals at similar levels, into the broader picture of delivering the Uganda National Minimum Health Care Package. Include the donor expenditure analysis within the Financial Report Review the progress made towards the specific commitments made at the last National Health Assembly and Joint Review Mission
1.4 Sources of Information
As with the previous reports, the compilation of this report relied heavily on the traditional sources of information enshrined in the Monitoring and Evaluation Framework of the HSSP and in particular the Health Management Information System
4 (HMIS). There were deliberate attempts to obtain information from the districts to supplement and validate the HMIS. Use has also been made of information from undertakings of partners as well as their regular performance reports. The contribution of the central support sub-sector was mainly obtained from the quarterly and annual performance assessment reports. Other sources of information included:
Reports of Undertakings sanctioned by the October 2004 GoU/DP Joint Review Mission and the 2nd National Health Assembly sessions. Area Team Reports Research and other studies undertaken by various stakeholder institutions
1.5 Outline of the Report
The Report is divided into five chapters. Chapter 1 is an Introduction and Chapter 2 covers an Overview of the Sector Performance for FY 2004/05 and includes the overall performance of the sector against HSSP indicators and the district level performance using the District League Table. Chapter 3 is a detailed presentation of the delivery of the Uganda National Minimum Health Care Package and Chapter 4 outlines the performance of the Integrated Health Sector Support Systems. Chapter 5 details the Monitoring of the Implementation of HSSP I focusing on trends and highlights in the achievements over the last five years. The last chapter, Chapter 6 looks as the way forward for Future Annual Health Sector Performance Reports and Monitoring for HSSP II.
5 Chapter 2 Overview of Health Sector Performance FY 2004/05
2.1 Performance against HSSP Indicators
The HSSP I contributed immensely to streamlining planning, and monitoring and evaluation of the health sector. Health Sector stakeholders agreed to a set of indicators for the monitoring of the HSSP I at the national and the district levels to be reported on annually in the an Annual Health Sector Performance Report (AHSPR). Targets for the indicators for the HSSP period were agreed at the time of launching the HSSP I in 2000, and were subsequently reviewed and updated at the Mid-Term Review of the HSSP (MTR) in April 2003, particularly in view of limited resources. The AHSPR 2004/05 is the 5th annual report. The report includes assessment of the FY 2004/05, and in addition examines the entire HSSP I (2000/01 - 2004/05). The performance against the 18 HSSP I monitoring indicators over the period 200/01 to 2004/05 is shown in Table 2.1. This report as in the previous AHSPR looks beyond the overall performance and analyses the variation of performance amongst the districts in the country.
The performance of the health sector has improved markedly over the HSSP I as illustrated by the achievement of most of the indicators in Table 2.1. Most of the input, process and output indicators have shown improvements. The trends of Poverty Eradication Action Plan (PEAP) health indicators will be discussed in more detail in this Chapter. There are challenges to note as the sector begins to implement the HSSP II. Performance against a number of indicators has not been systematically assessed due to lack of /poor information. These include the indicators measuring client satisfaction, Caesarean section rate, malaria case fatality and proportion of malaria cases that have been properly managed. Information on health outcomes to which the health sector is a key contributor is derived from the Demographic and Health Survey which is under way with preliminary results expected by October-November 2006. The DHS 2005/06 results will be compared with DHS 2000/01 to show whether the improved outputs over the HSSP I have translated into improved health outcomes for Ugandans.
The indicators that have shown improvement in FY 2004/05 over FY 2003/04 include: new Outpatient Department (OPD) attendance in public and private not-for profit (PNFP) health facilities, Pentavalent vaccine coverage, and Couple Years of Protection (CYP). There are some indicators which have stagnated or slightly worsened and these include the proportion of expected deliveries taking place in public and PNFP health facilities, proportion of expected TB cases that are notified, proportion of health units that are reporting no stock-outs of the of 5 tracer medicines/supplies and HIV/AIDS prevalence.
PEAP Health Indicators
Five health indicators were initially included in the Poverty Eradication Action Plan (PEAP) as part of the Poverty Monitoring and Evaluation Strategy (PMES). These included OPD attendance, DPT3/penatvalnet coverage, proportion of expected women delivering in public and PNFO health facilities, proportion of approved posts filled by trained health workers and national HIV sero-prevalance based on ANC sentinel surveillance.
6 Table 2.1: Performance against the HSSP Monitoring Indicators (still needs filling and cleaning) Category Indicator Purpose 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2004/05 Data ( What it measures ) Baseline Achieved Achieved Achieved Achieved Achieved Target source Value 1 Input Percentage of GOU budget allocated to health sector Commitment of GOU to health Alloc. 7.3 % 9.6% 10.2 % 10.8% MOH/ Exp. 7.5% 8.9% 9.0% 9.6 % 9.7% MOF 2 Input Percentage of PHC CG funds released on time to the Level of Govt. honouring its 97% ? Olle HPD sector ( Non salary recurrent and capital ) commitment to the sector MOH MOF 3 Input Total public ( GOU and donor ) allocation to health Equity of health resource allocation $ 4.80 $ 7.2 $ 7.83 $10.32 MOH per capita MOF 4 Process Percentage of disbursed PHC-CG funds that are Absorption capacity at the district 50 % 93% Olle Monitorin expended level g Reports 5 Process Proportion of districts submitting complete HMIS Management capacity for the 15.6 % 70 % 85% 85% HMIS monthly returns to MOH in time reporting system reports 6 Process Percentage of facilities without any stock-outs of Drug management protocols 29.1 % 33% 40% 35% HMIS/ chloroquine, ORS, cotrimoxazole & measles vaccine survey 7 Process Percentage of population residing within 5 km of a Equity and access 57 % 72 % Infrastr Mapping health facility ( public or PNFP) providing the MHCP ( Implementation of the UNMHCP ) by district 8 Output Percentage of children < 1 yr receiving DPT 3 Utilisation ( PEAP Indicator ) 41.4 % 84 % 83 % 89% 85% according to schedule by district 9 Output Proportion of approved posts that are filled by trained Level of staffing implementation of 33 % 66 % 69% 69% HMIS/ health personnel HRD policy Staff Inventory 10 Output Contraceptive Prevalence Rate ( CPR ) Utilisation 15 % NA NA UDHS Couple Years of Protection (CYP) 228,675 223,686 234,259 11 Output Proportion of surveyed population expressing Quality of care NA NA NA NA NA NA Comm satisfaction with the health services surveys 12 Output Urban / Rural specific HIV sero-prevalence rates HIV infection 10.9 % Urb 6.2% Avge. 6.2* Avge Lule/Kirungi ACP 4.3 % Rural reports 6.8 % Avge 7.1% Serosurvey 13 Output Percentage of deliveries taking place in a health facility Utilisation ( PEAP ) 25.2 % 20.3 % 24.4 % 25% HMIS ( Govt. and NGO ) Reports Deliveries supervised by health workers 38 % UDHS 14 Output Total Govt. and NGO OPD utilisation per person per Utilisation ( PEAP ) 0.40 0.43 0.60 0.72 0.79 .9 HMIS year Reports 15 Output Health facility level specific number of C/Sections per Level of surgical obstetric care at HC 14.0 per 1000 NA HMIS 1000 deliveries within the catchment area of the facility IV live births Records 16 Output Proportion of TB cases notified compared to expected Effectiveness of surveillance system 50 % 99.7% 49 %*** 51% NTLP Reports 17 Malaria case fatality rate among children < 5 yrs old Quality of case management 3 %**** Popn. Surveys 18 Percentage of fever/uncomplicated malaria cases ( all Access to effective malaria case NA NA NA NA NA NA Facility ages ) correctly managed at health facilities management based surveys *has not been updated since 2002/03;** 2002/03 & 2003/04 figures not really comparable to the baseline; *** the 2002/03 & 2003/04 figures not comparable as measurement changed; ****estimate from RRH
7 In the revised PEAP 2004 new indicators were added and these are: proportion of health facilities without stock-out of 4 tracer medicines/supplies; sanitation coverage/latrine coverage as proxy; and family planning uptake measured by Couple Years of Protection (CYP). Trends in the performance against these indicators for the FY 1999/00 to 2004/05 as presented in Table 2.2.
Table 2.2: Trends for the 5 PEAP indicators 1999/00 to 2003/04 Indicator Baseline 2000/01 2001/02 2002/03 2003/04 2004/05 2004/05 Value Achieved Target 1999/00 OPD Utilisation 0.40 0.43 0.60 0.72 0.79 0.9 0.7 DPT 3 / Pentavalent vaccine coverage 41 % 48 % 63 % 84.1% 83 % 89% 85% Percentage of deliveries taking place in 25.2 % 22.6 % 19 % 20.3 % 24.4 % 25% 35% Health Facilities ( Govt and PNFP ) Proportion of Approved Posts filled by 33 % 40 % 42 % 56% 68% 68% 52% Trained Health Workers National Average HIV Sero – prevalence 6.8 % 6.1 % 6.5 % 6.2% 7.1% 5% at ANC Surveillance sites Proportion of Health facilities without 33% 40% 35% stock-out of 4 tracer medicines/supplies Latrine coverage 57% Couple Years of Protection 228,675 223,686 234,259
2.1.1 New Outpatient Attendance in Government and PNFP health units
New Outpatient Attendance in government and PNFP units is a measure of utilisation of health services, and is used as a proxy measure for both the quality and quantity of services (supply side) and the health seeking behaviour of the population (demand side). There has been a steady increase in new OPD attendees since the launching of the NHP and HSSP. Per capita attendance has risen from 0.4 in FY 1999/00 to 0.9 in FY 2004/05, and has surpassed the HSSP I (FY 2004/05) target of 0.70. The increase in attendance is more notable in numbers. New OPD attendees have increased from 9.3 million in FY 1999/00 to 24.5 million in FY 2004/05 equivalent to 150% increase. This is attributed to the abolition of user fees in the public health units, decrease of fees at the PNFP facilities, increased geographical coverage of health services, increased quality of services by recruitment of health workers and increased availability of medicines and supplies.
A further increase in OPD attendance was noted, from 0.79 in FY 2003/04 to 0.9 per capita in FY 2004/05. The best five performing districts on this indicator are: Kisoro, Gulu, Rukungiri, Rakai and Kabale, and the other districts that have per capita utilisation of 1.2 or higher are Kabarole, Moyo and Adjumani. The five least performing districts are: Kampala, Kibale, Kotido, Nakapiripirit and Kamwenge districts, which together with Kiboga, Yumbe and Mayuge have per capita utilisation of 0.6 or less. The performance ranges from 0.46 attendances per person per year in Kampala to 1.58 attendances per persons per year in Kisoro.
Figure 2.1: Variation of New OPD Attendance by District FY 2004/05
1 DIstrict variation in OPD Attendances (new ) in public and PNFP health units in the FY 2004/05
1.8
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per capita Oper capita PD (new attendance) 0.4
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0.0 Lira Jinja Gulu Kumi Mpigi Arua Rakai Moyo Apac Bugiri Busia Nebbi Pader Soroti Mbale Hoima Kotido Pa llis a Kisoro Kamuli Tororo Iganga Kitgum Moroto Kabale Kiboga Yumbe Kibaale Wakiso Masindi Sironko Mukono Masaka Kasese Mayuge Luwero Katakwi Mbarara Kampala Kyenjojo Kabarole Kanungu Kayunga Rukungiri Adjumani Mubende Bushenyi Kalangala Ntungamo Kamwenge Bundibugyo Kapchorwa Nakapiripiriti Ssembabule Nakasongola Kaberamaido National Average National
The variation by district is similar to that noted in previous years. All the districts with per capita utilisation of 1.6 or more are border districts, a large percentage of the population in Gulu resides in Internally Displaced People’s (IDP) Camps, and Adjumani and Moyo both host a large population of refugees. The high utilisation of OPD services along the borders of the country especially in the North and West of the country indicates that people from neighboring countries seek better quality and/or more accessible services from Uganda. The poor performance of Kampala district on this indicator is explained by the proliferation of private providers (not included in the HMIS) and a higher proportion of the population that afford to seek care in the private sector. Utilisation in Kotido and Nakapiripirit may be explained by the nomadic nature of the population whereby most of the male population lives far away from established health facilities for most part of the year. The poor utilisation in Kibaale, Kamwenge, Kiboga, Yumbe and Mayuge are not as easily explained.
2.1.2 DPT 3 / Pentavalent Vaccine Coverage
Coverage with the third dose of the Pentavalent Vaccine (previously DPT 3) is used as a proxy for overall immunisation performance. The national coverage has improved from 41% in FY 1999/00 to 89% in FY 2004/05. The marked improvement of performance in immunisation has been attributed to the general improvement in the health services delivery system and a comprehensive revitalization of EPI services since FY 2000/01. This included: expansion of outreach points, high political support and advocacy for immunisation at national, district and lower levels, and integration of immuniisation activities with other activities of the UNMHCP and especially child survival programmes like Child Health Days. There is a more detailed discussion about Immunisation under Section 3.2 of the Report.
The performance for FY 2004/05 is an improvement over the FY 2003/04 performance of 83%, and is above target for the HSSP I period of 85%. District performance against this indicator in FY 20004/05 varies from Nakapiripirit district at 56% to Bugiri district at 153%.
Figure 2.2: Variation of Pentavalent Vaccine Coverage by district FY 2004/05
2 180
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entavalent vaccine covera vaccine entavalent 60 p
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ri i e ti u a a li ja o i a e m al o yi le gi ul ro o c la o ga r le ra la u in jo bi o ia o iri y k a e a a l ni er o e o e m ga di ti gi b o uge do o on a yo n Li mo e a J gu eb is s ga g o de ul ak kwi im ge a tid s a in iri Bu Ku M r ola y Soro Mpi G ai is k Apa a ba ra g g am njo un N ak Bu n M n Ra b Aru s o a Pad mb o e s p ba K Pallis mp Toror Iga g Ka n K Morot u a ta H uma u K Kitgu Kibo orw a iri Sironk Ma Mu a ibug era a ye W b Ma Ka wen Kib j LuwerY Kas h M p BushenKa ram K un Mba al K Kan Kayun Ruk Mube m m Ad c a und Nt K e ap k abe B Ka K Na Nakasong K nal Av Ss tio Na
The variation in performance by district is shown in Figure 2.2. There are 5 districts with performance above 110% (Bugiri, Kumi, Mbale, Sironko and Bushenyi) and 15 districts with performance of 95% and above. Sixteen districts have less than 80% coverage, with the worst performance in Nakapiripirit, Masindi, Kapchorwa, Kiboga and Kitgum. Nakapiripirit district is the only districts with less than 60% coverage.
A pattern is emerging on district performance for Pentavalent vaccine coverage. A part from Bugiri this year’s best performer, which has otherwise been an average performer, the other high performers such as Kumi, Mbale, Sironko, Kabarole and Bushenyi are consistently good performers, on the other hand Nakapiripirit Masindi, Kitgum and Kotido have been consistently performing poorly against this indicator. Sironko and Mbale have persistently had coverage of above 100%.
2.1.3 Sexual and Reproductive Health and Rights
Sexual and Reproductive Health and Rights has been indicated as a priority area for the last 3 years of the HSSP I. The sector performance at frequent intervals (at least annually and possibly quarterly) can be measured by progress on the 2 indicators: proportion of expected deliveries taking place in public and PNFP facilities and Couple Years of Protection from conception.
2.1.3.1 Deliveries in Health Facilities
The utilisation of the health facilities for safe deliveries remains low, with the proportion of expecting mothers who deliver in government and PNFP health units staying stagnant throughout the HSSP I period – 25.2% in FY 1999/00 to 25% in FY 2004/05. This is unsatisfactory performance given the central nature of supervised deliveries in preventing maternal and child morbidity and mortality. This has been attributed to: perceived poor quality of services in particular lack of equipment, supplies, water, light and privacy; poor attitude of health workers; inadequate access to maternity services and cultural barriers with the preference to TBAs and other alternatives in the society. Table 2.3 below shows that there has been some improvement in terms of absolute
3 numbers delivering in the health facilities, but given the very high growth rate of the country in relative terms this is not significant improvement.
Table 2.3: Total Number of Deliveries in Government and PNFP Units (Amos to confirm absolute figures) Financial Year 2001/02 2002/03 2003/04 2004/05
Number of deliveries 214,083 262,633 303,799 340, 095
Proportion of all expectant women 19 % 20.3 % 24.4 % 25% delivering in GOU & PNFP units
The best performing districts are Kumi, Kampala, Jinja, Mukono and Nebbi with at least 40% of expecting women in their respective populations delivering in the public and PNFP health facilities. The least performers are Nakapiripirit, Kotido, Kamwenge, and Kalangala with less than 10% of expectant mothers in their respective populations delivering in public and PNFP health services.
Figure 2.3: Variation in proportion of expectant mothers delivering in health units FY 2004/05
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30 facilities facilities 20
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0 a i a o ai o o i i e e o a ti mi nj no ro ul ga gi le yi o e a k n a wi m ge ra o e l t be a do ri i o o role llisa n pi a n id der g ga se a u u yo Li ac joj ro al i i Ku J ebbi s oroti m Gulu M am a n e on m Aru usia tg g ba o m rw g N S Pa ga Hoim asaka Mb Rak Moyo Pa era yu as B tak Bugir Ap en engeKot irip Ki aba Ka ukungiri I ng Tororo am v Kiboga Wakis Sir Masindi Ki Kibaal babulKa M Yu w p Kampala Muk K Luwero KanunguM Ka asongol K Mbarara dju Ka May Ky m R Ntu Bushe k A ndibu Mubende pcho Kalan ka ber al A u Kam a n Na B Sse Ka Na
% of expecting mothers delivering in delivering mothers % expecting of K atio N
It is noted that as in previous years, the best performing districts have at least 2 hospitals each, whereas among the least performers, Kamwenge and Kalangala have no hospitals. Nakapiripirit and Kotido are both in Karamoja where communities have peculiar cultural beliefs related to Reproductive Health. This finding has implications for the level of systems investment and functionality that is required to make significant progress on this indicator. The Health sub-district (HSD), strategy with the establishment of HC IVs in HSDs without hospitals, was a key innovation of the HSSP I. to date only a few of these are carrying out their designated roles. This is a key challenge for the HSSP II. More information and discussion is in Section 3.2.3 Sexual and Reproductive Health and Rights and Section 5 ??? Northern Uganda and Functionality of HC IVs.
2.1.3.2 Family Planning Uptake – Couple Year of Protection
4 This is one of the new PEAP indicators and reflects the importance the sector stakeholders place on maternal and child health. Traditionally Contraceptive Prevalence Rate (CPR) is used to measure use of the various contraception methods. However data on CPR is only possible from a population survey – usually the Demographic and Health Survey that is carried out every 5 years. The Couple Year of Protection (CYP) can be computed routine data in the HMIS. This reflects uptake of contraception from public and PNFP facilities and does not include services received in the private- for profit sub-sector.
CYP data is available for 3 years of the HSSP I, FY 2002/03 – 228,675, 2003/04 – 223,686, and 2004/05 – 234,259. There was no CYP target for the HSSP I and from the available information no clear trend in performance is discernible.
2.1.4 Approved posts filled by trained health workers
The performance of this indicator over the HSSP I has improved markedly due to both extensive recruitment especially at the Primary Health Care level, and more comprehensive data from the centralised payroll and the Health Workers Inventory (HWI). As at October 2004 the proportion of approved posts (HSSP I norms) filled by trained health workers was 68%. This exceeded the HSSP I target of 52%.
The information reported on this indicator in the HSSP I and PEAP indicator tables under the FY 2004/05 is from the HWI of October 2004. Recruitment has since taken place at the district, referral hospitals and central level. However the Health Workers Inventory (HWI) is yet to be updated. The HWI noted challenges of inequitable distribution of human resources for health across the country which need to be corrected.
2.1.5 HIV Sero-prevalence
In the 90s there was marked decline in HIV prevalence in Uganda. During the HSSP I HIV prevalence as measured by ANC sentinel surveillance sites stagnated between 6 and 7%. This indicates that the HSSP I target set at 5.1% has not been met. In the FY 2004/05 a national HIV serological survey was carried out to provide data representative of adults across the country. The figure of 7.1% thus derived is not significantly different form ANC surveillance data. Regional mapping of this information showed marked variation across the country with the lowest prevalence in West Nile at 3% and the highest in Kampala, central and mid-north regions at 9%. This is illustrated in theFigure 2.4.
Figure 2.4: HIV prevalence among adults in Uganda by region FY 2004/05
5 HIV
3% by 9%
4%
U 6% 7% 7% 9%
Kampala - 7% 9%
2.1.6 Essential Medicines availability
The HSSP I indicator that measures medicines availability (as a proxy for quality of care) measures the percentage of health units without any stock-outs of HSSP indicator medicines1 - i.e. zero tolerance for medicines stock-out. Information available in the routine HMIS has not been useful for this analysis, and for the last 3 years a survey has been done to collect data for this indicator.
For all the 6 indicator medicines there were only 35% of the health units surveyed that did not report a stock-out in 2002/03, 40% in 2003/04 and 33% in 2004/05. This is against the HSSP I target of 65%. This is indicates marked under-performance on this indicator, which is key for quality of care and patient utilisation of health services. A number of issue are likely to have contributed to this less than satisfactory performance and include: the low level of funding for medicines and supplies; lower than expected expenditure on medicines by the medicines budget holders (local governments and hospitals) and the challenges still evident at the local government and central level in medicines procurement and logistics management. More information is available on this in Chapter 4 on medicines management and financing.
2.1.7 Sanitation coverage Access to appropriate sanitation facilities was not originally one of the HSSP I indicators, but has been included for the HSSP II indicators and in the PEAP indicators given that a high proportion of the diseases in the country are associated with poor sanitation. Latrine coverage is used as a proxy measure for this indicator and has been included in the District League Table performance assessment for the last 3 years.Over the HSSP I latrine coverage is estimated to have improved from
1 Chloroquine, SP, ORS, cotrimaxazole, Depo Provera and measles vaccine
6 49% in 2000/01 to 57% in 2004/05. This is against the HSSP target of 60%. The Kampala Declaration on Sanitation by the district leaders in 1997 has been used as a spring board for sanitation related activities over the HSSP I.
2.1.8 Comment on Statistics for the HSSP I and AHSPR for FY 2004/05
On the whole data availability and quality over the HSSP I has greatly improved.
2.2 Summary Financial Report - HSSP I trends with focus on the FY 2004/05
2.2.1 The HSSP I Health Financing and the Resource Envelope
In the Health Financing Strategy (HFS), the cost of providing the UNMHCP in the medium term as laid out in the HSSP I was estimated at US $28 per capita2. In order to maximize efficiency and equity, it was recommended that the bulk of these resources are channeled through the GoU budget given the close alignment with sector priorities and flexibility to the funding of different inputs and geographical areas of the country.
The various sources of information used to analyse the performance against this target includes expenditure information from Ministry of Finance, Ministry of Health, Local Governments, donor projects, NGOs, and service providers.
National Health Accounts (NHA) data for 2000/01 provides baseline data for the HSSP I of Total Health Expenditure (THE) of US $18 per capita – this included both public and private spending, with public spending that can be best be applied to the UNMHCP only at US $8 per capita. Recent data based on surveys of actual expenditure from GoU and Donor Projects show that this level of spending has just been maintained with public health expenditure in the range of US $7-8 per capita up to 2003/04 and increased to US $ 10 per capita in 2004/05 – see Table 2.4. This period has been characterized by increasing GoU budget expenditure (including donor budget support) – the GoU expenditure in health in nominal terms more than doubled, and health expenditure as a proportion of the total government budget increased from 7.5 to 9.7% over the HSSP I period.
Table 2.4: Public Expenditure on Health over the HSSP I FY GoU Donor Total Public Per Capita Per Capita GoU expenditure Budget Increase on funding3 Project s and Health expenditure in expenditure on health as % of performance the previous Global Expenditure Shs in US$ total government for GoU year in GoU Initiatives4 expenditure allocation
2000/01 124.23 203.83 328.06 14,205.02 8.06 7.5 82.8 37%
2 this did not include high cost commodities like ARVs, the Pentavalent vaccine and provision of ITNs and HBMF
3 includes donor budget support 4 Figures for Donor Project spending for 2000/01 are from the NHA Report June 2004 and for FY 2003/04 and 2004/05 from a MoH survey; figures for 2001/02 and 2002/03 are from MoFPED documents
7 2001/02 169.79 144.07 313.86 13,128.09 7.45 8.9 96.2 15%
2002/03 195.96 141.96 337.92 13,653.90 7.25 9.4 96 6%
2003/04 207.8 153.26 361.06 14,109.17 7.29 9.6 95.4 5%
2004/05 219.56 254.85 365.5 13,813.03 10.5 9.7 92.8 Sources: Ministry of Health – AHSPR; NHA Report; MOFPED – Background to the budget;; popn figures – UBOS;
This clearly shows that the HSSP I was grossly under-funded – at about 1/3 of the funds expected through public funds for the UNMHCP. There were improvements in the channeling of funds during the HSSP I with the GoU budget funding exceeding donor project funding from the FY 2001/02 with this trend being reversed in the FY 2004/05. The marked increase in donor project funding in FY 2004/05 is largely accounted for by increased spending by the Global Initiatives – PEPFAR (US funded), GFATM and GAVI which contribute more than 50% of the project expenditure in 2004/05. The total public health expenditure has not grown enough to support increasing geographical and quality coverage of the UNMHCP and to take care of the increasing needs for a growing population.
2.2.2 Budget Performance and Management over the HSSP I with focus on FY 2004/05
Over the HSSP I period GoU budget performance improved from low levels – 83% in FY 2000/01 to above 90% for the rest of the HSSP I. However the FY 2004/05 shows a relative decline to 92.8% budget performance compared to the previous 3 years, and this poor performance has been attributed to poor wage budget performance. See section ???? and Annexx ???? for details on GoU budget performance by level and grant.
Table 2.5: HSSP Funding for the FY 2004/05 Source Budget Expenditure Performance Comment GoU Budget 236.88 219.56 92.8% From government documents at central local levels; Donor Projects & 85.13 254.85 299% Data collected from 19 projects Global Initiatives Total 322.01 473.61 147%
Previously annual budget performance assessment focused on the government budget. In the spirit of the SWAp and in a bid to improve sector efficiency efforts have been made in recent years to collect data on donor project budget performance with data from surveys now available for FY 2003/04 and FY 2004/05. Details of donor poject expenditure analysis are highlighted in the section on Health Financing (Chapter 4). Suffice to say here that it is very difficult to assess donor project budget performance because of the different budget figures usually available from different sources at different points of the Financial Year. The budget performance of 299% is based on budget figures from the MTEF by the MoFPED and donor project expenditure information from the donor projects. This is illustrative of unpredictability of donor funding.
8 The stagnation in the GoU budget expenditure for the FY 2004/05 and FY 2005/06, coupled with relatively poor budget performance in the FY 2004/05 raises concern about the direction of health financing at the end of the HSSP I and raise questions about the feasibility of implementing the HSSP II.
Expenditure at the Local Governments Write something short based on analysis done
Relating Funding, Health Inputs and Outputs Previous Annual Health Sector Performance Reports have indicated efficient application of sector resources to purchase priority sector inputs which in turn are converted into outputs. Although the AHSPR 2004/05 indicates improvement in performance of some output indicators (OPD attendance, immunization – Pentavalent vaccine coverage) there are also signs that unless major changes are made in the way the sector is funded – level and mechanisms of funding, fundamental changes will not take place in some indicators which include availability of essential medicines and supplies and key services like EmoC with resulting stagnation of the proportion of women delivering in health facilities which is likely to result in minimal changes in maternal and child mortality.
This is directly related with the declining GoU budget which in turn leads to fewer resources for the essential medicines and supplies budgets (see section on funding medicines and supplies for more on this) and other inputs into primary health care funding including development, wages and non-wage recurrent funds.
2.2.3 Financial Management Monitoring
The Ministry of Health continues to carry out Supervision, Monitoring and Mentoring to the local governments and hospitals for the purpose of improving financial management. Improvements continue to be noted at the various levels, however there still some challenges some of which are recurring. These include:
there is persisting poor expenditure against the indicative essential medicines and supplies budget as provided in the financial management guidelines. This is of great concern given the still high level of medicines stock-outs at the health units; inaccurate/insufficient information in quarterly and annual reports from local governments. This makes analysis and use of this information for decision making very difficult. There are local governments which still experience significant delays in disbursing funds from the CAO and DDHS offices to the implementers.
2.3 Measuring District Performance against the HSSP Indicators
The AHPSR 2004/05 is the 3rd time that an assessment of individual districts’ performance against the agreed district HSSP Monitoring Indicators has been carried out with the help of a District League table. The information from this assessment is used to determine good and poor performers.
9 For the third year running it was agreed that the same indicators for the League Table as for the FY 2002/03 and 2003/04 report be used to allow for a study of trends in performance.
2.3.1 Composition of the League Table
A number of both HSSP and non HSSP district monitoring indicators have been used for the league table. These are: Information Indicators (not scored): o District population o Number of HSDs o Number of hospitals and Management Indicators: o Management of the PHC-CG – measured by proportion of received funds that has been spent – which is influenced by timeliness of reporting/requests; o Management of health data – measured by completeness and timeliness of HMIS reporting; and o Expenditure on key inputs – measured by proportion of indicative PHC CG budgets spent on medicines; and o Management of inputs – proportion of staff norms appropriately filled. Service Delivery Output Indicators o DPT3/Pentavalent vaccine coverage; o OPD new attendances per capita; o Proportion of expectant mothers delivering in GoU and PNFP units; o Proportion of expected TB cases that are notified; o Proportion of pregnant women receiving IPT 2 [2nd dose of Sulphadoxy-pyrimethazine (SP commonly referred to as Fansidar) in Pregnancy]; and o Pit Latrine coverage.
The magnitude of contribution for each of the indicators varies and is determined mainly by 3 factors: Importance of the factor in terms of its contribution to the overall health outcomes - For example the indicator on medicines expenditure scores 10, whereas timeliness of HMIS is 5. Magnitude of district influence on the performance of the indicator - For example the indicator on staff norms although very important, the contribution by the district is relatively small thus the score of 5. The HSSP indicators that are also used as PEAP indicators are awarded the highest scores of 12.5 each.
2.3.2 The Purpose of the League Table
The League Table was put in place to facilitate the following: Compare sector performance between districts and therefore determine good and poor performers; Provide information to facilitate the analysis of circumstances behind good and poor performance at the district level, and thus enable appropriate corrective measures;
10 Design of appropriate corrective measures which may range from increasing the amount of resources (funds, infrastructure, equipment or staff) to the local government, to more frequent and regular support supervision as required; Increase Local Government ownership for achievements – the AHSPR is discussed at the NHA where political, administrative and technical leadership of the districts will be in attendance; Encourage good practices – good management, innovations and timely reporting.
The League Table is not meant to embarrass local government leaders of poorly performing districts, but rather to make them question why their district is performing poorly, and considering ways in which that performance can improve.
2.3.3 The League Table Scores for FY 2004/05 and trends over the HSSP I
The top 10 districts from the first to the tenth are: Gulu, Bushenyi, Jinja, Mpigi, Kampala, Masaka, Rakai, Ntungamo, Kyenjoojo and Rukungiiri. The bottom 10 districts from the last are: Kotido, Nakapiripirit, Masindi, Kibaale, Kiboga, Moroto, Kamuli, Lira, Yumbe and Kitgum. The detailed League Table is included in this Report as Annex I.
Figure 2.5: District Performance according to the League Table FY 2004/05
MAP League Table
Table 2.6: District League Table HSSP I Trends League Table 2002/03 2003/04 2004/05 For 2 years For 3 Position years Top 10 Jinja, Moyo, Gulu, Jinja, Gulu, Bushenyi, Gulu, Jinja,
11 Kabarole, Adjumani, Moyo, Jinja, Mpigi, Bushenyi, Rukungiri Kalangala, Kisoro, Tororo, Kampala, Masaka, Jinja, Mpigi, Nebbi, Luwero, Rukungiri, Mpigi, Rakai, Ntungamo, Kampala, Rukungiri, Bushenyi, Kyenjoojo, Rukungiri, Kaberamaido and Kampala, Busia Rukungiri Moyo Kanungu Bottom 10 Pader, Ktido, Apac, Kotido, Pader, Kotido, Kotido, Kotido, Katakwi, Yumbe, Yumbe, Nakapiripirit, Nakapiripirit, Masindi Bundibugyo, Kamwenge, Masindi, Kibaale, Masindi, and Masindi, Kitgum, Iganga, Wakiso, Kiboga, Moroto, Yumbe, Yumbe Nakapiripirit and Masindi. Lira, Kamuli, Lira, Moroto, Kampala Moroto and Yumbe and Kitgum Pader, Kitgum Mubende and Lira
The average league table score is 56.8 – which compares unfavourably with the FY 2003/04 at 60.2 and 2002/03 at 63.1. Table 2.6 above shows the trend of individual district performance in the league table for the top 10 and the bottom 10 positions for the three years 2002/03, 2003/04 and 2004/05. Jinja and Rukungiri districts have been in the top 10 for three years running and on the extreme opposite end the districts of Kotido, Masindi and Yumbe have been in the bottom 10 districts for all the three years. Possible reasons for these consistently good and poor performers will be discussed in the following section.
Between the FY 2003/04 and 2004/05 the districts of Katakwi, Ntungamo, Iganga, Wakiso and Pader showed the most improvement(about 15% league table points each) and the districts of Kiboga, Kamuli, Busia, Moyo, and Adjumani showed most decline. In a number of the districts in the latter position incomplete submission of data contributed to the decline.
2.4 Factors Influencing District Performance
The AHSPR 2004/05 continues the tradition of analysis with the view to highlight the reasons behind good and poor performance. A number of variables are used in this analysis including: Management ability of the district leadership – as judged by the performance against the Management Indicators; Peculiar circumstances which include: o Districts with insecurity in 2004/05 (and longer) o Karamoja Region – the nomadic culture Level of Development of the district - infrastructural, financial and human resources available to the district o New districts since 2000;
2.4.1 District Management Capacity
Medicines and supplies are a key input for health services delivery. Availing medicines and supplies in appropriate quantities and at the appropriate time therefore should be a key responsibility for health managers and administrative and political local government managers. Medicines management, in this case the proportion of the indicative PHC CG budget for medicines that has been expended on medicines, may be used as a proxy for good management practices. This has been
12 noted in previous AHSPRs and is also demonstrated using the performance for the FY 2004/05 on medicines spending and comparing it to the overall League Table scoring.
Table 2.7: Medicines Management Performance and the League Table FY 2004/05 District % of indicative Medicines League Table League Table PHC budget used Funding Rank Score Rank for drugs Bushenyi 105% 1 69.8% 2 Kitgum 99% 2 47.8% 47 Kumi 94% 3 63.2% 12 Nebbi 93% 4 57.0% 23 Rukungiri 92% 5 63.6% 10 Pader 22% 52 50.5% 43 Kisoro 18% 53 52.7% 36 Lira 15% 54 47.3% 49 Moroto 10% 55 43.2% 51 Yumbe 1% 56 47.6% 48
As is shown in Table 2.7 districts with good performance on medicines management are likely to perform well with regard to the overall league table - 2 out of the 5 best medicines management performers are in the top 10 of the league table, whereas poor performers are likely to perform poorly overall - 3 out of 5 worst performers on medicines management are in the bottom 10 of the league table.
2.4.2 Districts with peculiar circumstances
The marked health needs and challenges faced by the districts of Northern Uganda in providing appropriate health services for the population have been highlighted in Chapter 5. This section analyses the performance of these districts versus the performance of other districts in the country in the league table.
Districts with Insecurity and Displaced Persons Over the last 2 decades including the FY 2004/05 a number of districts in Northern Uganda have been markedly affected by insecurity with a large proportion of the population living in Internally Displaced Persons (IDP) Camps. The analysis here is relating the districts of Apac, Gulu, Kitgum, Lira and Pader, which have faced marked insecurity in the FY 2004/05, and the overall performance of the league table.
Table 2.8: Performance of districts with marked insecurity in FY 2004/05 District Districts with League League Insecurity Rank Table Score Table Rank Gulu 1 70.3% 1 Apac 2 51.9% 38 Pader 3 50.5% 43 Kitgum 4 47.8% 47 Lira 5 47.3% 49
13 Gulu district is top of the overall league table and the best performer amongst the districts of mid- north that have been affected by marked insecurity and displacement of the population. The rest of the districts in this group performed below average with Lira and Kitgum districts in the bottom 10 districts in the League Table. Pader is out of the bottom 10 of the league table for the first time in the three years of district performance assessment.
This mixed picture is difficult to unpack – the very good performance in Gulu could be attributed to the generally more stable situation there with the majority of people in IDP camps or Gulu Municipality where they can be reached by services, and an organized district health management team. This is reflected in the particularly high service delivery indicators: OPD attendance, Pentavalent vaccine coverage, deliveries in health facilities, TB notification and IPT 2 coverage all of which are above the national average. The improvement in Pader district performance may be attributed to improvements in security in that district over the last half of the FY 2004/05. The persistently poor performance of Lira and Kitgum districts can therefore not be attributed wholly to insecurity.
Karamoja region The Karamoja region has peculiarities with implications for health services delivery and health status given the nomadic nature of the population and strong adherence to cultural norms. Over the latter period of the HSSP I with the development of the league table it has become clearer that this region requires special consideration.
Table 2.9: Performance of Karamoja region in comparison with other districts District Latrine Deliveries in OPD Pentavalent Overall coverage health facilities utilization vaccine League Table coverage Score Rank Score Rank Score Rank Score Rank Score Rank Moroto 10% 53 14% 50 .6 48 85% 34 43.2% 50 Nakapiripirit 3% 55 6% 55 .6 53 56% 56 38.6% 55 Kotido* 2% 56 4% 56 .5 54 67% 50 34.5% 56
Table ??? clearly demonstrates the very poor performance of the Karamoja districts against 4 of the service delivery indicators and the overall league table. For all the 4 indicators and the overall league table (except Moroto on Pentavalent vaccine coverage) the 3 districts are in the bottom 10 performers. This is a matter of great concern, and as per objectives of the league table, corrective measures need to be put in place to ensure that the people of Karamoja have the opportunity to enjoy similar health services and health as the other people of Uganda. Some of the efforts being undertaken in this direction are included in Chapter 5 ……
2.4.3 Level of Development of the district
The level of development of a district is likely to have an effect on its capacity to deliver health services. In particular access to health infrastructure and logistics and ability to attract health workers and administrative personnel can play a significant role in health service delivery and uptake. This is noted to be a key challenge when the performance of new districts (taken as districts created since 2000 for this analysis) is studied. Table 2.10: Performance of the New Districts over last three FYs
14 District New district FY Overall League Overall League Overall League 2004/05 Rank Table Rank Table Rank Table Rank 2004/05 2003/04 2002/03 Kyenjoojo 1 9 16 27 Kaberamaido 2 11 38 9 Kanungu 3 14 23 10 Wakiso 4 27 51 44 Kayunga 5 30 43 28 Mayuge 6 39 40 36 Sironko 7 40 30 39 Pader 8 43 55 56 Kamwenge 9 46 53 37 Yumbe 10 48 54 52 Nakapiripirit 11 55 44 48
A number of the new districts have been steadily improving/ doing fairly well on the league table in the last 3 years and these include: Kyenjojo, Kaberamaido5 Kanungu and more recently Wakiso as shown in Table 2.10. Only Kyenjojo is in the top 10 of the district league table for the FY 2004/05. The rest of the new districts tend to be in the bottom 20 of the league table, with Nakapiripirit and Yumbe in the bottom 10 for the FY 2004/05. It is crucial that specific efforts are made to support these districts in improving their performance. The issues of HCIV functionality; and attraction and retention of staff in hard-to-reach areas are pertinent. This is even more important as additional new districts, largely composed of parts of districts that were considered remote and under-served are coming on board in FY 2005/06 and FY 2006/07.
5 was severely affected by insecurity in FY 2003/04
15 Chapter 3 Delivery of the Uganda National Minimum Health Care Package
The Uganda National Minimum Health Care Package includes a set of interventions which are known to improve the population’s health, with particular emphasis on improvements in child and maternal morbidity and mortality. During the HSSP I a number of interventions such as HBMF, VCT, and PMTCT were initiated in the country but most of these have not yet achieved geographical and/or functional coverage throughout the country. This was partly due to the inadequacy of funding, but also due to the fragmented prioritization process in the sector, with often new initiatives taken on before old ones have been rolled out across the country. However, achievements realized & progress that has been made in delivery of the package over the HSSP I period is highlighted in the following report.
3.1 Health Promotion, Disease Prevention and Community Health Initiatives
The major contributors to Uganda’s disease burden are the preventable and communicable diseases. Correct and timely health promotive and disease preventive measures could prevent over 75% of the disease burden. This massive burden of preventable disease results in diminished productivity and increased poverty. The health promotion, disease prevention and community health initiatives therefore help in increasing community awareness and health literacy on the health promotive lifestyles and disease preventive measures.
3.1.1 Health Promotion and Education
Health Promotion and Education supports all elements of the MHCP to achieve their objectives. Its major aim is to create health awareness, promote public participation and involvement in health care delivery, and increase demand and utilization of the services provided by the sector. This should result in adoption of appropriate healthy lifestyles and health-seeking behavior. Table 3.1: Trends in Health Promotion and Education Indicators FY 2000/01-2004/05 Indicator Baseline Achieved Achieved Achieved Achieved Achieved Target 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005 1 Proportion of villages with 0 0 10% 40% 50% 60% 70% trained VHTs 2 Proportion of health 0 0 80% 40% 40% 30% 50% facilities and community institutions with health promotion materials (IEC 3 Proportion of political and 0 0 50% 60% 50% 50% 60% religious and cultural institutions promoting health 4. Proportion of media 0 20% 100% 80% 50% 50% 80% institutions having own health promoting programmes
16
Village Health Team coverage
The health sector started the Village Health Team (VHT) strategy in FY 2001/02 on a pilot basis in districts that had vibrant community based programmes. However in FY 2002/03, the Ministry received support from the ADB for this training in the 11 SHSSP district of Northern Uganda. These districts have now achieved 100% coverage of VHTs. The indicator however declines because of other districts that have not completed the process beyond the sensitization of the District Councillors. This is because this undertaking is quite expensive for most districts.
Health facilities with IEC materials The Division had a large budget in FY 2001/02 for produc6tion of materials and each of the programmes was allocated an adequate amount of funds for development and production of their required IEC materials. In these subsequent years however there has not been adequate allocation of funds to cater for this activity. It is only a few programmes like malaria which got support from the GFTAM that have produced materials for distribution to the health units.
Proportion of political, religious and cultural leaders promoting health There has been increasing interface with the cultural leaders especially to promote vaccination. This has continued and has been included in the Child days. The interface has however been limited due to inadequate funds.
Proportion of media houses with health programmes There has been a healthy collaboration with the media houses. This was possible in the beginning because of the small number of houses involved and each of them provided a slot for health programmes. This collaboration also culminated in the Broadcasting Council giving a blanket concession of 50% on rate charges for health messages. This collaboration is still strong and has brought about the increased health awareness and especially in the upcountry stations where the Ministry has put emphasis. The apparent decline in the overall performance is however due to the fact that there are now many stations that have proliferated and can not all be taken on board because of reduced funding of the health promotion activities
3.1.2 Environmental Health
Environmental Health is an important component of the Uganda National Minimum Healthcare Package. However, poor sanitation and hygiene in Uganda continue to be a major predisposing factor to Uganda’s burden of disease. Data related to sanitation varies widely from district to district. It is estimated that 80% of Uganda’s disease burden is associated with poor sanitation. Currently, the national latrine coverage is estimated at 57% (MoH, 2004 DHIs’ Conference). Poor sanitation and unsafe water associated with ill health, low productivity and thus poverty undermine government’s efforts to alleviate poverty in the communities. Malaria is the lead cause of morbidity and mortality in Uganda now and it is partly due to poor sanitation. Diarrhoeal disease is a major killer of young children and it alone is responsible for 19% of all infant deaths in Uganda. Cholera has become an endemic disease in some districts in the country.
17 The overall objective of environmental health is to support the achievement and maintenance of healthy living conditions of all Ugandans living both in rural and urban areas through contributing to reduction in transmission of sanitation related diseases and strengthening the effectiveness of EHD by advocacy, monitoring and evaluation, national planning and coordination.
Table 3.2: Trends in Environmental Health Indicators FY 2000/01-2004/05 Indicator Baseline Achieved Achieved Achieved Achieved Achieved value 99/00 2000/01 2001/02 2002/03 2003/04 2004/05 1. Safe waste disposal 47.2% 49.23% 51.3% 55.6% 55.9% 57% (Latrine coverage as proxy) 2. Proportion of districts 2% 10% 15% 18% 18% 20% conducting water quality surveillance activities 3. Increased access to 47% 48% 51% 54% 54% 61.3% safe water (Rural)
Achievements: An environmental Health Act and subsidiary legislation has been submitted for cabinet approval There has been a steady improvement in national latrine coverage. This can be attributed to many factors including construction of demonstration latrines of different technologies by EHD in some districts, implementation of Kampala Declaration(KDS) in some districts(with activities like Sanitation Days), increased support for sanitation activities like home improvement campaigns and use of Household Sanitation Assessment Book to monitor sanitation and hygiene in the households. The proportion of districts conducting water quality surveillance has also experienced a modest increase to the current 20%. This has been due to the development and dissemination of water quality surveillance guidelines, training of environmental health staff, and acquisition of water testing kits for some districts. Increase in access to safe water is partly explained by the widespread sanitation promotion campaigns and establishment of District Water and Sanitation Committees (DWSCs) that have enhanced collaboration in this sector.
In spite of the above achievements there still many challenges that include: Geographical and technical constraints in terms of difficult terrain and peculiarities arising from rocky grounds, loose/sandy soils, high water table, termite damage, limited land for construction of latrines in highly populated areas. No single technological option for sanitation and hygiene is easily affordable nor are they permanent. Fishermen, Cattle-keepers/nomads and displaced persons/refugees pose a special problem to the promotion of sanitation and hygiene. Many socio-cultural factors (Taboos, negative beliefs, and myths) have not been overcome over the years as well thus blocking effective use and maintenance of latrines and other sanitation and hygiene facilities.
18 Safe water chain: Studies have shown that over 90% of households accessing safe water actually consume water of unacceptable quality because contamination experienced from the water source to the time of consumption.
3.1.3 Control of Diarrhoeal Diseases
During HSSP I diarrhoeal diseases (cholera and dysentery) outbreaks were controlled in most parts of the country. Incidence fell from 6.4/1000 persons in 2000/01 to 3.0/1000 persons in 2004/05. Cholera Case Fatality Rate (CFR) fell from 6% in 2000/01 to 2.5% in 2004/05(WHO recommends CFR of less than 1%). Propagation of outbreaks was due mainly to poor environmental sanitation, low safe water coverage (less than 50% in some parts) poor domestic and personal hygiene practices and constant mass movement of populations – Refugees and Internally Displaced Persons. Table 3.3 shows the performance on key indicators of the programme.
Table 3.3: Trends in the Diarrhoeal Disease indicators FY 2000/01-2004/05 Indicators Baseline Achieved Achieved Achieved Achieved Target value 2000/01 2002/03 2003/4 2004/5 2005 1999/00 Cholera Case Fatality Rate 6% -5.0 2.5% 2.5% 2.0% (CFR)
Incidence of diarrhoeal 6.4 - 3.2 3.0 2.5 diseases of epidemic potential (cases / 1000)
During the FY 2004/05, the following achievements were realized:
Strengthened diarrhoeal related epidemic preparedness and response with special attention to highly epidemic prone districts and those with IDPs (Districts along the county borders with Democratic Republic of Congo, Sudan and Kenya). Strengthen diarrhoeal disease management in affected and epidemic prone districts at the community level. This has been through establishment of Oral Rehydration Therapy (ORT) corners at village and health facility levels, training of Health workers, provision of guidelines, and emergency logistics and supplies. Districts reporting outbreaks were supplied with emergency logistical support buffer stocks (ORS, IV fluids, etc). Those at high risk were encouraged to purchase these supplies using the credit line scheme.
Constraints: Repeated stock out of Key drugs and supplies at National Medical Store: this affected buffer stocks and frequently interfered with supply of drugs to districts and ultimately patient care. Internally displaced persons (over 1,300,000 people in Northern Uganda live in camps with poor sanitation and inadequate access to safe water), refugees and constant migrations. Kampala City slums (cholera outbreak in Katanga, Bwaise, Nateete, etc) remain a big challenge to outbreak control efforts – for example in Katanga the illegal structures were constructed on sewage lines and communities refused National Water and Sewage Cooperation from widening the existing lines and connecting new toilets to match up with
19 the growing city population. Hence there is constant blockages and spillage of raw sewage which often leads to cholera outbreaks.
3.1.4 School Health
The health sector, in collaboration with the education sector, is aiming at providing an enabling environment for delivery of QUALITY education by providing health promoting services in educational institutions. Schools offer an unprecedented opportunity for Health Promotion and Education. Successful School Health programs can influence the behaviour and health of the school children, who also may influence their kins and parents in the societies/homes where they come from. Through this potential multiplier effect School Health can make a significant contribution towards the attainment of the Millennium Development Goals (MDGs) and Health for All (HFA). Table below shows the performance of the programme on key indicators of performance.
Table 3.4: Trends in the School Health Indicators FY 2000/01-2004/05 NO. INDICATOR Baseline ACHIEVED TARGETS 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 1 School Health Policy in None 10% 30% 40% 60% 75% Finalize place Policy 2 School Health None 20% 40% 50% 60% 75% Raise implementation coverage to guidelines and standards 50% in place 3 School Health advocacy None 10% 15% 20% 25% 30% Raise and I.E.C. documents in production place of I.E.C. to 25% 4 School Health None 40% 50% 70% 70% 75% Maintain monitoring and 75% or evaluation system/data better in place 5 School Health support None 30% 30% 30% 30% 25% Supervise at supervision conducted to least 50% of districts and HSDs districts and HSDs
The following were the main achievements fro School Health Programme: School Health policy was drafted but awaits endorsement by the Top Management of the Ministry of education for routine implementation in the schools. .Conducted a costing study on Uganda School Health Package with support from WHO Guidelines and standards for the School Health package were developed, printed and distributed to districts. These include Guidelines for Improving Health in Educational Institutions and Guidelines for Monitoring Health in Educational Institutions. School Health documentary video tape was developed and distributed to all districts. Conducted School Health Baseline survey in 2000/01, a behaviour survey in 2003 and a school health needs assessment/survey with support from WHO support Developed and printed School Health Cards and School Health registers.
20 3.2 Maternal and Child Health
The burden of disease among maternal, newborn and children is high in Uganda. There is need to take an integrated approach to reproductive, maternal, newborn and child health as a “continuum of care” from pregnancy through childhood cognizant of the fact that maternal, newborn and child health are inseparable and interdependent. This must take into consideration the rights of women, children and adolescents. This calls for programming interventions at all levels for high and equitable coverage for reproductive, maternal, newborn and child health care including health systems strengthening.
3.2.1 Sexual and Reproductive Health and Rights (SRH)
During HSSP I maternal mortality declined marginally (506/100,000 population in 2000 to 505 in 2001) and supervised deliveries stagnated at 38%. During the same period adolescent pregnancies reduced from 43% to 32%. The 2006 UDHS will provide progress on outcome indicators since 2001. Nonetheless, the absolute number of deliveries in health units has increased year after year. However, due to rapid population growth, the proportion of women delivering in health units still remains relatively low at 29%, but an improvement from 22.6% in 2000. The positive upward trend in the proportion of health unit deliveries is attributed to improved availability of drugs, some improvement in staffing at health units and increased functionality of health centres III. Couple years of protection have increased by 10% (212,089-234,259) since last year ostensibly due to improved availability of contraceptives at health units and intensification of outreaches. The contraceptive prevalence rate is at 23% (2001) from 15% the previous year.
Table 3.5: Trends in the Reproductive Health Indicators FY 2000/01-2004/05 Indicators Baseline Achieved Achieved Achieved Achieved Achieved Target Value 2000/01 2001/02 2002/03 2003/04 2004/05 2005 1999/00 Proportion of 25.2% 22.6% 19% 20.30% 24.40% 29% 35% deliveries in GoU & PNFP health units Couple Years of 210,839 212,089 234,259 Protection TT Coverage for 42% 50% 70% 50% 80% pregnant women
Enabling factors A focused RH strategy, clear guidelines to districts on key areas of focus. Increased investment in health systems, notably in drugs, infrastructure, and human resources have resulted in an increase in the number of deliveries in GoU and PNFP health facilities. RH has been identified as a priority within the health sector for the last three years and will continue to be a priority during HSSP II. It has therefore received increased policy attention.
Constraints Despite an improvement in availability of drugs & contraceptives, there is still a mismatch between what is required and what is available
21 Tendencies towards expansion of service points rather than consolidation, especially at HC IV level Persistent shortages in human resource in spite of the slight improvement in availability Insufficient political support for Family Planning No increase in funding for health, including RH, as a result, RH undertakings to expand EmOC have not progressed as required. Inadequate blood and blood product supplies in health facilities Integration of malaria, HIV and FP in RH was initiated late in the HSSP I and is still inadequate.
Figure 3.1: Reproductive Health indicators performance FY 2004/05
120,000
100,000
80,000
60,000
40,000
20,000
- Q1 Q2 Q3 Q4 FY 2004/05 Number of HU Deliveries Number of CYPs
Akoboi Community Constructed ANC Shelter, Soroti District
A few individual districts including Moyo made marked improvement in RH indicators.
22
Box 3.1: Increase in Health Facility deliveries in Moyo District
The proportion of women delivering in health facilities in Moyo has increased consistently from 15.7% in FY 2002/03 to 21% in FY 2003/04 and 26% in FY
2004/05. The strategy adopted by Moyo to increase health unit deliveries was as follows: 1. Redefining the TBAs role: The poor relationship between midwives and TBAs was recognised as a major barrier to increasing supervised deliveries in Moyo. In order to address this, a series of meetings were arranged between midwives & TBAs 2. Provision of Mama kits in health facilities: Shortage of delivery supplies and payment for these by the client was also identified as a major barrier to increasing health unit deliveries. In order to ensure that the delivery is free to the client, mama kits were made available in all health units resulting in an increase in uptake of services. 3. Regular monitoring from district to HSD: Quarterly RH review meetings are held between the district RH focal person and the HSDs to discuss strategies and progress. 4. District level IEC: Regular radio messages are aired, informing people that services are free of cost and encouraging them to use health facilities. 5. Expansion of PMTCT: The availability of free PMTCT services provides incentives for women to visit health facilities both for ANC and deliveryand TBAs. At these meetings, a new role was defined for the TBA as an escort to women in labour and an assistant during the delivery. As a result of this TBA referrals have increased.
Other achievements The RH communications, Family Planning Advocacy strategies were launched. The FP strategy aims to address insufficient political support. The National Adolescent Health Policy was developed and disseminated. A Peer Education guide among young people was disseminated to the districts and a ToT for peer educators was held in 31 districts National and district logistics training on contraceptives was carried out. Ordering of contraceptives in accordance with the pull system is likely to increase as a result of this training. The EmOC roll out plan is being implemented and 20 district hospitals have been covered so far. EmOC improvement teams were set up in each of the 20 district hospital Integration of malaria in pregnancy (MIP), PMTCT and Family Planning have been initiated. Districts have prioritised provision of goal oriented antenatal care
3.2.2 Newborn Health and Survival
Infant deaths, most of which occur within the first 24 hours after birth, is very high in Uganda. Ministry of Health has initiated plans to integrate newborn health in maternal and child care. A steering committee has been proposed to over see the development of a newborn policy and
23 planning framework. A comprehensive situation analysis will be done to develop a strategy for scaling newborn care in Uganda.
3.2.3 Integrated Child Survival
Interventions being implemented to address the high childhood and infant morbidity and mortality include; Uganda Expanded Programme on Immunization (UNEPI), Integrated Management of Childhood Illness (IMCI), Control of Diarrhoeal Diseases, promotion of good Nutrition, and Family care practices. The outcomes of these interventions are also influenced by other government sectors namely: Agriculture Animal Industry and Fisheries, Education & Sports, Gender, Labour and Social Services which are also important to Child Survival.
The achievements and performance of the child survival interventions during FY 2004/05 and entire HSSP I period include:
Bi-annual Child days Ministry of Health started implementing bi-annual Child Days in the months of May and November of every year from May 2004. During the Child Days accelerated delivery of an integrated package of key interventions to children including mass Vitamin A Supplementation, mass de-worming, routine and catch-up immunization, and promotion of key Family Care Practices are provided to children up to 14 years of age. . The following has been achieved during Child Health Days:
Child Days has improved on immunization indicators in addition to Vitamin A supplementation and de-worming with Albendazole raising coverage to 68% and 65% respectively for age groups 1-14 years old. All the 56 districts of Uganda implemented two rounds of Child Health Days in May and November 2004 but with varying degrees of performance. Performance in Child Health Days was better in 2004. Combination of rich and attractive health packages can improve delivery of Child Health interventions as witnessed in 2004. For example combination of de- worming, bed nets with immunisation, can improve immunisation coverage and service utilization at health units. Child Days add value to routine and outreach services.
Figure 3.2: Measles Coverage January – December 2003 - 2004
24 MEASLES COVERAGE JAN-DEC, 2003-2004
140%
120%
100%
80%
60%
40%
20%
0% Jan Feb M ar Apr May Jun Jul Aug Sept Oct Nov Dec
2003 72% 69% 81% 80% 86% 31% 75% 80% 33% 24.44% 58% 63%
2004 79% 79% 82% 73% 116% 48% 116% 58% 86% 79% 125% 36%
M onths
Box 3.2: Child Days Implementation in Kanungu District: A Success Story
In Kanungu District Child Days is commonly referred to as “Catching up with the missed opportunities in Heath Services delivery” - “Okwegarukanu omu magara”. The district level partners include DDHS, USAID, WHO, UNICEF, Vector Control Department of Ministry of Health and the Child Health Division.
The micro planning process is at 2 levels; District and Health facility. At the district level, the key sectors are: Health, Education, RDC’s office, CAO’s offices and the Political wing normally represented by the sectoral Committee of Social Services. Teams are created at this level and assigned to a particular sub county. Health facilities demarcate their service areas assisted by the District Teams and logistics for each level supplied according to the catchment area and previous performance with a 10% mark up. Mobilisation is carried out by drug distributors, TBAs, invermectin distributors, and LC 1 in each outreach centre. All this process has ensured that all the villages are adequately covered. Additional mobilization is done through Radio Kinkizi, a structured update from the Health Department is aired once a week.
Child Days have been successful over the years with coverage of over 100% in De-worming and Vitamin A supplementation. Missed opportunities during immunization are minimized and sanitation improvement campaigns are normally accelerated. ITN use and promotion including family planning are some of the interventions put on board, and have also started yielding results.
Cross-border populations and inter-district movements affect the target population and hence more resources required to cover the extra population. Normally the period coincides with the rainy seasons and school exams which interrupt the outreach programmes. PHC funds are utilized to implement the Child Days. Some PNFP Health units have not yet been provided for under PHC, and yet they provide a good source of manpower during the exercise.
With good planning, participation and commitment of key stakeholders it is possible to achieve 100% coverage and even extend the interventions to address the health care delivery gaps.
25 3.2.3.1 Management of Common Childhood Illness
Ministry of Health has been implementing IMCI as one of the priority programmes under the MHCP for improving child survival. The overall objective of the programme is to reduce morbidity and mortality among the under fives due to common childhood illness. Performance against the HSSP targets for IMCI is shown in Table 3.6. The following were some of the main achievements under the IMCI intervention:
a) Using the IMCI approach, the following key interventions were identified and hence prioritized for accelerating child survival and development: improving family care practices, bringing services closer to the community, improving health worker skills, applying innovative approaches for service delivery in war torn districts and strengthening health systems support for child health. For each of these priority areas time-limited priority activities were selected and strategies for implementation developed with partners. An integrated costed child health work- plan was developed for this purpose.
Table 3.6: Trends in IMCI Indicators FY 2000/01-2004/05 Indicator Baseline Achieved Achieved Achieved Achieved Achieved Target 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005 1 Proportion of Health Worker managing 15% 28% 75% 65% 54% ? 80% under fives trained in IMCI 2 Proportion of sick under fives seen by an 10% 15% 60% 50% 50% 45% 60% health worker using IMCI guidelines 3 Provision of Health Systems Support 15% 33% 40% 40% 70% 70% 80% 4 Community Based IMCI coverage 5% 10% 18%% 25% 33% 50% 60% 5 Proportion of under fives with fever, 10%*** 17% 25% 33% 34%** 50% diarrhoea, pneumonia seeking appropriate care within 24 hours of illness onset * 6 Proportion of under fives with acute 33% 45% 48% 56%** 60% diarrhoea receiving Oral Rehydration Therapy* 7 Proportion of under fives with pneumonia 28% 45%** 60% receiving appropriate antibiotic 8 Proportion of sick under fives with a 25% 44% 68% 51% 62% 75% missed opportunity for immunization *Indicators not collected through routine HMIS. Requires household surveys ** Family Care Practice Survey 2004.***IMCI DHS, 2000
b) A health systems diagnosis for IMCI was undertaken as part of the process to strengthen the evidence base for child health and a baseline survey for family care practices was undertaken in 8 districts in the four region of the country. The Multi-Country IMCI study conducted by Makerere University also fed into this process and recommendations from this study are being used to advocate for reducing infant and child mortality. The Uganda study was used to develop the child survival lancet series for 2003 by the Bellagio group.
c) Development of Health Workers’ Skills, an essential pre-requisite for the success of the IMCI strategy, was prioritized under HSSP I. During the period under review, the following was undertaken to develop health workers’ skills: Draft guidelines for the IMCI refresher course were developed
26 The national strategy for involvement of private practitioners in child survival was developed, Review of the 11 days IMCI course, to make it suitable for pre-service and short interrupted courses, was completed The handbook and chart for referral care guidelines were developed and disseminated in HC 4 and Hospitals. IMCI algorithms were adopted and included in the Uganda Standard Clinical Guidelines Paediatric HIV was included in the IMCI algorithm and health workers in 15 districts received training. A national paediatric HIV steering/advisory committee was set up Health workers were trained in IMCI and the module was included in the training of all Nursing Assistants. In addition IMCI is now part of the pre-service training in some institutions. At the health unit level, growth monitoring of the under fives was conducted routinely.
Minister of State in charge of General Duties Hon Capt Mike Mukula, launching the Polio Sub National Immunisation Campaign in Lira District 26-27 February 2005 d) Improvement of Health Systems Support. During the period under report, 170 out of the 214 HSD core teams were trained in planning and management. This was a collaborative undertaking with the Health Planning Department. Also as part of institutional capacity building, training of Tutors was conducted for 4 out of the 38 health training institutions. At the district level, 37 districts were supported in planning for IMCI while 31 districts benefited from the bi-annual technical support supervision. Prioritised IMCI drugs were procured and provided to health units through the normal channels and also as part of the enhancement of supervision of LG and other implementers by the MoH using area teams, IMCI was prioritised for the 2004 area team monitoring.
27 e) Community Based IMCI. To scale up community component of IMCI, several activities were undertaken A strategy framework for community IMCI was reviewed and is being disseminated Community Resource Trainers manual and counseling cards were developed. A Family care practice household baseline survey was conducted in 2004. Community sensitisation on childhood illnesses was carried out in all the 35 districts implementing community IMCI while training of CORPs was only accomplished in 30 districts. . To support the community mobilization, a behaviour change at household level based on implementing Family Care Practices, the Community Dialogue approach was designed and introduced at district level
It must be emphasized that a lot remains to be done in this area to ensure adequate linkage between health facilities and communities to improve family care practices.
3.2.3.2 Expanded Programme for Immunisation
The delivery of immunisation services continued to be treated as a national health priority. during HSSP I. This has resulted in the pattern of utilisation of immunisation services witnessed since the inception of the HSSP clearly indicating an upward trend for all the antigens as shown in Table 3.7 and specifically surpassing the target for DPT3. If the current trend is maintained, this points to the attainment of herd immunity levels for all the antigens. It is important to note that despite the introduction of the pentavalent vaccine, the reporting is only for DPT 3.
Table 3.7: Trends in EPI Indicators FY 2000/01-2004/05 Indicator Baseline Achieved Achieved Achieved Achieved Achieved Target value 2000/01 2001/02 2002/03 2003/04 2004/05 2005 1999/00 1 DPT 3 coverage* 41% 48% 63% 84% 83% 87% 85%
2 Proportion of children 44 % 70% 71%** 70% 12 –23 months fully immunised*** 3 TT2 coverage for 42% 80 % 46% 50% 48% 53% 80% pregnant women 45% *From corresponding Annual Health Sector Performance Reports **From coverage survey carried out in 11 districts from different regions of Uganda. ***Indicator not collected through routine HMIS. Requires immunization coverage surveys
The improvements are attributed to the comprehensive revitalization of EPI services implemented since FY 2000/01. Specific strategies included;
Expansion of static outreach points from 1,628 in FY 1999/00 to 1,713 in FY 2004/05. Functioning outreaches increased from 6,000 to 6,852 in the same period. Integration of immunization with other Child survival programs like Child Health Days. Improving injection safety by the introduction of safe single-use auto disable syringes and needles since 2000. High political support and advocacy for immunization at national, district and lower levels.
28 Support to parish mobilizers to educate and mobilize the communities for immunization activities The evidence based strategy of Reaching Every District (RED) was put in place to improve planning at local, HSD and district levels particularly in poorly performing districts. A sensitive laboratory backed surveillance system for polio and measles has been set up and integrated within the Integrated Disease Surveillance and Response framework. Operational research to improve performance and facilitate evidence based decision like Effectiveness of Hib vaccine, Hepatitis B sero-survey, Warehouse efficiency assessment and EPI 5-years review (on-going).
Figure 3.3: Reported routine infant immunization coverage, Uganda 1994-2004
110%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0% 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
BCG DPT3 POLIO3 MEASLES TT(PREG) TT(NON-P) Source: Health management information system monthly reports
Polio Eradication In response to the World Health Assembly resolution of 1987 of eradicating poliomyelitis worldwide, Uganda has implemented 16 rounds of polio S/NIDs, since 1996. The last round of SNIDs was implemented in Feb/May 2005 in the 15 high risk districts of Northern Uganda, following isolation of the wild poliovirus in South Sudan in 2004.
29
Minister of State in charge of Primary Health Care Hon Dr. Alex Kamugisha lauching the Polio Sub National Immunization Campaign in Gulu District
A laboratory backed AFP surveillance system has been put in place to monitor cases of wild poliovirus. Since 1997 no case of wild poliovirus has been identified yet the surveillance indicators are being achieved as shown in the Figure 3.4.
Figure 3.4: Progress of AFP Surveillance in Uganda, 1994-15th August 2005
350 100
90 300 289 Target stool adequacy>= 80% 80
250 70 222 224 210 60 200 173 174 178 50
150 # AFP cases 40 % stool adequacy % stool
100 30
60 20 46 50 41 30 20 10
0 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005(J- Aug) Year # of AFP cases % stool adequacy Source:
Maternal and Neonatal Tetanus Elimination (MNTE)
30
The programme has been implementing routine and supplemental TT vaccination targeting women of childbearing age especially in high-risk districts since 2002. Uganda has conducted three rounds of Tetanus Toxoid supplemental vaccination targeting women of childbearing age in the districts of Jinja, Kamuli, Iganga, Bugiri, Mayuge, Yumbe, Arua, Nebbi, Tororo, Luweero and Kayunga in FY 20003/04 to FY 2004/05. The total number of women targeted was 1,243,782 and a national coverage of above 80% was achieved. Figure 3.5 below shows the trend of NNT cases reported from 2002-2005.
Figure 3.5: Number of Neonatal Tetanus cases reported by period and year for all districts, 2002-2005
1st Phase 350 SIAs (S,O)
300
250
2nd Phase 200 SIAs (S,O)
150 # of NNT cases of NNT #
100
50
0
Jan-Jun 02 Jul-Dec 02 Jan-Jun 03 Jul-Dec03 Jan-Jun04 S1 Period/Year Jul-Dec04 Jan-Jun05 Jul-Dec05
Sources
Measles Control
Measles routine vaccination coverage has steadily been increasing since 2001/02. Following the implementation of the mass measles campaign in October 2003, there has been drastic decline in reported and confirmed measles cases and deaths through all the surveillance systems. Measles disease has been dropped from the top 10 causes of childhood morbidity and mortality.
Major constraints to the programme
1. Financial sustainability of the additional vaccines - Although the government is fully financing all the traditional antigens, substantial extra-budgetary resources are provided by the Global Alliance for Vaccines and Immunization (GAVI) for additional vaccines. The government had developed a Financial Sustainability Plan (FSP) and negotiations have been initiated to plan for future sustainability of GAVI funding within the LTEF.
2. Programmatic difficulties and sector wide barriers like inadequate transport and staff at the district level which hinder timely distribution of supplies to lower levels, supervision and maintenance of the cold chain equipment throughout the country.
31
Figure 3.6: Number of Laboratory confirmed measles and rubella cases by year and month, 2003-2005
80 MMC in Oct 03
70
60
50
40 # of cases
30
20
10
0 JFMAMJJASONDJFMAMJJASONDJFMAMJJASOND Month Lab confirmed measles cases Lab confirmed rubella cases Source:
3.2.3.3 Nutrition
The nutritional status of the population especially children and women is poor and was identified as a major health problem in Uganda. In order to achieve the programme objective of contributing to the improvement of the nutritional status of the population with special emphasis to mothers and children and also control diseases due to nutritional anaemia, protein energy malnutrition, iodine deficiency disorders and vitamin A deficiency, a combination of strategies including awareness creation, case management, rehabilitation, supplementation, food fortification and diet diversification were employed. The ministry of health is therefore pursuing a multi-sectoral approach with other sectors in implementation of strategies to improve the nutritional status of the population
The following were the main achievements during the FY 2004/05:
Growth Promotion Monitoring: Community based GPM carried out by CORPS with the supervision and support of the central and district level health workers continued in the districts of Bugiri, Luwero and Wakiso. The lessons learnt here are that with financial support and the continued monitoring of a focal person, GPM can be successfully carried out by CORPS.
Infant and Young Child Feeding (IYCF), Breastfeeding Promotion and Regulations for the Marketing of Breast milk substitutes Policy guidelines on feeding Infants and Young Children in the context of HIV/AIDS are being implemented. Guidelines for the management of severe malnutrition were printed. The accompanying training materials have also been developed, a pool of national trainers has been trained and training of heath workers in IYCF and counseling and management of severe nutrition is on-going. The Regulations for the marketing of breast milk substitutes have been reviewed and are ready for printing.
32 Conducted bi-annual surveys in the districts of Pader, Kitgum Gulu, Lira, Kotido, Moroto and Nakapiripirit, as a way of monitoring the nutrition and health situation to gauge the impact of the food interventions by the WFP and establish the extra food needs of the population. This was in responses to the nutrition situation in Northern Uganda.
Held the annual World Breast Feeding Week, which was instrumental in exposing a number of challenges yet to be addressed in implementing IYCF. There is inadequate information on breastfeeding, HIV and infant feeding as well as the rights to maternity protection.
A total of 528 (32.5%) health workers from 45 health units received training on integrated IYC Feeding and Counselling. This was a move to provide a critical mass of skilled health workers to help bridge the information gap mentioned above.
IYCF component still face a number of challenges. These include: Integration of IYCF activities in existing programmes makes it difficult to monitor its effectiveness The interface between Health Centre IIs and the community is weak partly because of the heavy workload of the health workers. This compromises the implementation of community based activities. There is currently no suitable, feasible, and sustainable locally available and social-culturally acceptable feeding option for children of HIV+ mothers.
Food Fortification: A number of industries, specifically the wheat flour processing and one of the oil producing industries, have volunteered to fortify their products. A proposal for the GAIN funds has been submitted for vetting. Uganda hosted a regional meeting on sustainable Partnerships for food fortification in late August.
3.3 Control of Communicable Diseases
During HSSP I, communicable disease control interventions were implemented to reduce the prevalence and incidence of communicable diseases and thus contribute towards the achievements of the health related MDGs and the overall goal of the Poverty Eradication Plan in Uganda.
3.3.1 Prevention and Control of STI/HIV/AIDS
After more than one quarter of a century of the HIV epidemic, HIV/AIDS continues to pose serious public health challenges contributing significantly to morbidity and mortality in Uganda and straining the public health budget. The last two decades of intensive public health interventions have registered significant achievements, with evidence of decline in new infections that has been attributed to positive sexual behaviour change.
The STD/AIDS Control Programme in the health sector is part of the multisectoral strategy for HIV/AIDS prevention and control, responsible for guiding the public health response. The objectives of the programme in the first Health Sector Strategic Plan were: i. To prevent the further transmission of STDs and HIV
33 ii. To mitigate the impact of HIV/AIDS through the provision of care and support iii. To strengthen institutional capacity for HIV/AIDS prevention and control at the national, district and community levels.
In order to achieve these objectives, many interventions have been implemented by the programme. The outcomes of these interventions during HSSP I are shown below
Table 3.8: Trends in STD/HIV/AIDS Indicators FY 2000/01-2004/05 Indicator Baseline Achieved Achieved Achieved Achieved Achieved Target 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005 1 HIV prevalence among women attending ANC 6.8% 6.1% 6.5% 6.2% 7.01 5.1 % 2 No of PMTCT service delivery outlets 7 7 11 140 224 286 3 No. of clients receiving ART 1,200 3,000 6,000 12,000 43,000 67,000 60,000 4 Proportion of population with knowledge on 55% 70% 80% condom use$ Condom procurement at National level (millions 80 80 80 95 120 5 Condom use at last sex with a non-regular 48 % 50 % 51% 75 % partner$ 6 Median age at first sex ( Years )$ 16 16 16.9 17 7 Proportion of STI patients who are appropriately 21 % 33 % 40% 50 % managed according to guidelines 1: Directly estimated from the population serosurvey, $These National indicators are ascertained every five years in the DHS or AIS
Data from the serosurvey indicated that the HIV prevalence among the general population is 7.0; the proportion of population with correct knowledge of at least 2 correct methods of HIV prevention is at 66% from 32% in 2000, while the percentage of the population with ready access to condoms is at 60% (60%) from 45% (2000)
Trends in Performance Indicators After a steady decline in HIV prevalence in Uganda during the nineties, HIV prevalence in the last five years has been more or less stable, ranging between 6-7%. The prevalence estimates reported for 2005 were directly ascertained the population based national HIV serological survey; however they are not significantly different from antenatal based estimates. The indicators of sexual behaviour continued to register improvements over the last five years reflecting positive outcomes of intervention programmes. The stable prevalence might be a reflection of improved care and treatment (including ART) for infected people resulting in reduced mortality, rather than stabilising new infections.
There was also improved performance in indicators of programme coverage with a steady increase in coverage of services for care and prevention (i.e. ART, PMTCT, VCT and condom use). The increased coverage results from scaling up of programmes to rural areas that were hitherto, underserved. In addition, there was also improvement in indicators of quality of care for services such as STI case management. However, in spite of the recorded improvements, there are still significant deficits in both quality and coverage of services that should be the focus of programme effort under HSSP II.
Achievements during FY 2004/05: During the FY 2004/05, the following outputs were realised:
34 i) Information, Education and promotion of behaviour change The IEC activities implemented continue to focus on creating awareness, knowledge and subsequently behavior change.
ACHS (Health Education & Promotion) Mr. Paul Kagwa at the launch of the Booklet on HIV/AIDS – Stand Up for Human Rights ii) Prevention of Mother to Child Transmission (PMTCT) The transmission of HIV from mother to child is the second most common means of HIV transmission in this country. The MoH is promoting a four pronged strategy that consists of primary prevention of HIV, prevention of unintended pregnancies among HIV positive women; use of a comprehensive package including ARV drugs in HIV infected pregnant mothers. During the last year, the following key outputs were achieved: The guidelines for Laboratory Quality control in HIV testing; HIV PCR testing; Social Mobilization; PMTCT counselling and infant feeding were developed The PMTCT policy guideline was reviewed and updated PMTCT service outlets increased from 140 sites in 49 districts to 224 sites All districts now have capacity to deliver PMTCT services with 846 health workers trained on strategies for PMTCT; 287 on PMTCT counselling; 262 on integrated infant & young child feeding counselling Abbott Laboratories donated 178,000 Determine HIV tests, while Boehringer-Ingelheim donated 8,240 tablets and 402 bottles of 20ml of Viramune (Nevirapine). Unigold and tie breaker test were procured by UNICEF, UACP and AIM projects At the PMTCT sites, 78% of pregnant mothers attending ANC are receiving, 63% of whom are tested. Approximately 10% of those tested turned out to be positive for HIV and 56% of all HIV+ mothers receive single dose Nevirapine. iii) HIV Testing and counselling HIV/AIDS Counselling and Testing (HCT) is an important component of the comprehensive strategy to address HIV/AIDS in Uganda. It is the responsibility of the sector to ensure quality and accessible HCT services. During the period 2004/5, the following outputs were achieved:
35 National policy guidelines for HCT were developed and the HCT tool kit was finalised with 1000 copies produced All districts in the country are now offering HCT services from at least one site The national HCT training manual was completed Approximately 1,200,000 people were tested for HIV around the country. All Regional & district hospitals and all HC4s will have HCT services by Dec 2005 iv) Infection control This component involves preventing transmission of nosocomial infections, with special emphasis on blood borne pathogens. In 2004/5, the following were the main outputs in this area: Infection control guidelines were revised, 3,000 copies printed and disseminated Infection control practice and on job training was done in four districts where 120 Health workers were trained in infection control practices. Infection control practice and on the job training was done in all hospitals and health centre IVs of 4 districts and 170 health workers were trained from these districts. v) STI Control STI control is one of the primary HIV prevention strategies. Effective STI case management in health facilities is the cornerstone for STI control. The emphasis for STI control therefore continues to be on improving skills of service providers for STD management and ensuring the availability of drugs. During 2004/5, the programme; Produced over 10,000 copies of the revised STI training and treatment guidelines and disseminated to all districts and trained 180 district trainers from 30 districts Conducted a national health facility survey to assess the quality of care for STIs in primary health facilities 12 districts in the country Trained 250 peer educators from tertiary institutions that include five universities Carried out a study of the epidemiology of genital herpes and its sexual networks. vi) Condom promotion Condom promotion and use are one of the three elements of HIV prevention strategy in Uganda. Condom promotion and distribution is done through the public sector working with social marketing groups and private distributors. In the 2004/5: The National condom policy was completed and the printing started Condom promotion is going on through IEC implemented by social marketing. About 90 million pieces of condoms were procured through UNFPA and DFID A national condom distribution plan together with guidelines was developed. Mapping of distribution sites is nearing finalisation. vii) HIV/AIDS care and treatment including Anti-retroviral Therapy The MoH comprehensive package of HIV/AIDS care services include clinical management, psychosocial support (counselling) and home based care. This package has evolved to include provision of anti-retroviral therapy. The Ministry has a policy of universal access to ART. The following outputs were achieved during 2004/05: A total of 173 health facilities (public and private) in 56 districts have been supported and accredited to provide ARVs of which about 160 are providing ART. About 67,000 people are currently receiving ART from different outlets, which exceed the target of 60,000 by end of 2005 set by MOH.
36 About 1663 health workers have been trained in ART (174 medical officers, 193 clinical officers, 431 nurses/midwives, 385 ART counselors and 280 expert patients. Figure 3.7: Health facilities providing ART services in Uganda June 2005
SUDA N
Yumbe Moy o Kitgu m Arua Adjuma ni Kotid Pader Gul o DEMOCRATIC Morot REPUBLIC Nebb Lir i CONGO a Apa c Katakw Nakapiripirit Masind Kaberamaido i i Sorot i Hoim Kum Kapchorw a i Nakasongol Sironka Pallis Bundibujo a o Kibog Kamul a Mbale Kibaal a i Luwer Kayung e Toror o a Igang o Bugir Kabarol Mubend Jinj a Kyenjoj i e e a Busi o Mukono Mayug Wakiso e a Kasese Kamweng Kampal e Mpig a KENY Sembabul i e Masak A a Busheny i Mbarar Rukungi a Kalangal ri a Raka Kanung Ntungam i u o Kabal Kisore Kampala o TANZANI Mulago KEY RWANDA
MOH ARV ACCREDITED SITES (NOT YET ACTIVE)
MOH ARV ACTIVE SITES
Recruitment of children on ART by health facilities has improved Procurement of public sector ARVs has been improving steadily. Currently there are enough ARV stocks in the country, though there may be stock-outs of some ARVs if procurement of replacement stock is not expedited. viii) HIV/AIDS Monitoring and Evaluation and Epidemiological Surveillance The Programme tracks the dynamics of HIV/AIDS through epidemiological surveillance of antenatal HIV seroprevalence. In line with second generation surveillance, HIV surveillance is complemented by STD/AIDS case reporting and behavioural surveillance through population surveys. Complimentary data is obtained from collaborating research projects e.g. MRC and Rakai Project population cohorts in Masaka and Rakai and programmatic data from HIV testing programmes like VCT and blood transfusion. The key outputs during 2004/05 are:
The National HIV sero-survey which provided accurate estimates of HIV prevalence and other programme indicators was completed. Preliminary results show a National HIV sero-prevalence of 7.0%, with regional variation as shown in the fig. below. A preliminary report of the survey is available, the final report is due in November 05.
37
Antenatal HIV surveillance will continue to provide annual prevalence data. A special survey was conducted in 2005 to provide data that will be compared with the population based survey. Laboratory testing of the 10,000 samples is completed. STD sentinel surveillance in the 20 sentinel sites and STD and AIDS surveillance integrated into the National HMIS is ongoing in all districts. The HIV surveillance protocol and that of STD sentinel surveillance were updated and submitted for ethical review. The revised HIV surveillance protocol addresses the shortcomings introduced by new programmes of PMTCT. Capacity building of districts for output monitoring through training of district based M&E focal persons was done for 20 districts. Outcome monitoring of quality of STI/AIDS care in PHC facilities in 12 districts was done. The development of M&E frameworks for new programmes such as ART, PMTCT etc were undertaken with technical assistance from WHO and CDC Operational research activities to inform programme implementation in ART, TB/HIV, PMTCT etc was done along with collaboration with partners in surveillance, M&E, and technical assistance.
Challenges and constraints: During the past year, the programme has operated with the following constraints: Shortage of human resources at the central, district and health facility level continues to negatively affect implementation of technical programmes. At the health facility level, there is serious shortage of clinical staff, laboratory workers and counsellors. Serious funding gaps continue to affect all aspects of the programme Shortage of medical and pharmaceutical supplies and commodities for prevention and care including laboratory test kits, equipment, supplies, condoms etc. Weak quality assurance and maintenance systems, procurement and logistics management systems have also constrained effective service delivery
3.3.2 Tuberculosis and Leprosy Prevention and Control
A: Tuberculosis.
National Tuberculosis and Leprosy Programme was reactivated in 1990 with three aims namely: 1. Detect and Cure as many cases of TB and Leprosy as possible and thus 2. Reduce the prevalence and Incidence of the two diseases to below public health levels and 3. Detect early, prevent and rehabilitate those found with disabilities.
The NTLP activities gained national coverage in 1995. The Programme adopted the Community Based TB care using the DOTS strategy in 1998 and attained 100% national coverage in April 2005. Collaborative TB/HIV activities have been initiated at national and district levels.
Table 3.9: Trends of TB Global 70/85 targets FY 2000/01-2004/05 Item Indicator Baseline Achieved Achieved Achieved Achieved Achieved Target 1999(%) 2000(%) 2001(%) 2002(%) 2003(%) 2004(%) 2005(%) 1 Case N/A 43 53. 50.8 52.9 53.0 70 detection Rate
38 2 Treatment 48 50 52.2 60 65.3 67.6 85 Success Rate 3 CB-DOTS 5 18 25 50 73.4 100 100 Coverage
Explanation of the Trends above
Though the new TB cases notification rate has increased by 6% in 2004 compared to 3.4% in 2003, the Case Detection Rates has still stagnated at 53%, in spite of the increase in number of Diagnostic and Treatment Units (DTUs) to 1036 in 2004 (DTUs’ Inventory, DELIVER JSI Report July 2005).
Reports from districts suggest that the district populations used (2002-Census) are not correct and some may be inflated which lowers the case detection rates. There is still a high rate of “missed opportunities’. Patients report to the health facilities but adherence to screening procedures and request rate for sputum examination is low especially in hospitals. Many patients are put on treatment without doing sputum examination. Many patients may be accessing care from purely private health units and are not getting registered on the district databases. Collaboration with private sector need to be strengthened.
TB cases Treatment Success Rate continues to increase very slowly over time despite the rapid expansion of the CB-DOTS strategy countrywide. Not all patients are being put on Community Based TB Care with DOTS (CB-DOTS). This is to be addressed in the CB-DOTS consolidation phase so that coverage is monitored by proportion of patients on CB-DOTS not districts. Inter-District Transfers are commonly missed in the cohort analysis. District exchange of data has been started as a quarterly activity so that NTLP ascertains the accurate treatment outcomes of these cases.
Achievements 2004/05: The expansion of CB-DOTS progress has achieved universal geographical coverage (country wide) at district level by April 2005. District coverage is 100%. TB cases Treatment Success Rate continues to increase very slowly over time and has increased to 67% among the 2003 Cohort. Improved technical staffing at the Central Unit with two Monitoring and Evaluation (M&E) Officers and one Management and Coordination (M&C) Officer. The TB/HIV collaboration has established the National Coordination Committee (NCC) in January 2005. A position of a TB/HIV Coordinator was established Drafts of TB/HIV Policy, M&E guidelines, IEC Strategy have been produced. 29 of the 69 districts have had HSD TB Focal Persons trained, and equipped to support supervise TB control activities in their catchments by August 2005. The program has accessed some anti-TB drugs The Global Drugs Facility (GDF) for the 2005 year to cater for a 6 months period.
Constraints:
39 Availability of anti-TB drugs has remained a persistent problem over the years, due to the fragile drugs procurement mechanism and reliance on only two suppliers. The absence of a dedicated budget vote for anti-TB drugs continues to compound the drugs stocks situation at the central level. The problem of HIV co-infection continues to fuel the burden of TB in Uganda among the dually infected cases. Inadequate Human Resource numbers of Laboratory scientist continues to hamstring Program performance.
Please Paste The Scanned Images of The Stamps here
Director of Health Services (Planning and Development) Dr. Herman Kyabaggu launching the NTLP Stamps - 31 May 2005
Leprosy
NTLP implemented the Multiple Drug Therapy (MDT) strategy for Leprosy patients countrywide since 1983. Leprosy is included in the UNMHCP under the element 4: other Public health interventions against diseases targeted for elimination and/or eradication.
Table 3.10: Trends for Leprosy elimination targets FY 2000/01-2004/05 N Indicator Baseline Achieved Achieved Achieved Achieved Achieved Targets 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005 1 New Cases 869 818 688 668 525 663 400 Absolute Nos. 2 Case Detection 0.40 0.37 0.31 0.27 0.21 0.17 0.25 Rate /10,000 3 Prevalence 0.55 0.46 0.42 0.29 0.26 0.28 0.25 Rate/10,000 4 Elimination at 41 47 50 50 50 50 56 District level 5 Child Proportion 11.1% 9.3% 10% 11.4% 11.3% 14.5% 5%
40 of new cases 6 New cases with 90.6% 90.2% 88% 89.1% 86.4% 90% 95% no visible deformities
Discussion of Trends While the absolute number of new leprosy cases has shown a slight increase in the 5th year, the case detection rate shows a very gradual downward trend. If infectious cases (MB) are analyzed separately, they do not show the downward trend. Going by the overall trend, it appears too early to talk about eradication of leprosy. The elimination target (less than 1 registered case/10,000 population) that was achieved in 1994 was sustained; it was anticipated that by 2005 we would have achieved this at district level in the whole country, some progress was made but the target was not reached. The remaining districts are mostly those hit by insurgency but also influenced by high prevalence in adjoining parts of neighboring countries. The stagnant child proportion, although influenced by methods of case finding, indicates a significant burden of infectious leprosy cases in the population. 70% of child cases are from the districts that have not achieved elimination. High percentages of cases detected with visible deformities indicate delays in detection, which are bound to increase as cases become fewer. They also indicate an accumulation of people needing life long rehabilitative care.
Achievements 2004/05: Leprosy elimination target achieved nationally. A regular supply of free and good quality anti-leprosy drugs was maintained; these were donated by WHO. Materials and equipment for rehabilitative care continues to be available through Germany Leprosy and TB Relief Association (GLRA) in all National Reference Health Units – Buluba, Kumi, Kuluva, Kagando, Morulem hospitals. Leprosy was maintained in curricula of most health training institutes and in –service training was provided by Health Centre Level staff. A system for monitoring of the control programme through support supervision and quarterly district reports remained in place. A development partner, Germany Leprosy and TB Relief Association (GLRA) provide financial and Technical support at central level, intermediate and district programme operations.
3.3.3 Malaria Prevention and Control
Malaria remained one of the leading causes of morbidity and mortality in Uganda. During HSSP I, major progress was made in implementing the national integrated malaria prevention and control Program strategies. The first line treatment of chloroquine and sulfadoxine/pyrimethamine was adopted, replacing chloroquine mono-therapy in 2002. Access to quality antimalarials was increased through the design and successful introduction of the new strategy for Home Based Management of Fevers (HBMF) in 2002. There has been significant improvement in the supply of antimalarial drugs
41 and overall strengthening health systems. Nationwide implementation of Intermittent Presumptive Treatment in Pregnancy (IPTp) was greatly accelerated and Insecticide Treated Nets (ITNS) were scaled up through a variety of delivery channels by a number of Roll Back Malaria (RBM) country partners. The coordination of stakeholders was strengthened through the functioning of the Inter- Agency Coordination Committee for Malaria (ICCM). Close monitoring of parasite resistance to antimalarial medicines at 7 sentinel sites was carried out leading to a new medicine treatment policy in 2005. The new treatment policy places artemesinin based combination therapy called Artemether/Lumefantrine (Coartem) as first line medicine for uncomplicated malaria and Artesunate + Amodiaquine the alternative. An order has been made for 15 million doses of Coartem to be disbursed through the WHO/RBM Partnership. The new policy will become operational during HSSP II. There has also been increased awareness by the central Government, local authorities and external partners of the burden of malaria and political commitment at various levels has also been demonstrated. Table 3.11 below shows the trends of performance against the indicators.
Table 3.11: Trends for the specific targets from 2000/01 to 2004/05 Indicator Baseline Achieved Achieved Achieved Achieved Achieved Target value 2000/01 2001/02 2002/03 2003/04 2004/05 2005 1999/00 1 Proportion of under 7.3% NA NA 25 %6 60%7 60% fives receiving recommended malaria treatment within 24 hours of onset of symptoms 2 Proportion of pregnant 0% 8.6% NA 20.3% 24% 34% 60% women attending ANC (AHSPR) (AHSPR) (HMIS) who receive 2 doses of SP for IPT of malaria 3. Proportion of 17.6% NA NA 15% (2003 25.8% Average 50% households with at least surveys) 20.4% Rural one ITN 59.9% Urban 4 Case Fatality Rate among 4.05% NA NA 2.7% 2.7% 3% malaria inpatients aged (HMIS) less than 5 years
Figure 3.8: Progress of Malaria Control Indicators 2000/01-2004/05
6 2003, various HBMF surveys 7 This figure is based on a survey carried out in IDP camps in Northern Uganda
42 Progress of Malaria control indicators, 2000/01-2004/5
70.00%
60.0% 59.9% 60.00%
50.00%
40.00% Baseline 2000/01 34.0% 32.9% 31.6% Achieved 2004/05 30.00% % coverage 25.8%
20.4% 20.00% 15.0% 15.0% 13.0% 8.6% 9.2% 10.00% 7.3% 4.05% 2.7% 0.0% 0.00% CFR Early &correct IPT2 coverage Mosquito Net Mosquito Net Household <5 Yrs using Pregnant treatment Cov. (Rural) Cov.( ubarn ) cov. of Mosquito Nets women Using among < 5 Yrs Mosquito Nets Mosquito Nets Indicator
Other malaria control indicators
Table 3.12: Trends in Malaria Control Indicators FY 2000/01-2004/05 Indicator Baseline Achieved Achieved Achieved Achieved Achieved Target value 2000/01 2001/02 2002/03 2003/04 2004/05 2005 1999/00 1 Proportion of pregnant women 31.6% 50% who slept under a mosquito net 13.1% the previous night 2 Proportion of under fives who 7.3% 13% 15% 50% slept under a mosquito net the previous night 4 Proportion of rural 0 43/56 8 56/56 communities covered by functional Medicine distributors (districts). 56 5 Proportion of rural Households 9.2% 20.4% with at least one Mosquito Net 50% NB: The figure quoted includes both treated and untreated nets. Efforts have been made to ensure that the available nets are treated through the national mass campaigns;
Explanation of Trends for HSSP Indicators
Information for proportion of under fives receiving recommended malaria treatment within 24 hours of onset of symptoms is based on a survey carried out in the Internally Displaced Peoples' Camps (IDPs) in Northern Uganda. All the 56 districts are now implementing HBMF and are
8 This represents the number of districts where the strategy has been introduced
43 fully covered with trained Medicine Distributors, resulting in improved care seeking behaviour and access to treatment. During HSSP II, efforts will be geared towards the sustainability of HBMF through support supervision, improvement in the delivery of services particularly issues related to medicine supply, as well as integration. The full scale up of HBMF is expected to raise the proportion of children receiving correct and prompt treatment to over 80%. There is also evidence to suggest that HBMF has led to reduction in the prevalence of severe anaemia among children as depicted in the case of Kitgum (See Figure 3.9)
Figure 3.9: Changes in Severe anaemia in children age 6-24 months in Kitgum
Changes in severe anemia in children age 6-24 months after introduction of Home Based Management of Fever, IDP camps, Kitgum District 2003/04
14
12 12
10 9.4 % 8.8
ia in in ia 8 baseline follow-up 6 4.8 4
Severe anem 4 2.9
2
0 6-12 13-18 19-24 Age in months
At the time of the baseline, the use of SP for IPT was not well established. The FY 2000/01 figure therefore refers to the use of any prophylaxis with an anti-malarial. However SP is now being administered for IPT, and is provided in most Health Facilities that provide ANC services. Currently training of district trainers for integration of malaria in antenatal care into reproductive health services is ongoing to ensure improved IPT 2 coverage. District Training of Reproductive Health Care Managers has been carried out in 24 districts. The training is aimed at strengthening the integration of malaria in pregnancy care into reproductive health services. Results from the follow up made so far indicates an improvement in the DOT method, counseling and data collection. Data from the National HIV sero-prevalence survey indicates that Net ownership varies with the highest coverage in Kampala (67% of households), followed by North-eastern region (40%); Eastern regions (19%); Western (18%), mountainous and less malaria-prone areas like the Southwest (13%). Procurement of 1.8 million nets is under way and is expected to raise the coverage to 50%. The nets will be freely distributed to pregnant women and children under five years.
Other Achievements in FY 2004/05
A Policy and Strategy for Indoor Residual Spraying (IRS) has been developed. Two rounds of net re-treatment campaigns were carried out in 20 Districts. The first round supported by the Malaria Consortium, while the 2nd round was fully facilitated by the Ministry
44 of Health, with resources from the Global Fund. Plans are underway to scale up the exercise to the remaining districts and sustain it in the original 20. Mosquito net sales and Distribution: - Strong partnership has been developed with the private for profit sector and other RBM partners. It is estimated that 51,640 nets have been freely distributed by partners to vulnerable groups of either pregnant women or children under five. By end of 2004, 845,669 nets had been sold out through the commercial sector. An Environmental Impact Assessment of DDT was carried out by an independent firm and a report has been produced.
ITNs can effectively be used to protect both mothers and children as depicted in this Diplaced Peoples Shelter in Lira District Figure 3.10: Comparison of 1st and 2nd Round of Net Re-treatment (2004-2005)
45 Comparison of 1 & 2ND Round Net Re-treatment (2004 & 2005)
80000
70000
60000
50000
1st round 40000 2nd round
30000 No. of Nets Re-treated
20000
10000
0
a li c i a ro a o o l so d g j o in ero n ro on mo jo ma g Kumi Arua Apa ki w Jinja o k a n n a as u yu T Busi Mbale g Hoi Kamu W L a n so M Kabarole mwenge K Mbarara Mu tu Kye a N aka K N District
Data on Malaria Case Fatality Rates has been drawn from HMIS. However data collected from inpatients is often incomplete and these figures need to be interpreted with caution.
Key Supporting Strategies
A: Monitoring & Evaluation The Implementation of the Highland Malaria Project was successfully piloted in two districts of Kabale and Rukungiri. The system has established an effective surveillance structure, which can detect epidemics within one week of onset. There are plans to integrate this surveillance scheme into the routine IDSR structure in all districts so that the other epidemic prone diseases can benefit from its effectiveness. Operationalisation of the Zonal Coordinator System - The Zonal Coordination System was reinstated in all the 11 zones for Malaria and IMCI. The Zonal Coordinators will assist MCP to provide support to districts in their zones with focus on coordination, planning, implementation and supervision of malaria activities While they have been partially equipped, operational costs have been interrupted by the suspension of the Global Funds. Technical Supervision to districts was carried out on a quarterly basis Worked with the Uganda Bureau of Statistics (UBOS) to develop a malaria module for the National UDHS Survey was developed in conjunction with the Uganda Bureau of Statistics (UBOS). A Database for Malaria Control Activities was initiated and an electronic bulletin (The Malaria Control Notice board) launched for information sharing. District Planning guidelines for malaria and IMCI were developed and disseminated to all the districts. As part of the orientation process, technical planning meetings were held around the country. The guidelines were developed based on the HSSP I & II and are aimed at complementing and elaborating upon the MoH Planning Guidelines (2004), as a way of improving planning at operational level, particularly for malaria and IMCI.
46 A Roll Back Malaria Scoping Study was carried out in 2002 to establish baseline data for RBM activities in Uganda and progress towards the Abuja targets. 8 out of 10 recommendations from the study and REAPING mission have been implemented in full while the remaining 2 recommendations have been partially implemented. A mapping exercise was carried out for 15 Malaria Epidemic Prone Districts and high risk parishes in these districts were identified. Two districts, Kabale and Rukungiri have been earmarked for piloting a strong IRS system.
B: Advocacy and social mobilization:
Advocacy: There was strengthened collaboration and coordination with partners, policy makers, the media, religious leaders and other stakeholders. A series of advocacy meetings were held at different levels; international, national and district. An advocacy package including a Documentary on Malaria in Pregnancy has been developed and will be distributed to MPs and other stakeholders.
Media Programs: A series of media activities were carried out including; Radio and Television Programs, Radio Spots. A newspaper supplement to commemorate Africa Malaria Day, produced in four different languages, (English, Luganda, Ateso, 4Rs) and circulated through the New Vision Newspaper and its sister papers, The Malaria Control monthly Bulletin; ‘The Notice Board’ was produced on a monthly basis and electronically disseminated to over 500 partners. The annual Malaria Newsletter was produced and disseminated to all the districts, A Malaria Control web page was finalized, and is ready for posting on the MOH website: www.health.go.ug/malaria.
Community Mobilization: Health Education/Community mobilization was carried out using film vans, community meetings, radio and TV programs especially in the epidemic prone districts. Film shows promoting malaria control activities were shown at the district and lower levels, a video promoting HBMF and ITNs was produced and distributed to all Health Sub districts. Community mobilization activities were carried out in Gulu District in preparation for Africa Malaria Day, and in Sironko and Mayuge Districts for the District Launch of the Home Based Management of Fever. A number of social mobilization materials were produced and disseminated to the districts for community mobilization. These included posters, stickers, and fliers.
Capacity Building: Guidelines were developed for all the malaria control interventions, including an information tool kit for Members of Parliament. The Communication Strategy was reviewed to accommodate the policy changes. The English version of the Strategy is ready for printing, and translations are being made into 7 different languages; Luganda, Runyoro/Rutoto, Runyankore/Rukiga, Luo, Ateso, Kupsabinyi, and Karimajong. Meetings for capacity building were also held different levels.
47
Political commitment towards Malaria prevention and Control: From left to right: Hon Dorothy Hyuha, Chair Parliamentary Social Services Committee, Prime Minister Hon Prof Apolo Nsibambi, Minister of Health, Hon Major General (rtd) Jim K. Muhwezi and Hon. Grace Akello, State Minister for Northern Uganda-Office of the Prime Minister during the Africa Malaria Day April 25, 2005 Gulu Municipality
C: Management, Financing & Administration The Inter-agency Coordination Committee for malaria (ICCM) was established with Technical working groups for Vector Control & ITNs, Malaria Case Management, Information Education & Communication, Malaria in Pregnancy, Monitoring, Evaluation and Research More financing was received through the Primary Health Care grants Two Global Fund agreements were signed: Round 2 (January 2003) and Round 4 (April 2005), and a proposal prepared and submitted for Global Fund Round 5 There was Increased access to health care facilities (49% to 72 %) contributing to improved access to treatment for malaria control. There was improved medicine availability at Health Facility level including antimalarial medicines.
3.3.4 Interventions against Diseases targeted for Elimination /Eradication
A: Guinea Worm
During HSSP I, guinea worm was virtually eliminated with only one village in Kotido reporting 13 cases in 2003. The program however still faces the challenges of cross border cases imported from Sudan. The persistent insecurity that prevails in most of the previously endemic districts results into movement of people across the border increasing the risk of importation of disease.
Table 3.13: Trends for the specific targets from FY 2000/01 to 2004/05
48 Indicator Baseline Achieved Achieved Achieved Achieved Achieved Target value 2000/01 2001/02 2002/03 2003/04 2004/05 2005 1999/00 1 To interrupt the 96 cases (? 51 6 13 cases 0 cases 0 cases 0 cases transmission of Graph shows indigenous Guinea 92) worm
Enabling Factors Strong partnership – Uganda Guinea Worm Eradication Programme (UGWEP) in collaboration with line Ministries, Development Partners and communities
Box 3.3: Maintaining Guinea Worm Programme Performance
At the conception of the Uganda Guinea Worm Eradication Programme (UGWEP) in 1991/92, Uganda was the second to Nigeria which had the highest prevalence of Guinea worm cases among the 22 endemic countries in the world. Uganda had 126,369 cases of Guinea worm in 2677 endemic villages from 16 of the then 39 districts in the country.
Reporting 0 indigenous cases places Uganda among the five countries in Africa under pre- certification phase pending certification free of Guinea worm by WHO after 3 years of reporting 0 indigenous cases and active surveillance
Constraining Factors Cross border transmission of Guinea worm from Sudan, the most endemic country in the world today Inadequate funds to finance supporting activities such as supervision, inter-district Guinea worm programme review meetings, advocacy meetings including the national Guinea worm day, operation and maintenance of vehicles and office equipment Persistent insecurity in northern Uganda and Karamoja regions Operation and maintenance of boreholes in endemic villages and IDPs who might be returning to their original villages
B: Onchocerciasis
The programme has continued with its objective of eliminating onchocerciasis as a public health and socio-economic problem through mass treatment with ivermectin to all eligible persons; and vector elimination in isolated foci where feasible. High treatment coverage (> 65%) of the target population must be achieved and sustained for many years in order to achieve the objective. Table below shows performance of the programme against the major indicators.
Table 3.14: Trends in the Onchocerciasis Programme Indicators FY 2000/01-2004/05 Indicator Baseline Achieved Achieved Achieved Achieved Achieved Target value 2000/01 2001/02 2002/03 2003/04 2004/05 2005 1999/00 1 Onchocerciasis treatment 68% 69% 70% 79% 87% 80% 85% coverage
49 2 Endemic districts with 0% 0% 19% 52% 76% 100% 100% CDTI integrated in work plans 3 Vector elimination: Crab 70% 0.0% 0.8% 0.0% 0.0% 0.0% 0.0% infestation in Itwara focus†
4 Crab infestation in 80% 69.9% 59.5% 27% 0.06% 0.7% 0.0% Mpamba-Nkusi focus 5 Training of community 11,320 15,506 34,201 12,768 29,936 34,227 35,000 directed drug distributors
† A focus is an area occupied by a discrete population of a vector of onchocerciasis which is geographically (or ecologically) isolated from other vector populations.
High treatment coverage over the years has been achieved due to: Community participation in the organization and execution of treatment. High individual and community perceived benefits of ivermectin treatment. A woman aged 35 years who had taken ivermectin for 11 years had this to say: ‘I had severe persistent skin itchiness and I used stones to scratch my self and sometimes I would tear my clothes while scratching. I could not dig. It was terrible. I used to spend a lot of money going to hospital in Fort Portal to get medicine for my skin disease. Now I am cured. I can dig and get some money from my crops’. The trend in crab infestation observed over the years in Itwara and Mpamba-Nkusi foci is an indication that the vector is on the verge of being eliminated. This has been attributed to the timely river treatment, monitoring and supervision. Financial support from the African Programme for Onchocerciasis control (APOC), the Ministry of health, District Health services and the Non Governmental Development Organizations (NGDOs) partners.
Table 3.15: Impact of Onchocerciasis control on the disease in sentinel districts District Pre control After control Microfilariae Nodules (%) Oncho- Microfilariae Nodules Oncho- carrier rate (%) dermatitis carrier rate (%) (%) dermatitis (%) (%) Kyenjojo 88 49 34 7.5 19.2 2.9 Kamwenge 78 49.1 34.2 27.8 14.2 9.5 Nebbi 98.8 80 72.5 19.7 19.7 20 Moyo 80 33.3 75.8 6.6 11.4 11.9 Kasese 70.6 18.3 36.2 10.1 3.8 1.2 Mbale 62.2 59.2 - 1.1 3.4 -
Pre-control assessment in Kyenjojo and Kamwenge districts were done in 1991 and post control assessment in 2003. In Nebbi, Moyo, Kasese and Mbale districts, pre-control assessment was done in 1993 and post control in 2005. Ivermectin treatment will continue until microfilariae carrier rate approaches zero in all the districts.
Constraints Level of counter funding from the districts is still too low to sustain the programme without external funding. The financial support from APOC is soon coming to an end and the achievement so far gained might be lost if the districts do not allocate and release adequate funds for the programme.
50
C: Trachoma
Trachoma is the second leading cause of Blindness in Uganda. Trachoma mapping conducted in 2002 indicated 15 endemic districts mainly in Eastern and Northern Uganda. Until this year, no active trachoma control programme had been in place.
In order to eliminate trachoma, it has now been included among diseases targeted for eradication. A task force has been established to spearhead trachoma rapid surveys that will generate prevalence data required for massive distribution of the drug of choice, Azithromycin. Trachoma survey teams have been trained in 2005 and the surveys are due soon. Patients with trachiasis receiving surgical services increased from 15% in 2000 to 20% 2005
D: Lymphatic Filariasis
Lymphatic Filariasis causes high morbidity and has been neglected for long time in Uganda. The Programme to eliminate lymphatic filariasis (PELF) was launched in Uganda in 2002. The objectives of the programme are to interrupt transmission of lymphatic filariasis and prevent/manage disability associated with LF
The proportion of cases receiving a single annual dose of ivermectin and albendazole was 5.8 in 2003 compared to 11.5 in 04/05
Main achievements Mapping of the disease was done, based on rapid assessment using Circulating Filarial Antigen (CFA) detection. Disability management has commenced in Obalanga (Katakwi) Hydrocelectomy started in Amuria HCIV(Katakwi) with support from DANIDA
Challenges Lymphatic filariasis is not ably captured at Health centre due to lack of widely acceptable case definition Persistent insecurity in Northern Uganda, Karamoja and neighboring regions Under funding from both the district and centre
E: Trypanosomiasis (Sleeping sickness)
During HSSP I, transmission of trypanosomiasis was nearly interrupted in the two major endemic foci for sleeping sickness in Uganda (West Nile and Eastern Regions). However a re-emergence of active transmission occurred and has now reached epidemic proportions in both foci. The disease has also spread to new areas within Soroti, Kumi & Kaberamaido districts. In 2000, the Pan African Tsetse and Trypanosomiasis Eradication Campaign was established and launched on 5/10/2001, calling for mobilization of the international community and African countries in particular, to combat sleeping sickness. During HSSP II, the focus is on scaling up efforts to interrupt transmission through integrated vector management and active case detection and management.
51 F: Schistosomiasis and Soil Transmitted Helminths
The aim of the programme is to reduce morbidity due to helminthiasis to levels where it ceases to be a public health burden. The specific objectives are to provide annual mass treatment to at least 75% of school age children residing in schistosomiasis endemic areas and to the whole community in high risk areas. Initially targeting 500,000 people in 2003/04, the programme covered 3.5 million people in 2004/05, in bilharzia endemic sub counties and in collaboration with Child Heath Days. In May 2004, it provided albendazole to another 3.8 million people. The programme also promotes access to dewormers in health facilities for treatment of clinical cases and collaborates with health promotion and education division to provide appropriate health education. Limited vector control activities are also carried out.
Achievements during the year: 910 trainers (target 713) have been trained and 9100 drug distributors (target 18,000) have been trained Within a period of 3 years, the coverage in most endemic areas is over 75.0% Initially, ascites, organomegally, persistent diarrhoea sometimes with blood and haematemesis were common symptoms in most fishing communities along the lakes Albert, Kyoga and Victoria and along Albert Nile. These symptoms are now rare in Uganda. Praziquantel and Albendazole have been included on the essential drug list. At least 70% of health facilities in schistosomiasis endemic areas now stock praziquantel from almost 0% before the inception of the programme. The financial support to this programme is mainly (95%) supported by SCI. Others are WHO, DBL and MOH. Integrated with mainly the Child Health Days and planning integration with the Programme for Elimination of Lymphatic Filariasis.
Constraints Praziquantel side effects have been affecting compliance, yet the programme has little funding for health education. Low levels of counter funding from the participating districts. Financial support from the SCI will end in 2007 and unless districts begin providing a budget line for praziquantel (especially) and albendazole, sustainability will be difficult. Most bilharzia transmission is along lakes and snail control by molluscicides is expensive and would kill fish. Thus vector control activities are limited to small dams and irrigation schemes. 3.4 Control of Non-Communicable Diseases
Incidence of Non Communicable Diseases (NCDs) is increasing in Uganda. Most common NCDs include: Diabetes Mellitus, Hypertension, Cardiovascular diseases, stroke and some cancers mainly lung, breast and cervical cancers. The World Diabetes Foundation estimates that in 2003 there were about 50,000 cases of Diabetes in Uganda, and it projects that there will be a 10-fold increase in this number by the year 2025 if no interventions are initiated. NCDs must be prevented through appropriate lifestyles.
52
3.4.1 Prevention and Control of Non-Communicable Diseases
The Ministry of Health is determined to reduce morbidity and mortality due to non communicable diseases through collecting essential data and using this data to develop evidence based policy and work plans to effectively deal with non communicable diseases in Uganda.
Achievements: The prevention and management of Non Communicable Diseases (NCD) prominently featured in the Draft HSSP II as Cluster 3 Non Communicable Diseases (NCD) Secretariat was established to coordinate the prevention and control of Non-Communicable Diseases in the Ministry of Health. Focal Person appointed. Prepared draft proposal for the national NCD risk factor survey. Submitted application to the World Diabetes Foundation (WDF) for financial assistance to conduct the survey. Community mobilized to improve health lifestyles during the celebration of World Days organized by the NCD Secretariat in conjunction with relevant stakeholders
Constraints Insufficient data is available on NCDs, especially risk factor prevalence, determinants of NCDs in the communities and health care facility preparedness to deal with NCDs. Baseline data to development of a focused and comprehensive work plan against NCDs not available NCD/PM Secretariat is in its infancy. It is currently under sourced (human, finance, equipment) for effective execution of its tasks
3.4.2 Injuries, Disabilities and Rehabilitative Health
Disability Section which was established in 1996 has gone a long way to offer Rehabilitative services and prevention of disabilities. The people with disabilities continue to benefit from these services in line with Uganda Constitution 1995, and International Norms and Conventions.
The proportion of districts providing services for hearing impairment has increased from 25% (2000) to 63% in 2005. However, despite, efforts made to increase access to assistive devices for people with disabilities there has been a marked decrease (14% in 2000 to 5% in 2003)
Achievements Policies on visual, hearing impairment, and Assistive devices in final stages of development. The section coordinated National Road safety project for two years. Conducted Audiology training Equitable distribution of eye care services. Only Nakasongola remains without an Ophthalmic Clinical Officer. All Regional Hospitals have new and well equipped eye departments except Kabale and Fort Portal. Standards and guidelines developed in all disability programmes. Developed rehabilitation package used for in-service training of health workers. Post-basic ENT course in place producing approximately 20 graduates each year.
53 Developed Communication Strategy on hearing impairment and deafness. District Support Occupational Therapy project setting up regional support structures for technical support of occupational therapists
Enabling Factors 1. Some Donor funding from Norwegian Agency for Development(NORAD), DANIDA, Lions Aid Norway, Sight Savers International, Uganda Society for Disabled Children, and Christofel Blinden Mission. 2. Good networking & commitment of stakeholders in disability
3.4.3 Mental Health and Control of Substance Abuse
The main objective of the Mental Health programme is to provide improved access to primary Mental Health services at all levels with quality referral services at District, Regional and National levels. The programme also coordinates the management of neurological disorders such as epilepsy which affects about 3% of the general population.
Achievements
Conducted a baseline survey in 10 districts in 2004 under the SHSSPP project and findings from the survey were: Regional Referral Hospitals with functional mental health units refers to those hospitals with a Psychiatrist or Psychiatric clinical officer running a regular mental health clinic. Other key findings in the above survey covering Soroti, Kapchorwa, Katakwi, Kaberamaido, Adjumani, Apac, Arua, Lira , Moyo, Nebbi, Yumbe, Bushenyi, Bugiri and Mubende include: On average there was a prevalence of 29.3% with moderate to severe depressive symptoms, 17.4% with alcohol abuse, 10.5% of families interviewed had at somebody who had attempted suicide in the last 12 months and 1.4% had post traumatic stress disorder. 80% of the 10 Districts which responded had Mental Health programmes, 40% had outreach programmes but only 20 % had a mental health worker at HC III. Only 2.3% were seeking Mental Health care from a modern Health unit, 59.2% especially those with emotional problems were getting help from religious leaders and 0.6% mainly suffering from psychosis were getting help from traditional healers.
The enabling factors for improvement of Mental Health services include additional resources from the SHSSP Project and the integration of Mental Health guidelines into all MoH guidelines at all levels
Box 3.3: Improvement of the Mental Health Services in Uganda
The funding from ADB under the SHSSP project has facilitated -construction of 6 Regional Referral Mental Health units at Gulu, Arua, Soroti,Hoima, Fort Portal and Kabale Hospitals. -rehabilitation of Butabika National Mental Hospital -Training of 12 Psychiatrists, 7 Clinical Psychologists, 33 Psychiatric Clinical officers, 6 Tutors, 4 Psychiatric Social Workers and 200 General health workers (trained in Mental Health in Primary care). -provision of additional Mental health drugs to supplement meagre supplies at Hospital level and facilitate outreach services. 54
Other activities done to strengthen Mental Health services include:
Reviewed Mental Health component of HMIS to include 6 Mental Health conditions, to improve data collection on Mental Health Developed guidelines for management of Mental Health complications of HIV/AIDS. Inclusion of Mental Health drugs among priority credit line drugs to improve financing of Mental health drugs Developed of IEC materials on the relationship between Mental and physical health to build capacity for holistic health care.
The major constraints to the programme include profound funding gaps to address the increasing problem of alcohol and drug abuse, activities to address Mental Health problems resulting from war and conflict and effects of gender based violence.
3.4.4 Gender Based Violence
Gender Based Violence which includes any act that results in physical, sexual or psychological harm or suffering to women and children and usually arises from discrimination and oppression particularly against women and children but also experienced by some men, was one of the strategies implemented during HSSP I.
Achievements Carried out sensitization and advocacy on reduction of Female Genital Mutilation. Carried out capacity building on gender mainstreaming to a number of senior health workers. Compilation of the available information on GBV was carried out in two districts.
Constraints Inadequate knowledge among health service providers on GBV Inadequate capacity of health facilities to manage GBV Poor linkage between health facilities, the community and other agencies involved in the prevention and management of GBV Inadequate institutional framework for gender mainstreaming all levels
3.4.5 Integrated Essential Clinical Care
The Integrated Essential Clinical care involves the management of communicable and non communicable disease conditions to achieve the best possible outcome. HSSP I uphold Essential Clinical care as an important element of the UNMHCP.
55 a. Hospital services
Hospitals provide vital and critical clinical care. These institutions also dispense substantial preventive and health promotive activities. In the last period of HSSP I implementation more keen interest has been generated in the hospital sub sector. The new National Hospital Policy was prepared and only awaits Parliament approval. The policy streamlines the roles and functions of hospitals, clarifies the linkages and partnership with other sectors and defines mechanism to ensure resource and accountability.
During FY 2004/05 focus has been put on strengthening of hospital services and their performance. This has been directed to management capacity and organization, capacity in financial planning and management, improving quality of care and infection control and strengthening supervision, monitoring and performance assessment. Specific efforts have been expended on the above using task- force approach to tackle each one of them. Training has been carried out targeted hospitals managers. Infection control and prevention, a core function in quality of care, has also received much emphasis in the FY
Assessment of hospital functions during FY 2004/05
Hospitals are a bastion of activities all of which could be measured in one way or another. Some outputs are routinely collected while others will need indirect measurements and surveys to capture them. In the Annual Health Sector Performance report for FY 2003/04 a first attempt was made to put forward an analysis of the patterns of inputs and outputs at the Regional referral hospital level using the Standard Unit of Output as a measure of performance. This year’s report also includes parameters trying to show outcomes of the regional referral hospitals. The report also tries to reflect the performance of general hospitals in terms of output and a couple of outcomes figures.
The role played by PNFP (UCMB, UPMB, and UMMB) hospitals has been underscored by their inclusion in the report with an attempt to capture their comparative performance.
Quality of Care
Quality Assurance department at the Ministry of Health is running a quality assurance programme called the Yellow Star Programme (YSP). The department has so far conducted surveys in 20 hospitals located in 16 districts in Uganda. A few hospitals have been assessed two times and the result showed a remarkable improvement in six standard indicators measuring quality of care. There is a rollout plan to introduce YSP to all hospitals and HC IVs in the country and to ensure consolidation of Quality of services in all units.
Infection control and prevention is a core function in quality of care. A survey in 8 regional hospitals carried out in January/February, 2005 showed a variable but a conspicuous application to infection control practices in these hospitals. Trophies were given to the best 3 hospitals; Mbarara, Kabale and Soroti.
Assessing quality of care in hospitals in terms of patient satisfaction is still elusive. This would reflect adequacy of drugs supplies, hospitality of the health workers administrative capacity etc.
National Referral Hospitals
56
Mbarara University Teaching Hospital was designated a National Referral Hospital in FY 04/05, bringing the number of national referral hospitals to 3 and the numbers of regional referral hospitals to 10. The process to upgrade Mbarara University Teaching hospital to the level of a national hospital is however still on going so for the purpose of this report Mbarara Teaching Hospital is still reported under the Regional referral hospitals.
Mulago Hospital:
Mulago Hospital serves both as the National Referral Hospital with a bed capacity of 1500 and as a teaching hospital for Makerere University Medical School. The hospital also provides referral services for the Central Region as well as the Minimum Health Package for a significant proportion of the population of Kampala and neighboring districts. Mulago operates as one Complex, comprising New and Old Mulago Hospital. This makes it difficult to disaggregate the national referral functions from other functions, including the management of minor ailments. The hospital maintained services to private patients. A total of 20,537 patients benefited from this scheme of which 2,834 were inpatients and 17,703 outpatients.
Butabika Hospital:
Butabika Hospital is the National Referral Mental Health Institution in Uganda. The hospital provides quality referral mental health services but also provide services as a general hospital. The hospital has been undergoing infrastructure rehabilitation. This is part of a broader mental health programme covering six Regional Referral Hospitals as well. As a referral facility for mental health, Butabika hospital attended to a total of 485 mental cases aged 5 years. These were: Epilepsy 123, Bipolar disorders 117, Schizophrenia 94, Alcohol abuse 44, Depression 31, others 76.
Whereas most of these diagnoses could have been inpatients, it can be noted that they form a small proportion of the total admissions which portrays the general nature of functions of all referral hospitals in the country.
Regional Referral Hospital
The functions of the regional referral hospitals are to provide specialist services in addition to the services offered at general hospitals. Besides, they are supposed to provide in-service training, consultation, supervision and research to community-based health care programmes. Service areas for the specialist services have been defined for each referral hospital (see Figure 3.11).
Figure 3.11: Districts served by the Referral Hospitals in Uganda
57
The specialized services a Regional Referral Hospital provides, depends on the availability of specialists and other inputs like equipment, medicines and supplies.
One of the outstanding drawbacks to service delivery was low staffing levels. However, the Health Service Commission continued recruitment of health workers in attempt to fill up existing staffing deficits. Senior doctors-positions still pose a problem to fill. Only 108 out of 262 posts for Specialists were filled by the end of the financial year and 152 posts stood vacant.
The RRHs are expected to provide technical support and capacity building for lower level units. The Clinical Specialists Outreach Services was revived last financial year under a wider umbrella of the Area Teams. Lack of specialists and transport for outreach services in some hospitals hampered this programme.
The Standard Unit of Outputs as a measure of performance at the Regional Referral Hospitals.
The Standard Unit of Output (SUO) has still been maintained in this report as a measure for assessing Hospitals’ performance. The SUO methodology is used to assess changes over time with regard to a set of indicators. The SUO is a composite index derived using information on some of the main Hospitals’ activities (Outpatient visits - new and re attendances for general outpatients, In- Patient days, Antenatal Care, Maternal and Child Health, Family Planning contacts, Immunizations and Deliveries). Activities are weighted using relative weights based on their cost of production index, SUO is derived. The SUO index can be used to assess the overall volume of services produced by the Hospital and as well used to build other indicators like Cost per SUO (as a proxy for efficiency) and SUO per Health Worker (as a proxy for Health Workers’ productivity). In this light it is interesting to monitor the Hospital changes over time in respect to the different indicators.
58 The analysis provided includes 10 public Regional Referral Hospitals and Mbarara University Teaching Hospital plus 4 PNFP hospitals with specialized services namely Lacor, Nsambya, Mengo and Rubaga.
Figure 3.12 compares SUO for FY 2003/04 and FY 2004/05. The majority of Hospitals have increased the overall amount of services produced, thus showing higher SUO values. Soroti and Lira Regional Referral Hospitals have moved backwards as compared to the previous year. In depth analysis has shown that the overall volume of services produced by the two hospitals has decreased for all the variables considered in the index (Total OPD attendance, Admissions and Deliveries). This is attributable to the restored peace in the regions, which may have had a moved the population back to the lower level health facilities located in their service areas of origin. Nsambya and Lacor Hospitals (PNFP) have registered a positive increment in volume of services (SUO) of 28% as compared with past year, while Arua Hospital has recorder the highest increment of 41%, attributable to a relatively large number of admissions (possibly explained by the recurrent surgical camps).
Figure 3.12: Standard Unit of Output in Regional Referral Hospitals and selected PNFP.
Standard Unit of Output - Comparison 2003-04 vs 2004-05
800,000
700,000 SUO (2003-04) SUO (2004-05) 600,000
500,000
400,000 National Average = 394,809 SUO
300,000
200,000
100,000
- i a lu a a t o ale u k ro ya rua g b im ag Lira o rara bale a o G b a mb A Jinja Lacor K H S Men M Masa Ru Mb Fort Portal Nsa
The financial resources available at the different hospitals were computed and analyzed in order to assess how efficiently the hospitals were using the available resources. The derived index, Cost per SUO, a proxy for efficiency, is therefore derived. (See figure below).
59 Figure 3.13: Comparison of Efficiency in Regional Referral Hospitals and selected PNFP Hospitals.
Comparison of Efficiency - 2003-04 vs 2004-05
14,000 Cost per SUO (2003-04) Cost per SUO (2004-05) 12,000
10,000
8,000
National Average = 6,306
6,000 Cost per SUO (UGX) SUO per Cost
4,000
2,000
-
ra a rua ulu go inja A G Li J ortal Mbale Soroti Hoima Lacor mbya Men Kabale Masak Rubaga sa ort P Mbarara F N
The overall tendency recorded is that the Hospitals are spending more to produce a unit of output: signaling 2004-05 efficiency losses. Arua and the PNFP Hospitals (Lacor, Nsambya and Rubaga) however gained efficiency, each spending less to produce one unit of output. Mbale Hospital still seems to be the most efficient producing a unit of output at a cost slightly less than 4,000 UGX. For the majority of hospitals the cost of production for a SUO is between 4,000 and 8,000 UGX while in Nsambya Hospital the cost per one SUO is higher than 10,000 UGX.
A different way of analyzing the efficiency of the RRHs is by using the human resources (health workers) available to the hospitals as an input and the SUO as output. Comparing the inputs and outputs gives an indication about the productivity of the health workers is assessed as SUO of each health worker in the hospital. Table XX below shows the results.
Overall, health workers are less productive as compared with the previous financial year. The units of output produced by a single staff have slightly decreased, with the exception of Arua and Jinja Regional Hospitals for the Government Hospitals and Nsambya Hospital for PNFP which have registered an increment of the SUO per Health Workers. The relatively high decrement observed for Lira and Soroti Regional Referral Hospitals has already been commented on previously.
Figure 3.14: Comparison of Health Workers’ Productivity in Regional Referral Hospitals
60
Comparision of Health Workers Productivity - 2003-04 vs 2004-05 3 500
Productivity 2003-04 3 000 Productivity 2004-05
2 500
2 000 National Average = 1,544
1 500 SUO per Health Worker
1 000
500
- l a a ja le r a g n ua o oti ale i ba r c Lir r ba J a A La Gulu Port u K Hoima Mengo So Mb rt sambya R Masaka Mbarara Fo N
Challenges with the SUO methodology
The findings of the above analysis need to be considered taking into account that the methodology adopted has some limitations. The SUO approach has been used and has proved to be a robust approach especially when applied to referral hospitals operating in rural settings. Even though its applicability may prove better when applied to general hospitals, the approach offers a way to appraise a hospital’s performance over time (trend analysis) rather that when comparing different hospitals with similar features. As observed there are a number of limitations in the approach, which need to be taken into account.
Quality of services
The approach does not capture quality information and it is merely based on quantitative information used to calculate volumes of outputs. Quality indicators may be used to adjust and validate quantitative indicators. Although a first attempt have been made to capture quality of care in this years report it is still a long way to go to get objective reliable figures scoring the quality of the services provided at the different hospitals. In the future when the YSP has been fully implemented, result from that program will be compared with HMIS data to get a more comprehensive picture.
Case mix and other complexities
The SUO methodology does not take into account the case mix of services and other complexities that have a bearing on the overall cost for producing the different specialized services. There are variations in case mix even with facilities at the same level. This has not been taken into
61 consideration for this analysis. The analysis does not show if the services provided at the RRHs are really services that should be provided at that level. How well the RRHs fulfill their roles as referral facilities is not well captured by this analysis. The analysis only includes general outpatients (both new cases and re- attendance), but it does not include specialized outpatients visits. It has also been recognized that the relation between new and re-attendance varies a lot between the hospitals. For example for Kabale 93 % of the total OPDs cases are new but for Mbarara only 67%. Furthermore, other factors like mass population displacements also affect the SOU for a hospital based on the prevailing situation, e.g., Soroti and Lira hospitals.
Data quality, classification and definitions
The quality of the data, and the definitions/classifications employed still need to be improved. For example, what should fall under major or minor surgical operation could differ between hospitals. As this is the second time this analysis has been done, the hospitals are encouraged to examine their performance in absolute terms and over time and also in relation to other facilities in order to judge their performance. Each hospital has access to more data, which should be utilized for a more detailed analysis. Constraints should be identified and plans made to overcome them. For example maternity audit should be used to analyze maternal death.
General Hospitals
There are 84 general hospitals in the country out of which 42 are public hospitals. Kamuli hospital in Kamuli district was added during the FY 2004/05. The outputs generated by the general hospitals are presented in Annex. 69. Hospitals submitted the Annual Reports, although not all were complete. The parameters included are:
Facility Outputs: - Out patient services: OPD attendance (new and re attendance) and Immunization -Inpatient Services: Total admissions -Maternal Services: Deliveries, C/S rate, ANC and Family planning visits
Facility Outcomes: Total Death Rate and Maternal Death Rate
PNFP Hospitals
Observations from a sample of 65% of PNFP Hospitals have shown positive trends of the main output indicators (cumulative values). Outpatient and Inpatient attendances have registered an increment of 21.33% and 8.97% percent respectively. Deliveries in the Hospitals have also registered a remarkable increment of about 25%, as well as the utilisation of pre and post-natal services, which shows an increment in utilisation of 5%.
Figure 3.15: Total OPD attendance (new and reattendants) cumulative in a sample of 65% of PNFP Hospitals
62 Total OPD attendance (new and reattendants) cumulative in a sample of 65% PNFP Hospitals 1,200,000 1,140,341
1,000,000 939,896 872,562 824,823 800,000 729,519 685,891
597,707 600,000 577,744
400,000
200,000
0 97 98 98 99 99 00 00 01 01 02 02 03 03 04 04 05
Figure 3.16: Total Admissions (cumulative) in a sample of 65% of PNFP Hospitals
Total Admissions (cumulative) in a sample of 65% PNFP Hospitals
300,000 278,565
255,635 250,000 238,621
199,464 200,000
172,318 159,706 154,705 149,872 150,000
100,000
50,000
0 97 98 98 99 99 00 00 01 01 02 02 03 03 04 04 05
Figure 3.17: Cumulative number of deliveries in a sample of 65% of PNFP Hospitals
63 Cumulative number of deliveries in a sample of 65% of PNFP Hospitals 45,000 42,555
40,000
35,000 34,064 32,377
30,000 28,403 28,949 26,918
25,000 23,709 22,618
20,000
15,000
10,000
5,000
0 97 98 98 99 99 00 00 01 01 02 02 03 03 04 04 05
b. Oral/Dental Health Care
Dental problems are important public health problems because of their high prevalence.
Achievements: Oral health was integrated into the school health programs and plans are to integrate it in other PHC programmes. Developed the following Guidelines which are ready for printing: o A guide for oral health care workers on community oral health care practice. o A guide for health care workers on nutrition in relation to oral health care o A guide for oral health care workers on the use of ART in community oral health care practice o A guide for health care workers on oral health care for PLWHA o A manual for health care workers on the management and treatment for PLWHA o A draft for the National oral health policy has been developed. c. Palliative care
Palliative care is an approach to improve the quality of life of patients and their families facing the problem associated with diseases not responsive to cure. This is done through prevention and relief of suffering by means of early identification, assessment and treatment of pain and other symptoms, physical, psychosocial and spiritual. Currently, very limited services are available.
64 Chapter 4 Integrated Health Sector Support Systems 4.1 Health Care financing
The HSSP I was costed in the Health Financing Strategy (HFS) at US $ 28 per capita. This is more conservative than the Commission of Macroeconomics and Health (WHO, 2001) estimate of US $409. Health financing sources include public and private sources of funding. Public sources are expected to be most applicable to government policy and guidelines, and in Uganda are mainly GoU budget including donor budget support and donor projects. Public expenditure for the HSSP I period is presented in Table 2 ???? , which shows overall public health expenditure for the HSSP I ranging from US $ 8 in 2000/01 to US $ 10.5 in 2004/05. This is about 30% of the requirement of the HFS.
4.1.1 Overall public expenditure (GoU and Donor budget support funding)
Funding levels and trends for the HSSP I
GoU expenditure in the health sector increased over the HSSP I period from 124 billion shillings in 2000/01, to 220 billion shillings in 2004/05. Expenditure per capita in Ug Shs however showed only modest increases from Shs 5,380 in 2000/01 to Shs 8,297 in 2004/05. This is because of the high population growth rate the country is experiencing. This translates into US $ 3.05 per capita in 2000/01 to US $ 4.78 per capita in 2004/05. The GoU health expenditure grew from 7.5% of the entire GoU budget in 2000/01 to 9.7% in 2004/05. Further detailed analysis of the GoU health budget shows that although the budget was growing significantly at the beginning of the HSSP I this growth has long dwindled – 37% between 2001/02 and 2000/01; 15% between 2002/03 and 2001/02, 6% between 2003/04 and 2002/03 and only 5% between 2004/05 and 2003/04. What about 2005/06?
Fig. M: Trends in percentage allocation by levels.
9 This excludes ARVs and pentavalent vaccine.
65 60%
50%
40%
30%
20%
10%
0% 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05
Central Central hospitals Districts Regional referral
Efforts have been made in the last 5 FYs to allocate more funds to lower levels where the majority of Ugandans live. Trends of allocation of resources by level are shown in fig. M. Highest percentage allocation is at the district level mainly for PHC services, and it has increased steadily over the last 5 FYs with reducing percentage allocations to the centre. Percentage allocations for central and regional referral hospitals have remained fairly constant (in nominal terms) over this period. With the achievement of this policy objective of allocating funds to lower levels for PHC services though, the hospital budgets have deteriorated, whereas they also offer PHC services and first and second level referral to the population. During the HSSP II period, hospital funding – levels and consideration of the most efficient way of targeting using public resources, will need to be revisited.
Budget allocation and performance FY 2004/05: During the FY 2004/05, the GoU allocation to the health sector on health was 236.69 Bn Ug. Shs. representing 10.8% of the total government budget. The largest proportion of funding was on recurrent non-wage while the lowest was on development.10 The GoU expenditure on health for the FY 2004/05 was 218.76 billion equivalent to 92.8% budget performance. This is a decline in performance from the previous 3 years of the HSSP with budget performance above 95%. The under-performance, amounting to Ush18.12bn is mainly attributed to under spending on wage which takes up 45% of the sector’s budget. The wage under-performance is attributed to a failure to recruit health workers as planned. Details of budget performance by grant and level are included as Annex??? and on wage performance in section 4.1.5).
Table F: Budget performance FY 2004/05
Approved budget Outturn Performance
10 This is domestic development, which includes counter part funding to donor development projects, and government infrastructure development such as construction of theatres and purchase of equipment.
66 Wage 106.46 90.65 85.1% Non-Wage 98.60 99.99 101.4% Development 31.82 28.12 88.4% Total 236.88 218.76 92.4% Source: MoFPED September 2005.
Wage bill pressures continue to strain budget execution. This is either a symptom of poor budgeting or malpractices in payroll management. This therefore calls for improved budgeting based on approved structures across government as well as effective payroll management. Further the delay to implement pay reform on account of negotiations that ensued between Government and the Medical workers union also created wage arrears under local governments See Annex XX for details on budget performance FY 2004/05.
GoU Budget expenditure at central level FY 2004/05
The MoH central level receives GoU budget, a proportion of which is PAF funding. PAF expenditures at the central level, mainly prog. 9 is meant to support PHC services at the district level, which include centrally coordinated purchases and centrally shared services. Budget performance was 100% for all departments. The highest percentage expenditure was on drugs (70%) while looking at departments, the planning department received the highest share at 5%. Mental health received the least share at 0.10%. With improvements in timeliness of releases within the MoH, transparency in reallocations, improved accountability and reporting, the challenge remains elaborating the allocation criteria and programs qualifying to be funded from Prog. 9 in HSSP II. See annex II for details on prog 9 allocations.
4.1.2 Donor Projects and Global Initiatives
Given the SWAP and in line with the MoU there have been efforts during the HSSP I for development partners to use the government budget as the preferred mechanism for funding the HSSP I. However a number of donor projects still exist with some development partners providing both budget and donor project support. In the recent past a number of global funding initiatives have been implemented which operate as donor projects. In a bid to improve the information available about the donor projects the health sector has carried out a number of surveys over the HSSP I period. For the period 1998/99 to 2000/01 information was collected from development partners which were used in the process of building the National Health Accounts. A similar instrument has been used to collect expenditure data for the FY 2003/04 and 2004/05 health sector. Data on donor projects was collected from 13 development partners namely; Africa development Bank (AfDB), DANIDA, Development Cooperation Ireland (DCI), DfID, European Union (EU), Italian Cooperation, Sweden (SIDA), UNFPA, UNICEF, USAID, WHO and the World Bank (UACP project)11. Belgian cooperation and JICA responded though they had no projects running for FY 2004/05.
Donor Project Expenditure FY 2004/05
11 Exchange rates for FY 2004/05 were Ugshs 1734.78 to 1US$; Ugshs 2093.89 to 1euro and Ugshs 3130.60 to 1GBP (Bank of Uganda)
67 An analysis of budgets against releases for donor projects was done and the results are presented in Table 4.1. The budget figures from MoFED have been compared with actual expenditures as provided by the different donors.
Table 4.1: Donor Project Expenditure against Budget FY 2004/05 Donor Budget (MoFPED) Expenditure Expenditure as /Initiative shs '000 Ug. Shs '000 % of budget UNICEF** 11,183,201 1,921,515 17% USAID 39,940 104,996,060 262884% DfID 998,500 2,223,853 223% EU * 1,498,801 3,033,672 202% DCI 735,764 WHO 19,970,000 5,069,149 25% Italian coop 9,785,300 14,051,036 144% Germany 2,569,100 0% JICA 599,100 0 China 79,880 World Bank 22,286,109 UNFPA 1,797,300 2,691,345 150% DANIDA 19,970,000 16,725,562 84% SWEDEN 399,400 9,194,387 2302% Spain 12,962,600 Netherlands 3,275,080 AfDB 21,619,935 GAVI 3,782,000 Global fund 68,635,000 46,516,271 68% Overall 85,128,202 254,846,658 299% Source: Budget; draft estimates of revenue and expenditure (recurrent and development) 2004/05. MoFPED; expenditure data; primary data collection. ** Expenditure figures for UNICEf don’t include funds spent in the PNFP sector and funds disbursed to districts. Data for these two entities was not available. Funding reflected here is for funds retained at the centre.
Expenditure on donor projects amounted to 254.847 billion Ugshs (US$ 146.895 million; per capita expenditure US$5.74). This is equivalent to budget performance of 299%. This is illustrative of the quality of information amongst sector stakeholders on donor project budgets and expenditure. The MoFPED donor project budget figures are include in the MTEF and have been used for this analysis. Donor project budget information at the MoH is usually different from information at the MOFPED, since the MoH database may be updated during the implementation year.
Table ??????: Donor Project Expenditure - comparing Data from MoH and MOFPED (Ug. Shs. billion) Financial Year Source of data MoFPED MTEF MoH survey 2000/01 114.77 203.83 2001/02 144.07 No survey done
68 2002/03 141.96 No survey done 2003/04 175.27 153.2612 2004/05 146.74 254.85
Donor project expenditure information from the MoH donor surveys is very different from expenditure information as found in official MoFPED documents. This is likely to be because of the more comprehensive and proactive data collection methods employed by the MoH as an implementing sector. Discrepancies may arise from: under declaring the number of projects to be supported by the different development partners (DPs); actual variation in expenditure compared to provided budget figures due to absorption capacity, failure to mobilize budgeted funds and project phase – especially at start up and end of the project. This is demonstrated in table ????? above. This highlights the need to institutionalize a systematic way of monitoring donor project expenditure that can be used by both MoFPED and MoH. There is need for increased transparency, improved predictability and consistency in expenditure on the side of DPs as far as projects are concerned.
Donor Project Expenditure Analysis A breakdown of project spending by inputs and alignment with sector priorities is given here.
Figure 4.1: Analysis of donor project expenditure FY 2004/0513 versus HSSP Priorities
HR Ugandan medicines and health staff medical supplies 4% 20%
Other recurrent 7%
Other inputs Capital non (non HSSP infrastructure priority) 4% 56%
Infrastructure 9%
The highest percentage of donor project expenditure (56%) is on inputs that are not prioritized in the HSSP and not costed in the health financing strategy. There is improvement compared to the analysis that was done in FY 2003/04 that showed that 68% was expenditure on non-HSSP inputs.14 Expenditure on human resource continues to receive the lowest priority (only 4%) much as it is one of the most critical inputs in health service delivery. The same pattern was observed in the FY
12 there was marked under-spending by the GFATM 13 Sector Priorities are laid out in the HSSP (I & II) and the inputs costed in the Health Financing Strategy. The Health staff HR refers to salaries and allowances for staff employed by GoU or Private Sector health providers - not project staff; other recurrent refers to office running costs, fuel, maintenance of vehicles and premises for HSSP services not project management; Capital non-infrastructure refers to vehicles and equipment. for HSSP services not project management; other input refers to all inputs not directly costed in the health financing strategy including: technical assistance and project management costs 14 Source: Ministry of Health, Annual Health Sector Performance Report 2002/2003
69 2002/03 analysis. There is need for detailed analysis of donor projects to ensure that they contribute towards identified sector priorities and efficient allocation of funds for key inputs. See Annex F for Detailed analysis of health sector projects
Figure 4.2 shows expenditure by inputs for the different DPs. Most of these DPs with the exception of USAID and the UN agencies provide both budget and donor project funding15.
Significant expenditure on medicines and medical supplies is noted for UACP (WB/HIV project), UNFPA and DANIDA while WHO biggest expenditure was on HRH. AfDB highest expenditure was on infrastructure and this was civil works for health facilities in 11 districts.16
Figure 4.2: Disaggregation of expenditure by inputs for the different projects:17
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% EU DCI DfID AfDB WHO UACP Overall UNFPA UNICEF DANIDA ITALIAN SWEDEN
HR Ugandan health staff Drugs and medical supplies Other recurrent Capital non infrastructure Infrastructure Other inputs
Figure 4.3 shows details of expenditure in the public and private sectors for the different development partners.
Overall, there is more spending in the public sector (55%) compared to the private sector (45%). All the expenditure in the Private sector is in the Private Not For Profit Sector (PNFP), only Italian Cooperation had a small (0.31%) expenditure in the private for profit sector. The National Health Accounts (NHA) 1998/99 – 2000/01 also showed a large portion of funds controlled by the PNFP entities. There is thus a need to regulate the activities and ensure accountability given stewardship role of government in this sector to ensure that they contribute towards identified priorities.
Figure 4.3: Donor Expenditure in public vs private sector FY 2004/05
15 Some of the DPs are implementing several projects as many as 20 in the case of USAID, 11 for Italian cooperation, and 7 for SIDA. 16 DfIDs expenditure on other inputs is for TA in MoH 17 USAID has been excluded in this analysis because of poorly disaggregated data.
70 100% 80% 60% 40% 20% 0% EU DCI DFiD AfDB Bank WHO World USAID Overall UNFPA UNICEF DANIDA ITALIAN SWEDEN
Public Private
Figure 4.4 shows expenditure at the district and central level for the different development partners for funds spent in the public sector.
Figure 4.4: Expenditure of Donor projects by level: district vs central FY 2004/05
100% 80% 60% 40% 20% 0% EU DCI DFiD AfDB WHO World USAID Overall UNFPA UNICEF DANIDA ITALIAN SWEDEN
Central District
In improving allocative efficiency, the sector needs to increase the consumption of services to reach more people and this translates into increasing the proportion of resources allocated to the district health services where the majority of population live. Over all the highest expenditure is at the district (75%) level compared to the district level (25%) and 50% of this is on drugs and medical supplies. The highest percentage of funds spent at the centre is on other inputs not costed in the health financing strategy (33%) and infrastructure (25%). This finding seems to suggest that for funds spent within the public sector, expenditure at the lower level (district) is easier to align with HSSP priorities than when funds are spent at the national level. Efforts can them be made in the design of projects to ensure that the biggest amount of funds is allocated to the district level.
Global Initiatives: GAVI, PEPFAR, Global Fund
Global initiatives were put in place to raise additional funding for health and support rapid scaling of coverage with effective interventions. Data was collected on revenues for GFATM and expenditure
71 on GAVI funding for 2004/04 n and as shown in table V. The PEPFAR data was mixed up with other project funding and couldn’t be disaggregated.
Table V: Funding from Global initiatives:
GFATM US$ million* Approved grants FY 2004/05 MoFPED budget Release in FY 04/05 HIV/AIDS - Round 3 70.358 20,044,878 TB - Round 2 2.055 877,737 Malaria - Round 2 23.211 5,891,316 Total 95.624 39,564,095 26,813,931
GAVI US$ million MoH Budget Expenditure 3.76 2.18 Source: GAVI annual report; UNEPI, April 2005; http://www.theglobalfund.org; Oct. 05 These are releases and not expenditures because we couldn’t access expenditure data at country level.
Funding released from GFATM was US$26.8 million, which was 68% of budget this is an improvement compared to last FY whereby only 51% was sent to the country18. Total expenditure for GAVI amounted to US$ 1,285,657.28 and this was 58% budget performance (98%) of which was spent in the public sector and only 2% spent in the private sector.19 The largest expenditure (94%) was on commodities (vaccines and medical supplies).
Global initiatives form a sizeable proportion of donor funding. There are variations in releases and expenditure of funds yet these are included in MTEF ceilings (especially GFATM). The unpredictability of these funds and absorption capacity constraints disrupt service delivery. There is need for rational and realistic planning to ensure that funds received in the country are utilized. 4.1.3 Analysis of health expenditure at district levels Analysis has been done on total funding received at the district level for 21 districts as shown in table YY.
Table YY: Details on total funding received at the district level.
Per capita Percapita % local expenditure total expenditure GoU Total revenue % Gou gov't % donor US$ funding only US$ Kayunga 2,099,916,286 73% 2% 25% 3.8 2.8 Kabarole 2,002,570,509 77% 1% 22% 3.0 2.3 Kaberamaido 1,102,813,161 56% 0% 44% 4.8 2.7 Gulu 2,668,392,005 89% 4% 7% 3.1 2.7 Bushenyi 3,403,733,676 84% 7% 8% 2.5 2.1 Kapchorwa 1,649,439,687 85% 1% 14% 4.6 3.9 Arua 4,130,293,143 72% 2% 26% 2.6 1.9 Adjumani 1,840,387,112 76% 3% 21% 4.9 3.7 Kasese 3,846,695,491 93% 2% 4% 3.9 3.6 Wakiso 3,696,654,353 79% 4% 17% 2.1 1.6 Pader 1,685,578,582 74% 0% 26% 3.1 2.3
18 Details of expenditure were not available. 19 This data refers to a calendar year; 2004.
72 Ntugamo 2,232,409,999 91% 0% 9% 3.1 2.8 Kyenjojo 1,656,131,319 68% 2% 30% 2.3 1.6 Mbarara 4,560,524,764 81% 0% 18% 2.3 1.8 Katakwi 1,554,538,347 69% 0% 31% 2.7 1.9 Kamwenge 1,178,319,987 87% 2% 12% 2.2 1.9 Iganga 3,432,188,385 88% 1% 11% 2.6 2.3 Jinja 1,767,343,395 73% 1% 25% 2.3 1.7 Yumbe 1,179,097,424 80% 0% 20% 2.5 2.0 Kanungu 1,709,933,807 96% 0% 4% 4.6 4.4 Mpigi 3,378,907,353 62% 1% 37% 4.6 2.8 Masaka 3,020,306,447 81% 0% 19% 2.2 1.8 Kalangala 764,366,439 73% 1% 26% 10.5 7.6 Sembabule 861,267,340 94% 0% 6% 2.6 2.4 Rakai 4,191,986,782 82% 1% 18% 4.9 4.0 Mayunge 1,742,577,233 67% 0% 33% 2.9 1.9 Source: data collected from districts.
GoU funding20 remains the most significant source of funding in all districts while local government makes the least contribution.21 Donor funding makes a significant contribution in some districts e.g Kaberamaido and Kyeonjojo compared to others e.g Kasese and Kanungu22. In absolute terms a district like Arua is receiving more than 1 billion shillings a year from project support. The percapita expenditure remains very low in all districts with or without donor funding, though we note that prog.9 expenditures for districts and funding for regional referral hospitals are not included in this analysis. This per capita expenditure is too low for effective service delivery and more funding needs to be mobilized for district health services. Per capita expenditure ranges from as high as US$10.5 for Kalangala (of which US $7.6 is contributed by government) to as low as US$2.1 for Wakiso. While taking note of the difficult topography of Kalangala district, its per capita expenditure is much higher than the other districts studied. This and the fact that a number of districts are still getting substantial resources from donor projects indicates that the allocation criteria may need to be reviewed to correct for these possible sources of inequity See Annex Z for details of amounts contributed by the different sources.
Releases from MOFPED as a percentage of budgeted funds23. Over 50% of districts and municipalities were below the overall average (92.4%) with the worst performers being municipalities. The under performing component was the wage component in most of the districts and municipalities and details are in section 4.1.5 (key inputs).
20 This includes PHC development, PHC non-wage, PHC wage, District hospital funding and NGO subsidy. Funding for regional referral hospitals in NOT included. 21 Most of the local government contribution is from LGDP. 22 There are a number of NGOs in Gulu and presumably a lot of donor funding but it does not seem to go through the district health office. 23 Releases have been used in this report as opposed to using actual expenditures because; districts are still working on submitting their accounts to MoFPED, therefore final actual expenditures per districts cannot be reported. In addition, the Area Monitoring Teams have noted that the districts have received PHC Funds released from MoFPED in general how ever; experience from field visits has shown that transfer of funds within the districts can be very slow. This is primarily a management problem within the district itself, at the District Head Quarters Office or/and at the DDHS Office.
73 Figure 4.xx: Releases Vs budgets for GoU funding for districts and municipalities.
ENTEB B E MUN. MBARARA MUN. MOROTO MUN. TORORO MUN. FORT PORTAL MUN. GULU MUN. MASAKA MUN. KANUNGU RAKAI K YEENJ OJ O NTUNGAAMO RUKUNGIRI MOYO SIRONKO BUNDIBUGYO PALLISA KASESE LUWERO KAYUNGA GULU KAMPALA KISORO KAMWENGE MBARARA Overall ADJUMANI NEBBI MUBENDE ARUA MBALE MUKONO NAKAPIRIPIRIT BUSHENYI MASINDI TORORO KUMI SEMBABULE KITGUM KABAROLE MPIGI PADER APAC SOROTI JINJA IGANGA KOTIDO BUGIRI KIBALE HOIMA MAYUGE YUMB E MASAKA KABERAMAIDO KALANGALA KIBOGA KABALE NAKASONGOLA KATAKWI BUSIA JINJA MUN. WAKISO MOROTO KAPCHORWA SOROTI MUN. KAMULI LIRA MUN. KABALE MUN. LIRA MBALE MUN.
0% 30% 60% 90% 120%
4.1.4 Expenditure on key inputs – Medicines and Human Resources
74 i) Medicines and health supplies FY 2004/05
Total inputs for medicines and health supplies availed to government and PNFP providers in FY 2004/05 from all sources amount to more than $3.00 per capita (Table 4.3). Financing sources include GoU funds, PAF, projects funded by development partners, and global initiatives. Of this budget, less than $1.00 per capita is disbursed through service provider budgets that enable the various government and PNFP cost-centres to manage medicines and health supplies in line with decentralization policy and guidelines. A small amount (about $0.16 per capita) is channeled through MoH programmes that arrange for centralized procurement and vertical supply of specialized items for national service delivery, such as vaccines, and other specified commodities of public health importance. The larger part of resources (estimated at more than $2.00 per capita) flows as commodities sourced by projects and global initiatives targeting selected diseases such as HIV- AIDS and malaria. There is a clear shift away from the integration principles of the SWAp and budget support towards a more fragmented mode of funding and resource allocation. This will result in increasing challenges to systems, planning and logistics of medicines supply during HSSP II.
Five-year trend analysis (FY 2001/02-FY 2005/06)
Figure 4.6 illustrates the exponential increase in financing of medicine and health supplies and the change in relative contribution by mode of funding over a 5-year period. Initially, increased PAF funding was directed towards service provider budgets and establishment of “credit lines”, a new mechanism for allocation of earmarked funds for essential medicines and health supplies to service providers. More recently, service provider budgets have stagnated while substantial new “off- budget” financing is channeled through projects and global initiatives often tied to specified commodities, with parallel procurement arrangements and vertical programming. Few expensive commodities account for a large part of the per capita budget, e.g. $0.70 for the new pentavalent vaccine ordered from the GAVI Vaccine Fund since FY 2002/03, and $0.40 for antiretroviral therapy (ARVs) with scaling up of procurement through the GFATM beginning 2004. Commitments for a new first-line treatment of malaria with artemisinin-based combination therapy (ACT) to be funded through the GFATM during FY 2005/06 amount to an additional $1.00 per capita annually, larger than the entire monetary medicines budget for service providers, and this will bring per capita medicines inputs to over $4.00.
75 Table 4.3: FY 2004/05 Medicines financing analysis
FY 2004/05 INPUTS UGANDA Public and PNFP Sector MEDICINES AND HEALTH SUPPLIES
FINANCING MODE OF FUNDING & BENEFICIARY INPUTS - MEDICINES & HEALTH SUPPLIES SOURCE RESOURCE ALLOCATION & BUDGET LINE UGS billions US$ millions US$ per capita (US$=1735 UGX) (popul 26.5 mil.)
ALL TOTAL 135.5 78.1 $3.11 (1-3) SERVICE PROVIDER BUDGETS 42.2 24.3 $0.92 (4) MOH PROGRAMMES 7.6 4.4 $0.16 (5) PROJECT PROCUREMENT 36.2 20.9 $0.79 (6) GLOBAL INITIATIVES 57.1 32.9 $1.24
1 INSTITUTIONAL BUDGET (a) AUTONOMOUS HOSPITALS 6.325 3.646 $0.14 GOU Cash purchases Regional Referral Hospitals, medicines (40% of RNW) 2.524 1.45 $0.055 GOU Cash purchases Mulago and Butabika Hospitals, RNW-medicines 3.801 2.19 $0.083 2 LOCAL GOV'T BUDGET (a) DISTRICTS / HOSPITALS 21.896 12.62 $0.48 PAF Cash purchases Gov't health centres, medicines (50% of RNW) 11.585 6.68 $0.252 PAF Cash purchases Gov't general hospitals, medicines (40% of RNW) 4.144 2.39 $0.090 PAF Cash purchases NGO health centres grants (assume 50% medicines) 2.708 1.56 $0.059 PAF Cash purchases NGO hospitals (assume 30% medicines) 3.459 1.99 $0.075
3 CREDIT LINES (b) DISTRICTS / HOSPITALS 14.000 8.07 $0.30 PAF EDA - Purchases NMS/JMS NSD - Essential medicines and health supplies 8.000 4.61 $0.174 DANIDA EDA - Purchases NMS/JMS HSPS - Essential medicines and health supplies 6.000 3.46 $0.131 4 MOH BUDGET (c) NATIONAL SERVICE DELIVERY (NSD) 7.550 4.35 $0.16 PAF Procured (UNEPI) EPI Vaccines 5.000 2.88 $0.109 PAF Procured (RH-NMS) Family planning supplies 1.350 0.78 $0.029 PAF Procured (UBTS) Blood bags 0.600 0.35 $0.013 PAF Procured (CH-NMS) Oral rehydration solution 0.400 0.23 $0.009 PAF Procured (?-NMS) Rabies vaccine 0.200 0.12 $0.004 PAF Procured (?) Disease programmes ? PAF Procured (?) Public health emergencies ? 5 PROJECTS (d) HEALTH PROGRAMMES (NAT'L/DISTRICT) 36.174 20.85 $0.79 WB Procured (UACP-PIU) Misc. (ARVs, HIV testkits, condoms) 13.280 7.66 $0.289 USAID Commodities in kind Condoms, family planning supplies 5.838 3.37 $0.127 USAID Procured (projects) Misc. (ARVs, HIV testkits, ITNs, Homapak) 6.000 3.46 $0.131 ADB Procured (project-NMS) Misc. (for mental health, ITNs, Homapak) 0.962 0.55 $0.021 Unicef Procured (UN agents) Vaccines/related 2.434 1.40 $0.053 UNFPA Procured (UN agents) Family planning supplies/SRH related 1.308 0.75 $0.028 Ital Coop Procured (??) District support 4.268 2.46 $0.093 Ital Coop Procured (??) PNFP Support 1.498 0.86 $0.033 EU Procured (??) SRH related and BTS 0.459 0.26 $0.010 WHO Procured (UN agents) Misc 0.127 0.07 $0.003
6 GLOBAL INITIATIVES (e) HEALTH PROGRAMMES / DISEASES 57.056 32.89 $1.24 GAVI Commodities in kind Pentavalent vaccine + inj supplies 35.056 20.21 $0.763 GFATM Procured (PMU-Cr. Ag) HIV-AIDS related: ARVs, HIV testkits 20.000 11.53 $0.435 GFATM Procured (PMU-Cr. Ag) Malaria related 2.000 1.15 $0.044 GFATM Procured (PMU-Cr. Ag) TB related ?
NOTES Sources: Analysis of published budgets and reports by donors in a format provided by the Health Financing Committee for the HSAPR. (a) Figures for service delivery providers represent budget lines for medicines; disbursement and utilisation are reported separately. (b) Channeled through a basket account managed by MoH; partly funded by Danish Health Sector Programme Support, earmarked for medicines Disbursement to the basket account was 100%. Utilisation is reported separately. (c) Figures represent budget and disbursement from MoFPED (100% was disbursed); actual expenditure not analysed. (d) Project figures represent reported expenditures by donors against procurements, not commodities actually distributed (NB Italian Cooperation). USAID did not specify contributions for medicines; these figures are MoH estimates based on expected procurements. (e) GAVI figures represent estimated value of in-kind commodities received ; GFATM contribution based on planned procurement, unverified.
76 Figure 4.6: Five year trend in the medicines budget FY 2001/02 – FY 2005/06
Per capita $4.00 inputs $3.50 (medicines) $3.00
$2.50
$2.00
$1.50 Global initiatives Project procurement $1.00 MoH Programmes Service provider budgets $0.50
$0.00 2001-02 2002-03 2003-04 2004-05 2005-06 E Global initiatives $0.00 $0.68 $0.70 $1.24 $2.20 Project procurement $0.38 $0.38 $0.48 $0.83 $0.83 MoH Programmes $0.14 $0.12 $0.13 $0.16 $0.15 Service provider budgets $0.38 $0.70 $0.90 $0.92 $0.88
More inputs – more outputs and service coverage?
Improved health sector outputs such as a doubling in annual outpatient cases in FY 2002/03 and FY 2003/04 have been partly attributed to the increased medicines supply, a consequence of modest growth of service provider budgets and efficiencies of the “pull system” underpinned by credit lines (see section on medicines management). The output level has been sustained in FY 2004/05 but remains at less than 1 visit/person/year. Outputs and service coverage indicators are once again stagnating, and the limitations of medicines supply may once again be a key-determining factor. While inputs from projects and global initiatives have dramatically increased medicines financing, the new funds are allocated for expensive inputs and new technologies and cannot be expected to result in proportionate improvement in coverage of the basic package of services or health sector outputs. Benefits from the relatively larger investments in scaling up antiretroviral therapy and provision of a pentavalent vaccine may only be evaluated in the longer-term and at the level of health status and outcomes.
Figure 4.7 shows the increased cost of treating malaria with expensive, patented ACTs relative to the current low-cost combination therapy. Inputs of $1.00 per capita from the global fund will be sufficient for only 15 million episodes of malaria, the projected requirement for outpatient treatment of malaria cases in the public sector. Additional funds will be needed to extend ACTs to the 5 million episodes in children currently treated through the home-based management of fever programme. Among the many challenges for implementation of policy change will be ACT coverage through home-based management of fever programmes and in the private sector, currently treating an estimated 5 million and 35
77 million episodes respectively. Both patented and generic ACT may be prohibitively priced for out-of-pocket payment24.
Figure 4.7: Escalating cost of treating malaria
Old CT regimen $0.12 generic, public
Generic ACT $0.60 public / private)
Patented ACT $1.20 public sector
Patented ACT $6.00 private sector
$0.00 $1.00 $2.00 $3.00 $4.00 $5.00 $6.00 $7.00 Cost price for a treatment course (child < 5 yrs)
Utilization of budgets and efficiency assessment:
Cost centres account for the service provider budgets following standard reporting procedures and expenditures are routinely reviewed by quarter and annually25. MoH has agreed indicative medicines budgets each FY, and provided clear policy and guidelines aimed at channeling purchases to the national medicines supply agencies (NMS and JMS) where quality and value for money has been demonstrated. Close monitoring of the earmarked “credit lines” during the two full years since establishment shows consistently high utilization (average >90%, see Figure 4.8) although performance has dropped from 95% in the first year of operation to 87% in the second year. In contrast, cash purchases of medicines and health supplies against indicative local government budgets and guidelines has shown great variability among the cost centres for gov’t health centres and hospitals and overall sub-optimal utilization. On average 50% or less is spent at NMS/JMS. Overall utilization may be higher if direct purchases from the private sector are included, but these data are not easily captured. Estimates based on reporting from a sample of districts indicates that about 10-20% of indicative budget spent in the private sector on average (see also section on Medicines Management). Many districts have failed to ring-fence the medicines budget, as agreed through annual FDS negotiations, and penalties may now be warranted for poor performing districts (i.e. move part of cash budget to credit line). Conversely, resources could be shifted from credit lines to cash budget in well performing districts. Expenditure patterns in the PNFP sector and performance against NGO grants may be a focus for study in the coming year.
24 Consideration of cost effectiveness ratios in the Uganda context may be increasingly important, comparing among the new high-cost interventions, and compared with preventive measures (e.g. ITNs for malaria, cotrimoxazole prophylaxis in HIV-AIDS, etc). 25 FDS, PAF and sector monitoring, public expenditure review, etc)
78 Figure 4.8: Utilisation of service provider budgets for medicines (cash/credit line)
Percentage utilisation of medicines budgets credit line cash
100% 95%
90% 87%
80%
70%
60% 50% 50% 47%
40%
30%
20%
10%
0% FY 03-04 FY 04-05
Efficiency of inputs from projects and global initiatives
Commodities are not easily tracked due to varying procurement arrangements, unpredictable “pipeline time”, and variable modes of distribution. Entitlements are not clear, and rarely communicated to beneficiaries in the same way as monetary allocations and published annual service provider budgets. Data on actual resource flows to the beneficiaries (GoU/PNFP, central/district, facility-based/community-based) are not easily obtained. Funding from USAID and Italian Cooperation flows through a large portfolio of projects with diverse beneficiaries, and inputs often served “in-kind” directly from the project. Some funding may be multisectoral (e.g. AIM project) or channeled through social marketing agencies.
Financing of specific categories of commodities may be fragmented across many donors and projects (summarized in Table 4.3). This applies to commodities for the new initiatives in HIV and malaria control (e.g. HIV test kits, ARVs, condoms, “Homapak” for HBMF or ITNs,). Long experience of project procurement indicates that transaction costs are high, there is duplication of effort, loss of economies of scale and questionable value for money, and higher wastage arising from vertical distribution systems and “push systems”. Experience with the expensive, in-kind commodities supported through GAVI and GFATM may be more limited, but raises many questions: Are they cost-effective? Is the bias towards medicines and health commodities tipping the balance of inputs at the expense of human resources? Is there system capacity to provide services to absorb the commodities, or are plans too ambitious? Is the supply sustainable? Will existing capacities and funding of requirements for the basic package of services be displaced? These critical issues will need to be addressed and considered in the next BFP, and throughout HSSP II.
79 ii) Expenditure on Human resources
Releases on wage, as a percentage of approved budget was 81% overall close to 50% of districts and municipalities performing below the overall average as shown in fig. M. Over 70% of municipalities and districts performed below 100%
Fig. M: Wage releases as a percentage of approved wage budget:
MBARARA ENTEBBE MUN. FORT PORTAL GULU MUN. MOROTO MUN. TORORO MUN. MASAKA MUN. KANUNGU RAKAI KYEENJOJO NTUNGAAMO ARUA MUN. MOYO SIRONKO BUNDIBUGYO RUKUNGIRI PALLISA KASESE LUWERO KAYUNGA ADJUMANI KISORO MBARARA KAMWENGE MUBENDE GULU KAMPALA NEBBI ARUA MASINDI MBALE MUKONO BUSHENYI Overall JINJA SOROTI IGANGA YUMBE KUMI KIBALE MPIGI TORORO JINJA MUN. HOIMA SEMBABULE APAC KABAROLE BUGIRI NAKAPIRIPIRIT KOTIDO KITGUM KIBOGA KALANGALA KAPCHORWA NAKASONGOL MAYUGE KABALE BUSIA KATAKWI KABERAMAIDO MASAKA PADER WAKISO KAMULI LIRA MOROTO KABALE MUN. SOROTI MUN. 0% 30% 60% 90% 120% 150%
80 Wide variations are noted with Soroti Municipality having the lowest wage release as a percentage budget followed by Kabale municipality. This poor performance in the wage components in municipalities where recruitment should be fairly easy may be accounted for by the delays in establishing the HRH structure in municipalities.
4.1.5 Contribution from Facility based Private Not for Profit Sector (FB- PNFP)
The health sector acknowledges the important role played by the PNFP sector in service delivery and in line with this, a Public private partnership policy is in place, cost of service delivery in the PNFP sector is included in HSSP II and the government has provided subsidies to the FB- PNFP sector since 1997/98.
The trend in total income for the FB-PNFP sector is shown in fig. JJ. Total income increased from 34.22 Bn Shs in 98/99, to 43.92BnShs in 99/00; 44.72 BnShs in 00/01. This reduced to 39.13BnShs in 01/02; reductions were in donor aid and user fees. There after the sector registered increases from 62.31BnShs in 02/03, 96.87BnShs in 03/04 and 79.32 in 04/05
Figure 4.xx: Trends in income for the PNFP health sector in Ugshs billions
100% 80%
60% 40%
20% 0% 1998-99 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05
Govt. Subsidies (money and drugs) User Fees Aid
Source: Bureax databases
An increasing trend in government subsidies as a percentage of total income is noted from FY 1998/99 to FY 2001/02 and thereafter fairly constant. Percentage contribution of user fees has remained fairly constant since FY 2001/02 to date. The FB-PNFP sector under took a user fees reduction initiative and improving efficiency of service delivery in their facilities in order to improve access to their services, more so for the poor and vulnerable. Given the increasing cost of service delivery, stagnating government subsidized will affect service delivery and may result in increasing user fees in order to raise revenue. This will have equity implications as poor will not afford to pay for services in these facilities.
81 Figure 4.10: Relative sources of income over time - PNFP Hospitals
100% 90% 33% 35% 80% 36% 37% 36% 43% 42% 70% 60% 50% 38% 36% 40% 56% 49% 44% 34% 35% 30% 20% 10% 27% 27% 23% 22% 11% 15% 19% 0% 1998-99 1999/00 2000/01 2001/02 2002/03 2003-04 2004-05
Delegated Funds Users' Fees Aid (Other financial Sources and Goods)
Source: Bureax databases
Much as delegated funds contribute a higher percentage at the lower level in the last 2 FYs compared to hospital level, lower level units continue to rely on user fees more than hospitals yet this is the level where majority of the poor seek services. Significant increases in user fee contribution are seen for FY 2003/04 and 2004/05 but again we note the reduced contribution from external donations especially at the lower levels. At the hospital level, despite a fairly constant percentage contribution from delegated funds, no increased contributions have been registered from user fees. This is a result of improved efficiency in service delivery that was implemented along side the user fee reduction initiative.
Figure 4.11: Relative sources of income over time - PNFP LLUs
100% 90% 22% 24% 80% 43% 46% 41% 70% 53% 60% 60% 43% 43% 50% 40% 31% 43% 32% 30% 36% 26% 20% 35% 28% 33% 10% 22% 11% 13% 14% 0% 1998-99 1999/00 2000/01 2001/02 2002/03 2003-04 2004-05
Delegated Funds Users' Fees Aid (Other Financial Sources and Goods)
Source: Bureax databases
82 4.1.6 Fiscal Decentralization
Government designed and approved the Fiscal Decentralisation Strategy (FDS) in June 2002. The process of implementing FDS started with 15 Local Governments piloting the new financing arrangements in FY 2003/04 and was subsequently replicated countrywide in the FY 2004/0526. Under FDS, LGs are allowed up to 10% flexibility in the use of the sector recurrent conditional grant non-wage to finance either un-funded or under-funded activities within a sector or in another sector. So FDS has been initiated to give districts the option to reallocate funds between and within sectors according to local priorities. In the health sector, the strategy is applicable to the PHC Recurrent Non-Wage grant.
The Local Government Finance Commission (LGFC) has undertaken various analyses of the trends and extension to which LGs use the horizontal flexibility (10% of non-wage recurrent). Using the preliminary work of budget re-allocations in FY 2005/06 BFPs and looking at the PHC non-wage grant one can extract the following information:
Total grant allocation from MoH for PHC non-wage is Ug Shs. 22.466 bn. After using the flexibility, LGs allocation to the health sector is Ug Shs. 22.072 bn (i.e. UgShs. 393 million or 1.5% was allocated AWAY from the health sector). These reallocations were made in the districts of Moyo, Kotido, Nakapiripirit and Moroto. The reason why these four districts allocate away from health is most likely that they receive very significant amounts of project and emergency aid related to health from various off-budget donors. This is not based on any information collected. It is just a suggestion/discussion to explain the occurrence. However, most districts leave the PHC-non-wage grant as it is or have minor additional allocations to health. In conclusion, therefore, one may say that compared to the earlier expectations and fears that the health sector would fall victim to the 10% reallocation flexibility, there have so far only been in-significant reallocations.
Not withstanding the progress made in a short period of time. There are a number of challenges hampering the full attainment of the intended objectives. Most of the LGs have neither internalised nor used the 10% flexibility for non-wage recurrent conditional grants. The LGs have attributed this scenario to among others insufficient support and backstopping offered to LGs27; the fear by the LGs to reallocate funds across budget lines and sectors, sector ministries informally communicating to the LGs instructing them not to reallocate funds, each sector having huge financial demands and unfunded priorities hence difficult to justify reallocation.
Hither to FDS, sectors were responsible for ensuring that sectoral activities at LG levels were adequately reported back to the center. However now under FDS, responsibility for ensuring reporting back from LGs is sorely the mandate of the Ministry of Local
26 The objective of FDS is to promote local government autonomy and widening of participation in decision making, in order to enhance the effectiveness in allocation of resources towards the achievement of PEAP goals in line with local priorities, whilst strengthening the efficiency, transparency and accountability of local government expenditures. 27 Some of the LGs claim that they received support in retrospect after the budgeting process for FY 2004/05.
83 Government, and for this, a simple form has been developed that captures feedback reports for all sectors. The sector need to devise means of collecting financing data from local governments, may consider including forms in the "conditions" that are agreed to during the annual sector negotiations.
Attainment of the benefits of FDS cannot be achieved at once. In the short-run there is need to consolidate through supporting and allowing the LGs to comprehend the FDS principles especially the flexibility in the use of the 10% recurrent grants non-wage with increased flexibility only with increased and proved LG internalization and capacity. LGs would require concentrated support.
4.2 Human Resources for Health
Human resources for health is key for achieving health sector goals and objectives through provision of skilled, efficient and equitable distribution of human resources to address the priority health needs of the population in the country. The Human Resource Division achieved the following during FY 2004/05:
Human Resource for Health Policy and Strategic Plan The process of developing the Human Resource policy was initiated and the first draft is in last stages of completion. The policy will be finalized by early next year. The development of Human Resources for Health strategic plan will follow once the policy is in place.
Human Resource Management During the Financial year, the sector still faced Human resource inadequacies. However following the lifting of the ban on recruitment there were attempts to fill the vacant posts to enable the health facilities deliver services to the population. Trained Health Workers remained both inadequate in numbers, skills mix and specialties. Table 1 gives the percentage filled in Regional Referral hospitals.
Table 4.xx: Established, filled and vacant posts in Ministry of Health FY 2004/05 Institution Approved Filled Vacant % 1. Ministry of Health Headquarters 701 460 241 65.6 2. Hoima Regional Referral Hospital 317 154 163 48.5 3. Mbale Regional Referral Hospital 362 301 61 83.1 4. Kabale Regional Referral Hospital 396 125 271 31.5 5. Fortportal Regional Referral Hospital 324 179 145 55.2 6. Gulu Regional Referral Hospital 330 195 135 59.0 7. Jinja Regional Referral Hospital 419 324 95 77.3 8. Masaka Regional Referral Hospital 348 262 86 75.3 9. Soroti Regional Referral Hospital 321 200 121 62.3 10. Mbarara Regional Referral Hospital 342 253 89 74.0 11. Lira Regional Referral Hospital28 * * * 0.0
84 12. Arua Regional Referral Hospital * * * 0.0 TOTALS 3860 2453 1407 Source: Staffing Lists as at May 2005. The figures are subject to a personnel audit exercise and may change. (Personnel Office Ministry of Health)
The table shows that Mbale hospital has the highest percentage of approved posts filled with 83%, while Kabale has the lowest with about 32%. Only 66% of approved posts are filled at the Ministry of Health headquarters. The data for Lira regional referral were not captured due to delays in submissions.
At the regional referral hospitals all categories of staff were recruited during the year under review. Figure 1 show that the biggest number recruited during the FY was of Allied Health category (Clinical officers, Laboratory staff and Radiology staff) with 92 health workers. The second category was that of support staff with 61 people while medical and dental staff recruited was only 42. The ministry recruited only 40 nursing and midwifery staff because their vacancies were already filled, thus priority was given to other cadres. Only 22 pharmacy staff were recruited because they were not many to recruit. The exercise of filling vacant positions is planned to continue during this FY.
Figure 1: Number of health staff recruited during FY 2004 by category of staff at Regional Referral Hospitals only.
100 92 80 61 Number 60 recruited 42 40 Last FY 40 22 20 0
Professional Category
Medical and Dental Allied Health Professionals Pharmacy Staff Nursing and Midwifery staff Support staff
Recruitment of Primary Health Care workers at the district was carried out towards the end of the financial year. UgShs. 4.5 Billion was allocated to cater for this recruitment of Health Workers to fill vacant positions at District level. The Ministry facilitated districts to utilize the funds. In consultations with the MoLG, Ministry of Health advertised the vacant posts as per the gaps of each district. The District Service Commissions carried out the interviews on the same day to avoid applicants moving from districts to district to sit for the same interviews and get offered a post in many districts. The data from the recruitment exercise has not been captured in the HRM inventory, because districts take long to make returns.
85 The recruitment target for the year was to increase the proportion of approved posts filled with qualified staff from 68% to 75%.
In order to address lack of attraction and retention of health staff in the hard to reach districts, the ministry wrote two proposals. One was submitted to the Global Fund–Geneva, and another one which was based on MOE&S Incentive Scheme Model was submitted to MOPS and MOFPED. It is hoped that Ministry of Public Service will approve the proposal.
Human Resources Tracking study was undertaken to establish the issues in training capacity, recruitment and deployment bottlenecks and wage bill as well as payroll management issues. A two days stakeholders’ meeting was held to discuss the report and the recommendations emanating from the study. Action has been taken on some of the recommendations while others are in the process of being operationalized
In an effort to increase of enrollment into ECN course and attract training near home districts for local deployment, infrastructure at Health Training Institutions has been expanded and entry qualifications were also lowered. The review of the ECN curriculum has started to accommodate the lowered entry qualifications.
Pre - Service Training
In collaboration with Mo`E&S entry qualifications for ECN were revised from 5 credits to 5 passes. This was done for equity reasons to bring districts that are weak in the teaching of science subjects in line with the rest of the country. All the four government supported schools are now enrolling ECN and have dropped EN/EM. In addition seven PNFP schools have taken on ECN. The PNFP schools have been encouraged to take on ECN training and drop EN/M when they acquire adequate funding, Tutors and infrastructure.
Government HTI have now been prioritized in the MOES MTEF and government funding for public HTI is expected to improve. However, the funding of PNFP HTI remains uncertain.
Studies to determine how PFNP health training institutions can be funded as well as determination of the cost of implementing field work in nursing schools were completed and results are being disseminated.
In-service Training
Ministry sponsored a total of 150 health workers to upgrade their skills through long course training. The beneficiaries comprised of doctors, nurses and hospital managers who were sponsored for training at diploma, and masters’ degree levels. Only one doctor was sponsored at super-specializing in cardiology. This was due to the gross under funding for in-service training budget.
Discussions are continuing between MOH, Training Institutions and Hospitals in an effort to streamline issues pertaining to health workers going for further studies e. g study leave, placement of salaries and disruption of service delivery while on training.
86
A total of 200 Theatre Assistants are being trained and retooling of 200 anaesthetic assistants has been planned in an effort to contribute to functionality of the Health Sub-District.
A comprehensive situation assessment on In-Service Training was performed. The findings are being disseminated. Next steps include an in depth analysis of the findings and subsequent drafting of an operational intervention plan.
Challenges Negative attitudes of leaders and managers in some districts towards health workers erode staff morale and the quality of Health Care that they provide to the population Conflicting roles in the structure. The restructuring of the entire Ministry of Health has never been completed. This has remained a sector problem leading to role conflict, unclear reporting relationships and mandates.
4.3 Health Infrastructure Development and Management
Health Infrastructure constitutes one of the key inputs for health service delivery and is comprised of buildings (both medical and non-medical), medical and hospital equipment, communication facilities (Radio calls, ITC) and ambulatory Services and other transportation facilities
The above health infrastructure components support the delivery of health services. Proper planning and maintenance of Health infrastructure is therefore necessary for efficient and effective delivery of health services.
Effective health service delivery therefore requires a network of functional health facilities. HSSP I aimed at improving accessibility from 49% (pre-HSSP) to 80% by 2005. As at end of HSSP I accessibility, measured by the percentage of the population living within 5 kilometres radius of a health facility, increased from the baseline value of 49% in 1999/00 to 72% in 2005. This coverage will however be updated when the mapping exercise is completed.
During the Financial Year 2004/05, the health sector achieved the following:
4.3.1 Policy Formulation and Development of Standards and Guidelines The health sector formulated and prepared/developed the policies and standards/guidelines: Prepared draft guidelines on health care waste handling and management Prepared the Standard drawings and specifications for incinerators for health care waste handling facilities Developed Solar Energy packages and technical specifications for HCII, III and IV Developed draft policy on Information Communication Technology
4.3.2 Construction/Rehabilitation of Selected Health Facilities The health sector has undertaken construction/rehabilitation of the following selected health facilities: Major rehabilitation of Butabika Hospital
87 Construction of six Mental Health units at Hoima, Arua, Fort Portal, Soroti, Gulu and Kabale Regional Referral Hospitals Partial rehabilitation of Fort Portal Regional Referral and Nakaseke, Abim and Kaabong General Hospitals is ongoing: Rehabilitation and Upgrading of the following Health centres: i. 32 Health Centres by the SHSSPP/ADB Project on-going ii. 27 Health Centres by the Kamuli-Kisoro Project completed iii. 34 Health Centres by the EU/MPP completed Completed the construction and Upgrading of Kamuli and Kisoro health units to Hospital Status Of the 151 health centres which had been proposed for upgrading to HC IV and hence the same number of operating theatres and doctors’ houses, construction of 118 operating theatres and 130 doctors’ houses have been completed. Construction of 56 incinerators, demontfort type, was completed, and construction of 2 incinerators at Mbarara and Masaka Regional Referral Hospitals started.
4.3.3 Procurement Supply and Maintenance of Equipment A number of equipments were procured, supplied or maintained all over the country: 6 X-ray and Ultra sound machines were procured and installed at Entebbe, Masaka, Kabale, Kawolo, Nakaseke & Mubende hospitals under ORET project. 11 HC IV theatres were equipped under ORET project bring total number of equipped theatres to 78 16 diesel generators were provided to the 10 HC IVs and 6 hospitals above Contract for supply of 20 multipurpose vehicle for HC IVs was signed 10 mobile HF radios were procured under SHSSPP/ADB 340 VHF radios were procured for Health Centres in Aura, Yumbe, Nebbi, Adjumani, Moyo, Soroti, Kaberamaido, Katakwi, Lira, Apac, & Kapchorwa districts. 10 Ambulances were procured by SHSSP/ADB 360 Sewing machines were procured for making bed nets under SHSSPP/ADB 11 Audio visual sets were procured under SHSSPP/ADB 1 staff Van was procured for Butabika Hospital under SHSSPP Regional Maintenance Workshops continued to carryout medical equipment maintenance in the hospitals and health centres
4.3.3 Installation of Energy Equipment in Health Centres The health sector commenced the implementation of developed standard energy packages at Kyamusisi HCIII and prepared tender documentation for Sigulu HCIII and HCs in Arua, Yumbe & Nebbi districts.
4.3.5 Capacity Building and technical support for Better Infrastructure Management The Division organized training for Health Facility Managers, DDHS, In-charges of HCIII and LCV Secretaries for Health in Energy efficiency and management. It also carried out support supervision as part of the Integrated Support Supervision and provided technical support and advice on various projects like SHSSPP, Lions Aid Norway, AMREF, UNEPI and UBTS. The Regional Maintenance Workshops Managers carried out User trainings.
88
4.4 Management of Medicines and Health Supplies
The HSSP I period (2000/01 – 2004/05) was characterized by encouraging developments in medicines financing, procurement, management and regulation. The National Pharmaceutical Policy frame work was reviewed. Specifically, the National Drug Policy (NDP) and the Uganda Clinical Guidelines were revised and a new bill to regulate the Pharmacy Profession and Pharmacy Practice was submitted to cabinet. The NDA increased its scope of operations, especially in conducting international and regional inspection of pharmaceutical industry and registration of products for the Ugandan market. Further support will be required if to NDA is to effectively regulate the internal marketing of pharmaceuticals and for surveillance on counterfeits. Medicines management was and remains the biggest challenge in the health sector, noting that inputs of medicines and health supplies are expected to represent 30% or more of the recurrent budget in the sector, and the sector is severely resource-constrained. A number of innovations were adopted during the HSSP I period to mitigate this situation and ensure efficiencies in use of available resources. The District Medicines Management Programme (DMMP) was established at the MoH headquarters, and focused on development and capacity building of the districts in various aspects of medicines management. In the last year of HSSP I, multidisciplinary Medicines and Therapeutics Committees were established (or revived) as a key strategy to improve medicines management at all levels of care, and taking into account the shortage of competently trained pharmaceutical cadres in the public health care delivery system. Through the Sector Wide Approach strategies (SWAPs), coordination of inputs from the development partners and some projects improved through integration of essential medicines and health supplies under the Push – Pull transition.
Findings of the several system studies of the public sector medicines management and distribution system (a situational analysis of medicines management in 2000 and the Push- Pull study of 2001, and the Drug Tracking Study in 2002) shaped the integrated pull system of procurement and distribution of supplies. Efficiency within the public sector improved after creation of a Credit Line (CL) for priority items financed through a dedicated Essential Medicines Account at central level, mobilizing a larger share of the available PAF budget and as well as project support earmarked for medicines (see also Health Financing Section – Key inputs: medicines and health supplies). Following the recommendations of the Joint Review of 2003, and a Technical Review of NMS in May 2004, additional financing was programmed for the NMS, including capitalization to enable scaling up of procurement of medicines and health supplies to service the CL and other cash procurements by the district health system. A number of challenges remain, and in particular increasing project financing of inputs through vertical arrangements under bilateral agreements and through global initiatives like the GFATM, STOP TB, GAVI etc. These arrangements are less within the control of the Ugandan health sector, and raise issues of predictability and more importantly sustainability, at a time when the newly established integrated systems are unable to deliver the core medicines and supplies to ensure a basic quality of services.
Availability of medicines
89 Availability of medicines is one of the national HSSP indicators. The indicator should report the percentage of health units without any stock-outs of HSSP indicator drugs. Unfortunately, due to limitations in HMIS reporting there were no reliable figures at the national level throughout HSSP I. To date, monthly HMIS reporting is of questionable value because the section of the form on “stock-outs” is often left blank by health units, and the reported figures grossly underestimate the real situation. Furthermore, for calculation of the HSSP indicator requires data on a stock-out of any of the basket of indicator drugs at a given health unit, (“zero tolerance for stock-out”) and this is lost once HMIS data are aggregated. The recently revised HMIS forms will correct these issues.
Table 4.xx: Stock-out of any HSSP indicator drug by level of health unit
Percentage of health units with a monthly stock-out of any HSSP indicator drug* Based on stock card review at 33-36 health units, average of 6 months (Q2 and Q4).
FY 04-05 FY 03-04 FY 02-03
Num of HU % HU Num of HU % HU Num of HU % HU All levels 33 65% 36 60% 36 67% HC II 10 69% 10 67% 10 70% HC III 14 79% 17 70% 17 75% HC IV 9 52% 9 35% 9 46% * 'Zero tolerance' indicator: the health unit was considered to have a stock-out if any one of the 6 HSSP drugs was out of stock in the month reviewed.
Table 4.xx: Stock-outs by HSSP indicator drug
Percentage of health units with a monthly stock-out of HSSP indicator drug Based on stock card review at 33-36 health units, average of 6 months (Q2 and Q4).
FY 04-05 FY 03-04 FY 02-03 Stock % HU Stock % HU Stock % HU card (n=33) card (n=36) card (n=36) months* months months 1 Chloroquine tab 189 21% 198 16% 198 13% 2 Sulfadoxine Pyrimethamine tab 189 17% 201 13% 193 28% 3 Cotrimoxazole 480mg tab 189 37% 201 35% 196 50% 4 Oral Rehydration Salts (sachet) 144 27% 134 20% 130 18% 5 Medroxyprogesterone inj ("Depo") 111 5% 106 17% 117 13% 6 Measles vaccine 171 5% 127 8% 167 5% Average of 6 HSSP indicator drugs 166 19% 161 18% 167 21% *Number of stock card months reviewed out of a maximum of 198 (33 health units X 6 months = 198). Less than 198 stock card months reported because health unit stock card often not available for review, or not updated. Data was about 84% complete (166/198) on average for 6 items.
Stock-outs have therefore been assessed through a series of annual surveys at a sample of facilities in six districts (see Tables 4.1 and 4.2). In FY 2004/05, 65% of health units
90 experienced a monthly stock-out of any HSSP indicator drug, on average. The situation has deteriorated since last year, particularly at the level of HC IV. Stock-outs of antimalarials and ORS are more prevalent than last year, but availability of the injectable contraceptive (“Depo”) has improved. Co-trimoxazole (an oral antibiotic) continues to have the highest HU stock-out rate at 37%, consistent with last year. On average for the 6 HSSP indicator drugs, a monthly stock-out was found at 19% of HUs. The same indicator calculated using national HMIS data (56 districts) was found to be only 6%, but the likely explanation for the difference is incompleteness of the HMIS data, mentioned earlier. However, it should be noted that the survey figures represent a “worst case estimate” because they measure stock- outs according to zero values on the store-room stock cards, while those medicines may continue to be available in treatment areas of the health unit for one week or more.
Shortfalls and failures on the part of the pharmaceutical manufacturers/suppliers of anti- malarials to NMS and others, in combination with uncertainties due to the proposed change of policy for malaria treatment may have affected access to anti-malarial medicines at national level towards the end of 2004. There was a stock out period and or under stocking of chloroquine and sulphadoxine + pyrimethamine (SP) for a period of close to six months at NMS, and limited supplies at JMS. The national supply of ORS has also been irregular due to over-reliance on a single local manufacturer having limited capacity.
Procurement practices and utilization of medicines funding
At the national level, the NMS and JMS remained the major supply agencies, mandated to maintain trading stocks for the sector through bulk procurement and supplying to the service delivery providers throughout HSSP I. Starting from 2003, the predominantly pull (order based) procurement was applied by districts and HSD for most of the key items. This facilitated improved understanding the priority needs of the various levels of care and appropriate planning. Health Sub Districts (HSD) have consolidated themselves as the procurement entities in most districts and managed procurements from the two national supply agencies on behalf of the lower level health units. However, there remain a number of challenges, often in districts that have not relinquished the procurement functions and budget management from DDHS to the HSD.
FY 2004/05 monitoring data show that districts and hospitals did not utilise their decentralised funds according to guidelines, spending only half their target/indicative budgets for medicines at NMS and JMS on average, compared with average 90% utilisation of earmarked credit lines. There is wide variation in performance on PHC expenditure on medicines among districts, with 10 districts utilizing 75% or more of their indicative budgets at NMS and JMS, and 9 districts spending 25% or less (Figure 1). Many of the high performers were able to attain 90% utilization of PHC funds at NMS/JMS, apparently overcoming constraints through good management and adaptive strategies. Notably Hoima and Mubende districts spent nearly all their funds at NMS.
Figure 1: High and low performers on utilization of the PHC medicines budget
91 YUMBE MOROTO LIRA Cash NMS Cash JMS KISORO PADER KAYUNGA ADJUMANI MUKONO KALANGALA
MUBENDE BUSIA HOIMA KATAKWI KYENJOJO RUKUNGIRI NEBBI KUMI KITGUM BUSHENYI
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 110% 120%
Spending in the private sector is not captured in the above data and not included in the league table on the assumption that justifiable spending in the private sector will be relatively equal among districts, and is expected to be no more than 5-10% overall. There are a few districts with known high proportion of purchases from private for-profit suppliers (e.g. Ntungamo). The recent area team monitoring visits aimed to assess the extent of private spending, identify preferred suppliers, and their performance as perceived by the districts. Based on 23 districts’ reports analysed by the time of publication, districts spent an average 15% of the indicative PHC medicines budget in the private for profit sector, with a skewed distribution ranging from zero percent in six districts to 67% in Ntungamo district.
Table 3: Expenditure against PHC medicines budget – district and central data
Percentage of PHC indicative medicines budget spent Total Total Data source NMS JMS PFP NMS+JMS NMS+JMS+PFP DISTRICTS 36% 33% 15% 69% 84% CENTRAL 27% 25% n/a 52% n/a
The expenditure at NMS and JMS as reported by the district is substantially higher than the “central figures” obtained directly from those supply agencies (Table 3). Central figures reflect the actual value of medicines issued to the district between 1st July 2004 and 30 June 2005. Districts have a tendency to record large amounts as expenditure in June, whereas these may be commitments to suppliers that may or may not be served in the early months of the new FY. The central figures include this type of “carry-over” expenditure from the previous FY, and systematically reports the value of medicines actually supplied during a 12
92 month period, and avoids double counting which is possible in the districts’ scheme of reporting.
Performance of National Medical Stores and Joint Medical Store
Figure 1 illustrates the rapid growth in sales at both the national supply agencies from FY 2002-03 onwards, corresponding with the growth in health sector budgets for service providers (see Health Financing section). The National Medical Stores (NMS) made a dramatic recovery in performance from a “low point” at the outset of HSSP I, following disbanding of NMS management consequent to exposed fraud, compounded temporary suspension of NMS’ mandate by the MoH Director General, allowing gov’t institutions to buy directly from the private sector. NMS performance and sales volumes were further boosted by the return of “guaranteed business” through the new credit line system, growing to over 11 billion by 2004/05. However, growth in NMS sales has stagnated because NMS is unable to procure sufficient stocks, and performance is hindered by a number of identified constraints identified by the Technical Review, including lack of financial capital, changing regulations for procurement and longer lead times under “PPDA”, and limited planning and management capacity. Service level (% of order value actually supplied) deteriorated to 50% by June 2005, compared with performance in the range of 66-75% during the period Jul- 2003 to Dec-2004.
Figure 2: Growth in annual sales at NMS and JMS
30 Annual 25 Sales (UGX billions) 20
15
10
5
0 2000/01 2001/02 2002/03 2003/03 2004/05 JMS 10.8 12.3 15.5 20 25.3 NMS 6.2 7.5 11.7 15.3 16.8
Figure 3: Joint Medical Store partnership role
93 6 5.9 JMS Sales 5.6 (UGX billions) 5.4 5 5.0 4.8
3.9 4 3.6 3.1 3.1 3 2.7 2.3 2.3 2
1 PNFP cash purchases Gov't cash purchases 0.4 0 PNFP credit line 2004/05 2002/03 2003/03 2000/01 2001/02
Over the HSSP I the Joint Medical Store (JMS) steadily responded to increasing demand for medicines and health supplies in the health sector in Uganda, and from international NGOs serving the region. JMS was a responsive partner in supply of medicines and health supplies through the credit line for PNFP health units, with sales climbing to 3 billion by FYE 2004/05 (see Figure 3). This joint MoH-JMS initiative promoted JMS services to PNFP lower level health units, a link that was broken when uptake of essential drug kits declined after introduction of cost recovery. JMS has for many years been the major supplier to government health facilities in the area of medical equipment and instruments. Figure 2 illustrates that routine cash purchases of medicines and health supplies by gov’t institutions has grown faster than the JMS core customers, the accredited PNFP units under UCMB and UPMB. This is a consequence of the notable gap in NMS service level in the past year. Overall, JMS has been impressive in managing change, and sustaining growth of a well diversified customer base (see Figure 4) fully using its own resources, and the flexibility in financial and procurement procedures of a PNFP institution. Not least, organizational change in these few years was supported by the JMS Board’s recruitment of an experienced and accomplished executive head, providing strategic direction and leadership, and successfully mentoring the existing JMS management to the point where executive powers were handed over. Continuing challenges facing JMS include the need to facilitate a delivery service for rural health facilities and improvements in computerized management information systems and reporting on key indicators such as service level.
NMS has taken strategic steps in response to opportunities presented by growth in Third Party supply. However, the Technical Review (May 2004) pointed out that NMS is in fact subsidizing third parties by charging fees based on “marginal cost” for distribution of their supplies. Whereas NMS stock-holding of third party items ranged from 4.0 to 5.5 billion UGX in the early years of HSSP I, the introduction and scaling up of in-kind donations and products owned by projects and programmes (e.g. HIV test-kits, ARVs, Homapak) raised
94 stock-holding to 17.2 billion by June 2005 (Table 3). In this new context, third party fees should arguably cover the larger share of NMS overhead costs. This is a critical issue for NMS financial viability. By contrast NMS’ own trading stock, valued at 5.9 billion in June 2005, has not grown proportionately to sales. NMS therefore turns their stock over more than three times in the year, and though this is efficient use of limited financial capital, it has now become a major obstacle to meeting the demands and requirements of its customers.
Table 4: Comparison of NMS trading stock and third party supplies
2000/01 2001/02 2002/03 2003/03 2004/05
NMS own trading stocks (year end, UGX bil) 3.6 4.1 4.7 5.9 4.9 NMS sales (UGX bil) 6.2 7.5 11.7 15.3 16.8 Ratio - NMS sales : trading stock 1.7 1.8 2.5 2.6 3.4
Third party stocks (year end, UGX bil) 5.6 4.3 3.9 7.9 17.2 Third party sales (UGX bil) 8.7 14.2 Ratio - Third party sales : stock 1.1 0.8
Source: Figures submitted by NMS, 2005
Achievements of the MoH Pharmacy Section – FY 2004/05
The MoH Pharmacy Section has yet to be upgraded, though it is now 4-5 years since the JRM proposal. This limits the MoH role and pace for harmonization of systems for medicines supply. MoH has assured a minimum level of functionality through temporary arrangements such as secondment of two pharmacists from regional referral hospitals, and TA support. During the past year the key achievements of the team included:
Capacity for training health workers and provision of technical support for medicines management at the districts was built using a regional team of pharmaceutical resource persons. Quantification tools developed in the previous year were applied in a further sample of districts and piloted at a hospital level. Advocacy and support for the formation of Medicines and Therapeutics committees (MTC) at HSD, hospital and in some cases district level. Where MTC were timely established, they have served as vehicles for improving bottom up management of medicines, other health supplies and logistics and motivated interactive feed back within the system. A total of XX MTCs were trained from both HSD and hospitals to consolidate their work from the previous advocacy and orientation meetings. An additional 15,000 USCG were printed and distributed to supplement the previous round of distribution, last year. Regular technical meetings with NMS were held as part of the MoH responsibilities for monitoring and management of the credit lines. The NMS technical review recommendations are in the process of implementation following the commitment (since April 2005) of Danida funds for capitalisation (US$ 2.1 million disbursed and a
95 further $ 1.2 million planned), and for new equipment, rehabilitation and constructions of additional 2000 square meters of space for storage (about US$ 1.8 million planned). Support for human resource development in accordance with the National Pharmaceutical Sector Strategic Plan (NPSSP) was agreed through Danida HSPS Phase III support to build a new school of pharmacy and additional capacity building for trainers of pharmacy cadre ($ 2 million total). A Memorandum of Understanding was signed by MoES and Makerere University, and a steering group established for the project. Supported both local and international training of health workers in Appropriate Medicines Use. Over all 110 health workers were trained in this area.
4.5 Blood Transfusion Services
During FY 2004/05, the total number of units of blood collected was 112,250. This was an increase of 10% over the last Financial Year’s collection but below the 20% set target for increase. 98.3% of the blood was collected from voluntary non-remunerated blood donors.
In order to cope with the increased need for blood due to new Health Centre IVs, blood collection centers were set up at Lira, Soroti, Fort Portal and Kabale. Staff for these centers was appointed but could not start because of lack of vehicles. All blood collected was tested for HIV antibodies, Hepatitis B Surface antigen and Syphilis. HIV sero-prevalence in the collected blood was 1.69%; this is a significant success given that HIV sero-prevalence in the general public is 6-7%. Seroprevalence for Hepatitis Bsag, however, is still higher (5.48%) than the set target of 5.0%. This is due to very high prevalence rates from Mbale, Arua and Gulu. Syphilis was tested in all blood units.
The interim Board of Directors of UBTS approved the establishment for UBTS. The Ministry of Health has submitted this establishment to the Ministry of Public Service for approval. Key staff appointed include: the Manager for Finance and Administration and the Blood Donor Coordinator (Blood Services Manager). An Acting Quality Officer has also been appointed. Work on formation of relevant Human Resource policies is expected to start in the first quarter of 2005/2006.
Capacity building for UBTS staff in various courses has been undertaken. These include 11 blood donor recruitment officers, 135 hospital blood bank laboratory technicians and 241 clinical officers.
UBTS continued to receive funding from 2 sources i.e. Government of Uganda and CDC (Atlanta) under PEPFAR support. No funds were received from the EU as had been expected.
UBTS experienced a lot of constraints in the area of blood collection due to shortage of blood bags during the period October to December 2004. Shortage of vehicles for blood collection also contributed to the collection of less blood than was anticipated for the whole
96 Financial Year as some of blood collection teams were unable to travel to blood donation sites. 4.6 Information for Decision Making i) The Health Management Information System
Health information both as an input and output of a health system provides important management tools for directing the critical interventions in the health system. The HMIS has continued to provide the bulk of data for monitoring the health sector and for AHSPR for the entire HSSPI period. With the achievement of HSSP I targets for timeliness and completeness of reporting, the focus of HMIS during the year has expanded to include data utilisation at all levels of the health systems in addition to data collection.
The progress made in HMIS activities over the HSSP I period includes:
Policy Baseline survey to inform the health sector ICT policy was conducted and the ICT policy draft developed and presented to MoH,
Guidelines HMIS tools were revised to provide appropriate data for HSSP II. This was a rigorous and meticulous activity involving participation of all HMIS stakeholders in MoH and beyond. The outputs of the exercise included revised and updated Health Unit/HSD/District Manual, revised & updated Health Unit/HSD/District databases and national manual and database. Indicator guidelines however still require updating in view of HSSP II. Standard HMIS software for the National and District levels was developed by RC staff and is being piloted in some districts before national roll out. A Master Facility List was also developed and can be found on the MoH website. It contains a code of all facilities in districts and will be regularly updated by districts under co-ordination of the RC. This means that all users can access the same list of facilities and datasets can be shared
Training and capacity building The Databank was re-equipped with new computers for data management and an equipped Computer Training Centre was established at MoH library. The Wide Area Network (WAN) was established for UNEPI and Wabigalo.
Monitoring the health sector HMIS has continued to provide data to monitor programme performance periodically, and for weekly epidemiologic surveillance. However, there is more need for programmes to seek and utilise data. Monthly feedback to districts has also been provided.
Success Timeliness of reporting by districts steadily improved throughout the HSSPI period from a baseline of 15.6% in 2000 to the present 85% in 2005. Completeness of districts reporting to national has also improved. For HSSP II, RC will focus on completeness in terms of filling all data elements on reporting forms.
97 ii) Integrated Disease Surveillance and Response
In 1998, Uganda together with other member countries within the World Health Organisation (WHO) Regional Bloc for Africa, adopted integrated disease surveillance and Response (IDSR) as the strategy for multi-disease. The disease priority list for Uganda is categorized into: - Diseases with epidemic potential - Diseases for elimination/eradication, and - Other diseases of significant public health importance.
In Uganda’s integrated disease surveillance strategy, several activities from different technical programs are coordinated by a single focal point in order to make best use of limited resources. The activities are combined so as to take advantage of similar surveillance functions, skills, resources, and target population. In the IDSR strategy, coordination and integration of surveillance activities is conducted for diseases of national and international public health importance. The main objectives of the programme as stipulated in HSSP 1 were prevention, early detection and prompt response to health emergencies and other diseases of public health importance.
The National targets for the programme by the end of the HSSP 1 plan period were a functional integrated disease surveillance system in place and response to all confirmed epidemics within 24-48 hours. Box 4 summarises the key achievements of IDSR during HSSP I.
Box 4.xx: Key Achievements: FY 2004/05 and over the entire HSSP I
The epidemiological surveillance division has been strengthened for rapid transmission of information for appropriate action through increased coverage of the radio
communication network for district to national and for HSD to district communication An early warning system based on 24-48 hourly reporting for notifiable diseases and
weekly reporting for priority diseases has been established. The early warning system has led to an improvement in the timeliness; completeness and prompt response to all suspected outbreaks/epidemics. Relevant tools for IDSR have been reviewed, harmonized and disseminated such as:
suspected outbreak log books, standard case definitions and action thresholds for priority diseases and reporting tools. Laboratory capacity to confirm priority diseases in peripheral health units has been strengthened and laboratory networks for specimens’ referral are being developed
based on existing national referral zones. Capacity for regular feedback and dissemination of information on priority diseases has been strengthened through provision of generic guidelines for feedback and sensitizing health workers to manage and utilize data for decision-making.
Personnel at district and health sub-district (HSD) levels have been specifically targeted for in-service training using the adapted IDSR modular training. The existence of a rapid response teams (RRTS) at national level ensures that a team of
experts quickly investigate and respond to outbreaks in the districts. Similarly, the RRTs at district and health sub-district levels are the first line multi disciplinary team to verify suspected outbreaks The use of the Masters of Public Health98 students from the Makerere University, Institute of Public Health ensures that capacity is built for future health managers. There has been a general decrease in the case fatality ratio (CFR) and attack rate (AR) for most of the epidemic prone diseases.
Progress in IDSR implementation The implementation of IDSR in Uganda has followed the step-wise approach recommended by the World Health Organization, African Region (WHO/AFRO), commencing with sensitization of key stakeholders in the health sector; conducting a situation analysis of the national surveillance, epidemic preparedness and response systems, setting priorities and preparation of a five-year strategic Plan, which was then incorporated in the overall HSSP 1. The five-year IDSR Strategic Plan has been the basis for the preparation of the annual IDSR work plans and for preparation of proposals for supplementary resource mobilization.
Inputs for IDSR Financial resources: There has been a gradual reduction in budgetary allocation to the implementation of IDSR activities. To narrow the resource gaps in the Government of Uganda budget, ESD developed proposals to mobilize additional resources to enable the implementation of critical activities. In addition, the WHO country office provided financial support for the implementation of a range of IDSR activities.
Equipment and Materials: The Division was equipped with 5 new vehicles in the HSSP1 period, which have greatly facilitated implementation of IDSR activities. In addition, data management hardware and software and other materials have been provided to the program over the HSSP 1period to improve data management.
IDSR implementation process Coordination of surveillance activities IDSR implementation in Uganda has achieved remarkable progress since the year 2000/2001. At the central level the involvement of key programs and development partners is evident. There is an established linkage with districts and HSDs which are the operational areas. There is a formal coordination body in the Ministry of Health comprising of program managers, public health training institutions, development partners and other stakeholders in the health sector. The committee meets monthly to determine priorities, assess data requirements and provide guidance on data use at different levels.
Integration of surveillance activities Most of the programs have witnessed substantial integration of surveillance activities since the inception of the IDSR strategy in the year 2000/01. At the district, HSD and health facility level, the degree of integration of surveillance activities is very good and well appreciated, and there is a designated multi disease surveillance focal person to oversee the implementation of activities.
Training on IDSR At national level, several officers have had additional training in epidemiology and data management, and therefore have the capacity to manage disease surveillance and conduct
99 outbreak investigation and response. At district and HSD level, modular training based on the adapted IDSR Training Modules has been conducted. The latter training, which is ongoing, targets the DHT, health sub-district teams, and health unit in-charges and records officers. To-date 320 health personnel from 20 out of the old 56 districts have attended the modular training program. Central Public Health Laboratories and Uganda Virus Research Institute The Central Public Health Laboratories and Uganda Virus Research Institute have established the capacity to confirm all the priority diseases except Viral Haemorrhagic Fevers (VHF). These units presently have capacity to collect, preserve and store stool, blood, serum and cerebral spinal fluid (CSF) including VHF specimens. The specimen referral process is now fully established in 4 of 11 regions (Mbale, Mbarara and Arua), with the CPHL serving the central region. These regional laboratories have been equipped with reagents and transport media. In addition, CPHL has trained a total of 51 laboratory personnel in 2 out of the 3 regions. Another 5 laboratory data managers were trained in laboratory data management and have been provided with computers for analysis of laboratory data.
IDSR Outputs and Outcomes There have been several tangible outputs and outcomes. Despite the shortcomings due to dwindling resources, the IDSR core indicators have been used to measure the progress of implementation at national level and this has commenced at district level as well (Table 3). There has been a general decrease in the case fatality ratio (CFR) and attack rate (AR) for most of the epidemic prone diseases. The latter is attributed to the strengthening of IDSR implementation.
Table 4.xx: Trends in key IDSR performance indicators at National level Indicator Baseline 2001/02 2002/03 2003/04 2004/05 (Target) Completeness of monthly 52 % 72% 92% 97% 90 % (current reporting 100%) Completeness of Weekly 49 % 67% 92% 97% 90 % (current reporting 97 %) Timeliness of Monthly 51% 59% 79% 89 % 80 % reporting Timeliness of Weekly reporting 49 % 92% 94% 96 % 80 %
Attack rate per 100,000 56 27 63 36.1 50 population in affected districts (Cholera) Attack rate per 100,000 4.5 9.1 8.8 6.4 <5 population in affected districts (Meningitis) Case fatality ratio (CFR) for 6.8 % 5.6 2.9 % 2.4 % <1 Cholera Case fatality ratio (CFR) for 16.3 % 16.1 % 13.5 % 16.5 <10 Meningitis
100 Case fatality ratio (CFR) for 2.2 % 1.8 % 2.1 % 0.2 % 0 measles
Challenges Despite these successes, major challenges at national level include ensuring regular validation of the data, identifying innovative approaches to synthesize and analyze all health information system (HIS) data. At district and HSD level the main challenges are limited monitoring of IDSR performance, untimely outbreak investigation and response, inadequate utilization of the outbreak logs and inadequate preparedness.
4.7 Health Research and Development
4.7.1 Uganda National Health Research Organisation (UNHRO)
Achievements UNHRO bill 2005 has been introduced to Parliament by the minister of Health Production of the Health Research Policy Review of Health Research Priorities Development of National Health Research Strategic Plan 2005-2010 Production of UNHRO Newsletter-Biannual Two Research groups in Uganda were selected by the African Health Research Forum (AfHRF) leadership training. Participated in the development of the East African Integrated Disease Surveillance Network (EAIDSNet) now under the East African Community. Participated in the development of Regional East African Community Health-Policy initiative (REACH-Policy Initiative)
Constraints Slow Progress in the development of UNHRO Bill
4.7.2 Uganda Virus Research Institute (UVRI)
Achievements Contributed research information necessary for the understanding and prevention of diseases of viral etiology as well as other diseases of public health importance such as malaria, schistosomiasis, plague etc.
During the FY 2004/05 the institute conducted field and laboratory research on Viral Heamorrhagic Fever(VHF) studies and was also involved in epidemic investigations of suspected haemorrhagic fever outbreaks and arboviral diseases.
The UVRI carried out border surveillance and preparedness for any suspected cases of VHF in the border districts of Gulu, Moyo, Arua and Pader when an outbreak of Ebola Virus Heamorrhagic fever (VHF) occurred in Yambio, Western Equotoria and South Sudan.
101
In Zoology research, UVRI carried out trials of alternative treatment for naturally occurring human plague in West Nile region.
Concerning the Ecology of dogs and rabies (Ecological research) a study on rabies virus risk showed that there is a cultural role of some dog owners who do not take them for vaccination.
4.7.3 Uganda National Chemotherapeutics Research Laboratory (UNCRL)
Chemotherapeutic Research Laboratory has been responsible for standardisation of Herbal Therapies, ensuring availability of Biodiversity and development of related policies.
Achievements Herbal fingerprint profile of “Ekere” a herb from Karamoja used in human reproductive health has been done. Nine medicinal plants identified, three herbal formulas (immunobooster, Malaria and Sickle cell anaemia) standardised Formulations based on finger millet and Moringa leaf powders for improved nutrition by women groups in Ireda, Lira and Luweero. Brochure on traditional use of herbal medicines/foods used in diabetes One herbal antimalarial product under development Operationalisation of community centres for traditional medicine, e.g. Kawete in Iganga District Institutional infrastructure and technical capacity of NCRL has been boosted Students on training have acquired various skills including laboratory extraction, and screening of herbal medicines Draft guideline for registration of herbal medicines Four centres visited and assessed Nakaseke, Iganga, Apac, Bushenyi Healers of Luweero district trained in cultivation of four different medicinal plants
Constraints Inadequate and expensive chemicals for fingerprinting
4.8 Legal and regulatory framework.
4.8.1 Professional Councils a) Pharmacy Council
The goals of the Pharmacy Council is to promote good health by enforcing Pharmacy Practice Standards and Ethics in both the Public and Private Sectors, Regulating the training of pharmacy cadres, and Controlling the Conduct/Discipline of Registered Pharmacists.
102 The following was achieved during the year 2004/05:
Policy, Guidelines and Standards Guidelines & Standards for pharmaceutical practice were developed and 1500 copies printed and disseminated. Draft Bill was approved by cabinet and submitted to Parliament for enactment. Byelaws were developed and approved by PSU general assembly and in use The Internship manual was developed
Capacity Building A curriculum developed with collaboration with the School of Pharmacy Makerere
Communication sensitisation Quarterly Pharmaceutical Journal was produced, conducted radio spots and talk shows on radios, and trained drug shop operators in 25 districts
Supervision, Monitoring and Evaluation Conducted enforcement visits to private and public pharmacy practice units in 20 districts and carried out prompt investigations into reported disciplinary cases and appropriate disciplinary measures taken
Registration and Deregistration of Pharmacists Registered 65 newly qualified Pharmacists and Pharmacy Practices Premises. Two pharmacists were deregistered.
Regulation of training of pharmacy staff Provided technical advice to Makerere and Mbarara University pharmacy schools and Mulago School of Dispensing
Constraints There were delays in enacting the Pharmacy Profession and Pharmacy Practice Bill, 2005 and also experienced inadequate Financial, Human and Material resources to enforce standards country wide
4.8.2 Uganda National Drug Authority
The key role of NDA is to promote the health of the population of Uganda through use of safe, efficacious and good quality medicines and also protect them against the use and effects of poor quality, fake, expired and otherwise unacceptable medical items (both human and veterinary pharmaceuticals), irrational use of drugs and unscrupulous, unethical promotion of medical items including herbal drugs.
In fulfillment of its mandates, NDA carried out the following during the year 2004/05:
Registration of human and veterinary medicines
103 a) A total of 414 new applications (400 human, 15 veterinary) were processed in the year. The number of pharmaceutical products on the current register is 2549 human and 356 veterinary products. b) A number of applications for herbal medicines from foreign manufacturers have undergone preliminary evaluation and 60 herbal products have been place on a provisional list of notified products. c) A number of applications for food/nutritional supplements (Nutriceuticals) from foreign manufacturers have undergone preliminary evaluation and 280 products have been placed on a provisional list of notified Nutriceutical products.
Quality Control and Assurance of medicines a) The National Drug Quality Control Laboratory (NDQCL) tested 1064 samples of drugs. 50 batches failed the tests and were either destroyed locally or re-exported. b) 610 batches of antimalarial drugs were tested and 4.1% (25 batches) failed the tests and were either destroyed locally or re-exported. c) A policy of mandatory post shipment analysis of antiretroviral drugs was introduced and 257 samples were analyzed and only 2 failed and were either destroyed locally or re- exported. d) A policy on mandatory post shipment analysis of all condoms was introduced but due to lack of local capacity, NDA uses foreign laboratories selected using PPDA guidelines. 401 batches of condoms have so far been analyzed and 32.4% (130 batches) have failed (many of them failing the smell test) and either been destroyed locally or re-exported. The process of purchasing condom testing equipment for NDA using World Bank funds is in advanced stages.
Inspection local and foreign manufacturers of medicines a) Six (8) local factories (4 large scale and 4 small scale) were audited for current Good Manufacturing Practice (cGMP) and licensed. b) 112 foreign factories in Africa, Asia and Europe were inspected and audited for cGMP compliance, out of which 72 were found compliant, 30 non-compliant and the reports of the others await discussion. Products of non-compliant factories were removed from the register.
Inspection and licensing drug outlets a) A policy and guidelines to facilitate equitable distribution of drug outlets was developed and published. b) 3273 drug shops and 261 pharmacies were inspected and licensed. They are distributed as follows: Table 4.xx: Category Central Eastern Northern Western Drug shops 1673 583 393 624 Pharmacies 213 9 6 33
104 c) 5 Regional Offices have been established in Mbarara, Lira, Tororo, Jinja and Kampala. Plans to open others in Arua and Hoima are underway.
Control of Importation of human and veterinary medicines a) 94 imports licenses and 4328 verification certificates were issued to importers of human and veterinary medicines and related items. b) 2163 consignments were inspected at official ports of entry in Nakawa, Entebbe airport, Malaba and Busia, of which 94% passed inspection.
Detection and removal of unauthorised drugs from the market a) There were 33 consignments of expired/substandard/unauthorised drugs detected and removed from the market. Of these, 24 were destroyed locally and 9 re-exported. b) 21 consignments of drugs queried at the port of entry were released after laboratory analysis showed that they were of good quality.
Pharmacovigilance and Provision of Drug information a) District Health Teams (DHTs), LC III & V councilors, drug shop operators and health workers from 18 districts were sensitized on pharmacovigilance and effective drug regulation measures b) Radio and TV programmes on appropriate use of drugs were aired on 12 radio stations and 2 TV stations. c) 32 advertisements for drugs were screened and approved. d) The NDA web-site (www.nda.or.ug) has continued to be maintained and updated to provide our clients with guidelines and information about NDA activities.
Strategic plan and Corporate Governance a) A workshop on corporate governance was held for the Board Members and Management of NDA. b) The Public Procurement and Disposal system continues to work efficiently with regular meetings of the Contracts Committee and regular reports to the PPDA.
Financing NDA activities a) The income of NDA in the past financial year has been as follows: Table 4.xx: Source Budget UgShs Actual (June 2005) NDA Income 4,121,478,000 5,410,636,194 GoU *71,000,000 Nil HSPS 375,000,000 345,347,457 Other Sources - 12,513,467 Total 4,567,478,000 5,768,497,118 *This was the figure approved following a budgeted request of approximately 1.4 billion shillings
105 b) The expenditure of NDA in the past financial year was as follows:
Table 4.xx: Type Approved Budget Actual (June 2005) Recurrent 4,399,687,167 5,065,708,258 Capital 926,790,000 546,930,026 Total *5,326,477,167 5,612,638,284 The budgeted expenditure included a deficit as a result of a shortfall from amount expected from G.O.U. c) NDA has revised its fees to ensure that all clients, including Government Departments, who receive their services, pay for them. The Government Departments are expected to budget for these fees.
Constraints/problems of financing a) The dual allegiance of the District Assistant Drug Inspectors (DADIs) both to the district and NDA does not augur well for efficient and effective drug regulation in the districts. NDA proposed either to directly recruit the DADIs or a phased introduction of NDA recruited zonal drug inspectors (total 21 Zonal inspectors), but due to budgetary constraints, this has not been carried out. b) Although NDA has obtained the land for constructing a national incinerator, there is no money to carry out an environmental impact assessment (EIA), purchase the incinerator equipment and construct the necessary storage and administration facilities. c) There is inadequate space for office, laboratories and storage of confiscated drugs, registration dossiers and samples. d) Some departments are under staffed and efforts to recruit have not been successful due to non-competitive terms of employment.
106 Chapter 5 Monitoring Implementation of HSSP I: Trends and Highlights 5.1 Monitoring the performance of HSSP I
Health Sector Strategic Plan I was implemented through the Sector - Wide Approaches (SWAps) in which all health sector stakeholders agreed to work through common working arrangements to support the plan implementation. The SWAps partnership has grown over the years and its implementing structures are functioning effectively. National ownership and leadership is now well established with increasing readiness of Government to shoulder responsibilities that go with this. Partners on the hand have continued to show trust and understanding and appreciate the progress being made.
The health SWAp has resulted in a modest growth in the health resource envelope (both Government and external sources), as well as an important shift in the pattern of financing the sector, with an increasing proportion of external funding being in the form of budget support. .The budgeting process became more consultative and transparent. The health sector budget has been redistributed in favour of the District Primary Health care. The proportion of health budget allocated to districts increased from 32% in 1999/2000 to 68% in 2004/05. This prioritization was to increase access to the Minimum Health Care Package at the health facilities. User-charges were abolished in 2001 in all government health facilities except for private wings in hospitals to further increase access of the poor population to basic health services. Deliberate efforts were made to make available essential health system inputs, especially drugs, vaccines, human resources, medical equipment and health infrastructure. As a consequence, the sector has registered increased availability of essential medicines, increased access to health facilities and deployment of additional trained staff and improved sector performance in key indicators.
During the HSSP I period, the health sector further decentralised the delivery and routine management of health services from the district to the Health Sub-District level. Each Health Sub-District was mandated to have a hospital or an upgraded Health Centre type IV as its headquarters (Referral Facility). The HSD Referral Facility is either a public or Private not for Profit (PNFP), signifying the maturing public private partnership in health policy. As the hospitals were already established structures in the health system hence already appropriate and equipped to function as HSD Referral Facilities, HSSP I prioritised the upgrading and functionalisation of HC IVs so as to fully operationalise the HSD strategy. The functionality of HC IVs is discussed in detail in section 5.3.
The insecurity in Northern Region of the country persisted and continued during the entire period of HSSP I. This has led to far reaching and detrimental effects on the health of the people in the region. The health situation in Northen Uganda is discussed in more detail in section 5.3. 5.2 Monitoring GoU/DPs Memorandum of Understanding
107 The principles of SWAps arrangements were set out in an agreement, the Memorandum of Understanding (MoU), between development partners and the Government of Uganda. After five years of implementation of the MoU along with HSSP I, it is important to take stock what was achieved under the first MoU. The process of reviewing what was achieved under the first MoU began with the harmonization workshops which were held independently by both parties in 2005 with the aim of streamlining the cooperation between development partners and Ministry of Health. The experiences were compiled into a common Joint Action Plan for Alignment and Harmonization. The materials from the workshops and the experiences of those who have been able to follow the SWAp processes from the beginning till the end of HSSP1 implementation allow a monitoring of how the MoU has functioned.
The guiding principle of the MoU was that the partnership between donors and government should be led by the national authorities – a principle often described as “national ownership”. Both development partners and the MoH recognize that the cooperation during HSSP1 has managed to uphold this principle. When problems in this area have arisen, they have originated in short term capacity problems within the Ministry of Health.
A second principle has been that of financing obligations of the government and partners. Government had undertaken in the MoU to “endeavour to ensure that all resources for the Health Sector Strategic Plan are reflected in the resource envelope and the Medium and Long Term Expenditure Frameworks”. Similarly government is obliged to ensure “that the proportion of the overall Government budgetary allocation to the health sector increases annually in real terms over the five-year period of the Health Sector Strategic Plan”.
As observed on several occasions, the financial obligations of Government have not been met. Proportion increases in the budget allocations to the health sector have not taken place every year. More strikingly, the resources set aside for the health budget have been far below those needed for the full implementation of the strategy. The trends in the budget allocations for both GoU and Donor Projects are contained in the Health Financing Section
Obligations of development partners were outlined to ensure, that resources for budget support and projects were timely and that pledged funds were made available for government in their announced format. The Budget Performance Report of the Government of Uganda for the FY 2004/05 makes clear, that this has not always been the case.
A third principle has been that of developments partners predominantly using government structures and processes. Some partners from the very beginning made it clear, that institutional obstacles exist for them to fully comply with this principle. Even those partners that have failed to make such reservations seem to be slow to live up to the expectations of the third principle. A heavy burden rests on the Ministry of Health for addressing demands for separate consultations, monitoring missions and similar tasks. In some areas, such as procurement, this problem has been particularly obvious. The underlying dilemma seems to be the slow coming of trust in government processes as well as a tradition among development partners of building planning processes and monitoring processes for the benefit of headquarters to feed into national planning processes of donors.
108 The MoU makes clear that Budget support is the favored alternatives for economic support to the HSSP I Implementation. During the first 3 years of HSSP 1, a clear development in line with agreed policy was visible. The later 2 years, show an impact of new financing mechanisms – such as the Global Fund, GAVI and the Presidential Initiatives against AIDS (PEPFAR) – creating a return to an earlier financial architecture dominated by projects. While thus mobilizing otherwise hard to get economic resources very effectively, the Global Health Initiatives have eroded some of the main principles of the MoU – lower transaction costs, clear national ownership, capacity building through use of established government structures and processes and sustainability. The importance of the work guided by the MoU has thus become less prominent.
A particular importance should be attributed to the role of project oriented Global Health Initiatives in the context of the macroeconomic policies of Uganda. Increased resources for the health sector by means of project support can cause a crowding out phenomenon whereby budget support originally intended for the health sector is replaced and resources used in other sectors instead. The discussion around this question is often found under the headline of “additionality”.
The structures established for an open and transparent form of co-operation and consultation in the implementation of the strategic plan – the Health Policy Advisory Committee, the Joint Review Mission and its working groups have in general functioned well with a high level of activity. An exception to the rule is the Health Sector Working Group, established during the course of HSSP I implementation, that has suffered from capacity problems and difficulties in finding a workable format. In the period of HSSP1 implementation, a broadened forum for discussions has emerged in line with the MoU – the National Health Assembly (NHA). The NHA has brought stakeholders outside the immediate vicinity of donors and government into the health debate and contributed to a broader understanding of the issues.
In sum – the result of five years of MoU implementation makes clear that the high ambitions of the first MoU, will need considerable effort for realization in the second phase of the Uganda’s Health sector Strategic Plan. The Joint Action Plan adopted by the HPAC and now presented to the 2005 JRM, is a first important step in that direction. 5.3 Health Centre IV functionality
One of the key innovations introduced during HSSP I to improve access to the basic health services by the population was the upgrading of some health centres to Health Centre IV status. This involved construction and equipping of operating theatres, construction of doctors’ houses, posting a resident medical officer and other core staff. The operating theatre is for providing emergency surgical services especially those related to pregnancy and childbirth, acute life-threatening illness and accidents. In addition to providing emergency surgical services, HC IVs (or an existing hospital) were expected to manage referred cases, provide in-patient care, and support the management and delivery of health services in the lower level health units within the HSD. 150 health centres were proposed for upgrading to HC IV status, hence the same number of operating theatres and doctors’ houses to be constructed.
109
As at 30th June 2005, construction of 118 operating theatres and 130 doctors’ houses were completed, 78 theatres were equipped and 134 HC IVs were provided with a multi-purpose vehicle. Many of the HC IVs were staffed with Medical officers and all of them receiving operational budgets. The level of functionality of the HC IVs however varies considerably from district to district.
In this year’s performance report therefore the functionality of HC IVs is highlighted. A special exercise to assess the level of functionality of HC IVs was carried out on Shuuku, Nsiika, Lugazi, Kyabugimbi, Kabwohe and Mitooma HC IVs in Bushenyi District, Atitir, Serere and Apapai HC IVs in Soroti District, Bwijanga and Bulisa HC IVs in Masindi District, Ndegeya and Namayamba HC Ivs in Wakiso District and Busia and Masafu HC IVs in Busia District. The specific objectives of the exercise were to: Assess the level of functionality of HC IVs in those districts, Describe the process the districts went through to operationalise the HC IVs, Document best practices, if any, which could be promoted in other districts. Identify problems affecting the functionality of HC IVs.
Level of functionality of HC IVs Functionality of HC IVs was assessed by the ability of the HC IV to perform or carry out the following 7 critical services; major surgical operations (including caesarean sections), blood transfusion, in-patient, maternity (deliveries at the centre), laboratory services, dental services and ambulance services.
Table --- shows of the level of services provided by HC IVs Service No. of HC IV % of HC IV providing providing the service the service Major surgery 5 33% Blood transfusion 4 27% In-patient 15 100% Maternity 15 100% Laboratories 13 87% Dental services 3 20% Ambulance 15 100%
Maternity, in-patient and ambulance services were provided by all the HC IVs visited. Dental services were the least offered services, followed by blood transfusion and major surgical operation. All HC IVs without dental equipment don’t have Dental Assistants to provide the services.
Figure ---- shows the services provided by each of the HC IV visited.
110 Serices offered per health center
7
6
5 Dental
ambulance
4 blood transifusion inpatient 3 Lab No.of services offered theatre 2 fuctional
1
0
I U E IR K IKA H PA YE IMBI O OMA IR LISA G UU G T ANGA U E BUSIA SAFU H NSI U W O A B D A LUGAZI B T SERERE APA IJ S B W N M KA MI B KYA NAMAYUMBA HC IVs
The range of services provided varied among the HC IVs visited. Masafu HC IV in Busia District was the only unit providing all the services assessed, followed by Mitooma, Kabwohe and Lugazi HC IVs all in Bushenyi District. HC IVs in Soroti were providing the least variety of services.
Analysis of the performance of the operating theatre showed the following: Only 4 HC IVs (Mitooma in Bushenyi, Serere in Soroti, Ndegeye in Wakiso and Masafu in Busia) are providing blood transfusion.
Only 4 HC IVs (Lugazi, Mitooma, Serere and Masafu) were performing major operations in the ranges of 25 – 45 operations per year. Only 4 HC IVs (Lugazi, Mitooma, Nsiika and Masafu) were providing caesarean section operations. Mitooma HC IV had the highest number of c/s of 35 in one year and Nsiika had the least of 1 c/s.
Only 5 HC IVs (Nsiika, Lugazi, Mitooma (all in Bushenyi), Serere and Masafu) were performing minor operations. Mitooma HC IV had the highest number (90 minor operations) and Nsiika had the least number (15 minor operations in a year).
9 HC IVs (Shuuku, Kyabugimbi, Kabwohe (Bushenyi), Apapai, (Soroti) Bwijanga, Buliisa (Masindi), Ndegeya, Namayumba (Wakiso) and Busia (Busia)) do not perform any form of surgical operations.
Table – shows level of theatre functionality of the HC IVs in the five districts visited District No. of HC IVs Level of functionality
111 Bushenyi 6 4 (67%) Busia 2 1 (50%) Masindi 2 0 (0%) Soroti 3 0 (0%) Wakiso 5 1 (20%)
Bushenyi District has the highest level of functionality of HC IV theatres, with 4 out of 6 HC IV theatres (67%) functional. A functional HC IV was the one that has a functional theatre and performing caesarean sections for pregnant mothers.
Process used to fully functionalise the HC IVs focusing on innovative and best practices Theatre Construction Districts used various approaches in functionalising the HC IV theatres. In almost all the districts visited, the construction phase of the operating theatres took 1 – 3 years with many repeated civil works and the quality of construction was generally poor. The theatre design also kept changing and this brought confusion and frustration among the district leaders and the contractors. With the exception of Shuuku HC IV in Bushenyi District, all the HC IVs visited had completed operating theatres. Districts with strong and committed leadership to supervise the civil works, e.g Bushenyi and Busia Districts, took shorter periods to complete the construction phase and the quality of construction was much better. In Bushenyi District, the users of the theatres i.e. Medical Officers, were involved in correcting theatre designs to increase sense of ownership and usability. The district also used a policy of completing one theatre at a time and using it as a model for local contractors to use as reference.
Theatre Equipment & Supplies Supply of theatre equipment was another critical phase in the functionalisation of HC IV theatres. 90% of the HC IVs visited had received theatre equipment. It was interesting to note however that in a number of HC IVs, the theatre equipment was still packed in factory boxes without being opened and utilised. Districts with strong and committed leadership, like Bushenyi, Busia and WakisoDistricts, took initiates to solicit for extra funding from other sources (like local revenue, LGDP, PMA, community funding) for purchase of theatre linen, drugs and supplies to supplement the central government budget.
HC IV Management District with committed leadership and good management styles effectively supervised and motivated the staff especially the Medical Officers to stay at their stations to correct the unfinished civil works and provide staff accommodation. They arranged for orientation of Medical Officers in surgical skills in hospitals. In Bushenyi District for example, the supervision of HC IVs from the District Hospital (Kitagata Hospital) and attaching anaesthetic assistants to the hospital till the theatres were ready was strongly emphasised and implemented. In some other districts the newly recruited Medical Officers were required to first rotate in the hospital for a specified period before posting to the HC IVs. Some districts, like Bushenyi and Wakiso, recruited Accounts Assistants for HC IVs. This has streamlined financial management in the HSDs and freed the medical officers to focus on technical work.
112 Problems affecting functionality of HC IVs
Human Resources HC IVs are still inadequately staffed. In particular, having one Medical Officer at HC IV, who is the manager and at the same time the technical officer, is not adequate. The new Local Government staffing norms which propose an increase in staffing levels of health centres and in particular having two medical officers at HC IVs is a step in the right direction. There is also a high turn over of Medical officers in the HSDs. This has proved very disruptive at attempts of building capacity in the HSD Teams and HC IV clinical practice. Many of the medical officers at the HC IVs have lost surgical skills due to prolonged periods of not operating. This has resulted in lack of confidence by the doctors and hence delays to start operating even when all the required logistics like theatre equipment and generators are available.
Funding for HC IVs The funding allocated to HC IVs, about 30 – 40 million per year, is inadequate to carry out all the functions of the HC IVs. When the HC IVs are fully operationalised, this funding level is just too little.
Health Infrastructure and Equipment There are inadequate accommodation facilities for health workers in the HSDs and especially at the HC IVs. Most of the staffs have to hire accommodation outside the duty station. Services such as maternity, theatre and many others that are required on a 24 hour basis are severely compromised during the night hours. There is inadequate infrastructural space, like office, stores, surgical wards or dental clinics, at most of the HC IVs. The construction of a small office block for office, store and meeting place at the HC IVs in South Western Uganda by the EU has had a very positive effect on the management of the HSDs. Many of the HC IVs lack utilities like running water, electricity and telephone and social amenities is not conducive to the health workers. Blood transfusion services are still a big challenge even where theatres are operational. This is because there is limited blood supply in the Regional Blood Banks usually located at the Regional Referral Hospitals. Some of the HC IVs still lack electricity for running the fridges to keep the blood.
Conclusion and recommendations
From the above assessment it is clear that with almost the same levels of inputs (funds, human resources, theatres and theatre equipment) there are very varied levels of functionality of HC IVs across districts. In the five districts visited, nearly all the HC IVs (67%) in Bushenyi District are functional, while none of the HC IVs in Masindi and Soroti Districts were functional. The level of commitment and seriousness of the district leadership and management style play a key role in the HC IV functionality. It is therefore recommended that:
District leadership should take keen interest and get involved in supporting HC IVs. The support and involvement should include regular supervision of the HC IVs and especially the in-charges, allocating extra funds to the HC IVs and provision of accommodation for staff.
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Implementation of the new Local Government structures and hence recruitment of the approved cadres for HC IVs especially the second Medical Officer and other essential staff like theatre attendants, more nurses, accounts assistants and administrators.
Regular technical supervision of HC IVs from the hospitals (General and Regional Referral Hospitals) is essential and the key staff especially the Medical Officers and theatre staffs should rotate through hospitals to orient and update their skills. All the new Medical Officers should first rotate in the hospitals for a period of not less than one year before being posted to the HC IVs.
Increase funding for the HC IVs to address the operational requirements of these facilities. The cost of running the operating theatre, the ambulance for referral and management functions, the increased workload due to the presence of the Medical officer and other high cadre health workers necessitate increased funding.
Construction of other infrastructural like office block and stores, staff houses and extra wards for the HSD
5.4 Health situation in Northern Uganda
Northern Uganda has been recognised by stakeholders in the health sector as requiring special consideration given the peculiar challenges there which include: Insecurity and internal displacement in Apac, Gulu, Kitgum, Lira and Pader and to a less extent Katakwi and Kaberamaido; Insecurity and unique societal norms in Kotido, Moroto and Nakapiripirit; Marked refugee populations in Adjumani, Arua, and Moyo; Generally lower socio-economic levels than the rest of the country;
In particular the 19-year-old conflict in the mid-north sub-region has resulted in approximately 1.7 million Internally Displaced persons (IDPs) living in about 180 camps, with an estimated 1.2 million currently displaced in the districts of Gulu, Kitgum and Pader alone.
5.4.1 Districts with marked insecurity and internal displacement of population
Many studies have been undertaken in Northern Uganda and other crisis-affected districts over the last 5 years with varied information (see Annex XYZ)). However these studies have used varying methodology and have covered different areas – geographical and technical.
In a bid to provide comprehensive mortality information for the sub-region a study was conducted to estimate Crude Mortality Rate (CMR) and Under 5 Mortality Rate (U5MR) among populations living in IDP camps in Gulu, Kitgum and Pader districts covering the
114 period January to July 200529. The study findings were very revealing and some of the key points to note include:
Table kljsh: Highlights of the Health & Mortality Study Report on IDP camps in Acholi Region Gulu Gulu Kitgum Pader Acholi District Municipality District District Region Survey Profile Estimated IDPs 462,580 99,535 310,111 319,506 1,191,732 Household size 6.6 6.9 6.2 6.4 6.4 CMR 1.22 1.29 1.91 1.86 1.54 U5MR 2.31 2.49 4.04 4.24 3.18 Interviewee reported cause of death Malaria 25.3% 22.5% 34.7% 28.9% 28.5% AIDS 15.6% 19.7% 15.1% 11.4%(cough) 13.5% Violence 11.7% 4.5% 10.5% 11.4% 9.4% Services Uptake Measles vaccine coverage 94.8% 95.7% 85.1% 90.6% U5 seeking care within 24 hrs 70.4% 66.7% 53.4% 52.3% 60.4% Bed net coverage 25.5% 30.5% 29.4% 31.2% 28.0% Water availability Litres per person 11.0 12.8 9.7 8.8 10.3 Waiting time 2 1.3 3.6 3.5 2.7
CMR and U5MR in the surveyed populations were well above emergency thresholds (1/10,000/day and 2/10,000/day respectively) and national estimates (0.46/10,000/day and 0.98/10,000/day respectively)30 as shown in the table kljsh. These rates translate into about 1,000 deaths per week in the 1.2 million population IDPs; Malaria/fever, HIV/AIDS and violence were the most frequently reported causes of death; There was fairly high utilization of health services as shown by the proportion of under 5s seeking care within 24 hours which ranged from 52% in Pader to 70% in Gulu district; Measles vaccine coverage (according to card and caregiver) was above 90% in Gulu and Pader, but only 85% in Kitgum district; Age/sex population pyramids in the three districts display an apparent deficit in males and to a less extent females 20 to 30 years old.
A table containing more details about the study findings is included as Annex lkas. The study had some limitations which include: issues of recall period, interviewee reported cause of death, and failure to provide questionnaires in the local language. However these results are useful in providing a comprehensive picture and do not differ markedly from findings of smaller studies. In particular when compared with a UNICEF Report which shows that although the mortality levels are very high in this sub-region, they have been coming down
29 MoH, WHO and partners July 2005: Health and mortality survey among IDPs in Gulu, Kitgum and Pader districts in Northern Uganda. 30 Computed from data from the UDHS 2000/01
115 in the last 3 years as noted in Gulu and Pader districts. A similar pattern is noted when nutrition levels are considered31.
Figure 5.xx: Under 5 Mortality Rate in Gulu and Pader Districts
U5MR in Gulu and Pader Districts 2003-2005 6
5
0 4 2003 3 2004 2005 eaths/10,00 2
D 1 0 Gulu Pader Source: UNICEF Report ??????
A number of interventions have been carried out in Northern Uganda involving government (central and local), development partners and NGOs both international and local. The list below is not exhaustive: Planning and resource allocation – efforts have continuously been made by government and other stakeholders in the sector to support the local governments and other implementers in developing appropriate work-plans and securing funds for the activities. This has happened at the level of the Office of the Prime Minister, Ministry of Health and local government levels. Since the FY 2003/04 the PHC CG per capita allocation to these districts was proportionately increased in line with the challenges there. The Health Development Partners support activities in these districts through general budget support and some directly through donor project support and these include: ADB, DANIDA, Italian Cooperation, UNFPA, UNICEF, USAID, WHO and the World Bank – Northern Uganda Social Action Funds (NUSAF). There are very many NGOs providing humanitarian assistance in these districts especially Gulu which has been reported to have more than 200 active NGOs.
Health programme interventions: a number of activities have been carried out in this region in addition to routine service delivery of the Uganda National Minimum Health Care Package (UNMHCP), a few of which are mentioned here. After noting relatively poor coverage of routine immunisation, coupled with the increased vulnerability of relatively malnourished children living in crowded conditions and the ever increasing threat of imported polio form Sudan, a programme to conduct accelerated routine and supplemental immunisation was carried out in 15 districts in the North and North East in February and May 2005. The two rounds achieved average coverage of 93 and 81% in the round 1 and 2 respectively for Oral Polio Vaccine (OPV). Case management for common diseases and conditions has been strengthened through home based care with provision of HOMAPAK, mamma kits and ITNs. Malnutrition has been managed at
31 What is the specific document to quote on this?
116 therapeutic and supplementary feeding centres. Child days have improved coverage of a number of interventions like de-worming and Vitamin A supplementation.
Although efforts have been made to improve the health of the people in the crisis affected districts, the mortality study report and other sources of information show that there is still a lot that needs to be done. Some specific challenges that have been identified include:
IDP Camp environment and the challenges for health: overcrowding, inadequacy of water and sanitation provision; inadequate nutritional provision and idleness/unemployment of many of the IDPs all have implications for the health of the people living in the crisis affected districts. There is a much higher rate of transmission of infectious diseases both endemic and epidemic, and increased vulnerability to diseases. High rates of alcoholism and STD/HIV transmission have been noted in the displaced populations.
Health services delivery: implications of insecurity for services delivery include movement of populations away from established health units to some places without facility and staff accommodation; fear by health workers leading to difficulty in attracting staff, high attrition and challenges in managing existing staff; high costs – require armed escort to move around the district for routine activities. For example in Kitgum district less than 50% approved staff posts are filled with appropriately trained health workers.
Coordination and management issues: there are very many stakeholders involved at the various levels of policy, planning resource mobilization, health services management and implementation of services for the people living in crisis affected districts. There have been marked challenges in coordinating these players and ensuring efficient utilization of resources for the production of outputs which should in turn translate into improved outcomes.
The Ministry of Health working with stakeholders at the various levels, especially the development and partners and the local governments is working towards improved health for the people of Northern Uganda affected by insecurity and displacement. The strategies to be employed are outlined in the HSSP II and these will be translated into annual Plans of Action. The Emergency Plan of Action for the FY 2005/06 is being finalised (as implementation continues) and is to be presented to stakeholders at the National Health Assembly and Joint Review Mission of October 2005. Key interventions in there include:
Key health interventions: this involves scaling up in depth and geographical coverage the UNMHCP with adjustment of targets to fit the emergency circumstances. Particular areas of emphasis are treatment and control of malaria, HIV/AIDS, respiratory tract infections diarrhea diseases and immunisation against childhood illnesses. Provision of key health Inputs: with a focus on availing appropriately trained health workers as per norms; infrastructure and equipment; and medicines and supplies. Crosscutting issues: there is need for close working relationship with other sectors especially those involved in regulation and/or provision of water and appropriate
117 sanitation; those involved in nutrition and those involve din human resource for health development and management. Coordination and management: a process of mapping the different stakeholders is taking place, which will provide an inventory of stakeholders in the health sector in this region. This will make it possible to determine the gaps in input availability and intervention coverage and thus the resource gap that needs to be covered. As much as possible existing structures are to be used for improving coordination
5.4.2 Karamoja Region
The way of life in the Karamoja region has particular implications for the health status and health-seeking behaviour of the communities there. Information from the routine HMIS, different studies and anecdotal evidence note particular challenges in the areas of: Access to basic health services by the nomadic population; Socio-cultural, gender and reproductive health linkages amongst the Karamojong and implications for health service delivery Sanitation and Hygiene knowledge, attitudes, beliefs and practices amongst the Karamojong.
For each of these areas a brief mention is made here of what the challenges are and what is being done by the health sector and other stakeholders about them.
Access to basic health services by the nomadic population The Karamajong have adapted to their environment by having two different lifestyles. There are fairly permanent households, commonly referred to as the manyatta in which families stay and practice animal rearing and some crop cultivation. Different institutions have been established to service these homesteads including: administrative centres, trading centres, schools, health facilities and places of worship. A proportion of the population, usually the males – boys, young men and the middle-aged men, have to regularly move with the animals in search of grass and water in the dry season, whereby they set up temporary households referred to as kraals. The kraals may be more than 60 km from the manyattas. There are no health services available to this segment of the population for a large part of the year.
It has been proposed in the HSSP II, with initial stages of planning and early implementation taking place in the FY 2004/05, to have a strategy of bringing health services to this significant proportion of the population. The strategy involves the utilization of a new cadre of health worker the Nomadic Community Health Worker (NCHW) (Nursing Assistant level or less formal training) who would move around with the nomads and would be trained and equipped to provide basic treatment for common human and veterinary ailments. The NCHW would be linked to the formal health system through the HC II, III and the HSDs, from which they would get logistics and supplies. Appropriate infrastructure and logistics would be availed - tents and donkeys for the NCHW and motorcycles for the supervising HC IIIs and off-the-road vehicles for the HSD level.
Reproductive Health in the Karamoja Region Compared to other parts of the country RH indicators are very poor in the Karamoja region, both at output and outcome levels; antenatal care attendance for example in Moroto district
118 was found to be 35% compared to the national average of 90%, deliveries in health facilities at 7% against the national figure of 24% and MMR at 750 deaths per 100, 000 live births compared to the national figure of 50432.
The HSSP II and district strategic plans propose special effort to reach the Karamajong households with RH services to prevent high morbidity and mortality that are prevalent today. The special services it is proposed should include access to obstetric and peri-natal care through domiciliary care (shelter within manyatta), waiting/delivery shelter for mothers at health units to enable the delivery to take place with a TBA with the supervision of a trained midwife, and make it possible for the mother to carry out any rituals that may be considered necessary. The proposal also provides for appropriate referral, with particular focus on distant manyattas and the poor road infrastructure.
Sanitation, Water availability and Hygiene in Karamoja According to a recent study in Nakapiripirit district latrine coverage is 6.5%, with most of the pit latrines found in growth centres and institutions like schools, health centres and other public places. Only 1.5% of the surveyed population own latrines, 5% share while 93.3% use the bush to dispose of excreta. Amounts of water utilized in households are well below the 20 litres per capita as recommended by the WHO. Problems faced in fetching water included long distances (27%), over crowding with animals (21%), too few boreholes (18%), breakdown of boreholes, and contamination.
The HSSP II and district strategic and annual work-plans emphasize continued sensitisaiton and mobilization of the communities including the leaders to appreciate the link between sanitation and hygiene and disease. Technical and logistical support to communities for purposes of constructing appropriate sanitation facilities is planned for.
5.4.3 Refugee Health
There is an estimated population of 250,000 refugees from Sudan and DRC in the North and North West parts of the country with most of the refugees in the districts of Adjumani, Arua and Moyo districts. Efforts have continued to be made to make provision for challenges resulting to the host districts by giving them due consideration during the planning, resource allocation and implementation stages of service delivery. It is expected that with end of the civil war in Sudan more of these people will be able to go back to their homes.
5.5 Health Sector Accountability: Client Satisfaction
The voices of the people in form of feedback on services should be used to inform policies on key aspects of health services delivery. Client satisfaction has been noted to be very important and is one of the indicators for monitoring the HSSP. Several studies have collected data on this aspect and key finding have been pooled together in this section. There is however no data on the comprehensive client satisfaction indicator. A survey to
32 Source: Moroto District HMIS and survey data
119 determine the proportion of the population expressing satisfaction with the health services has never been conducted.
There is generally a high utilization rate of public facilities reported in all the surveys. The National service delivery (NSD) survey showed that 63% of people who had been ill 30 days before survey had utilized formal health services (government, private, PNFP) with 33% used government facilities as a first source of treatment. UPPAP II reported similar findings of high utilization of public facilities.
Over 40% of respondents who had had a sick episode within 30 days prior to the NSD survey did not utilize government facilities and cited long distance to facilities as the main reason. Poor physical access to health was also reported to be a major problem for maternity care and was reported to have resulted in many maternal deaths in UPPA II. Poor access to services by disabled people and elderly was mentioned. Health workers were reported not to be able to use sign language to communicate with the deaf patients.
In the NSD survey, 86% of respondents were satisfied with (this refers to only public health units) the services and details of the parameters assessed are shown in fig. 1.1. Availability of drugs was ranked poorest.
Figure 5.1 Percentage distribution of households by level of satisfaction with health services
100% 11.9 11.7 11.8 11.3 4.8 16 17 80% 42.3 25.3 60% 39.3 37.9
40% 27.8 58.7 20% 32.8 33.4 18.1 0% overall quality Responsiveness Availability of Cleaniliness drugs
Good Fair Poor Don't know
Source: National service delivery survey; UBOS; April 2005.
Much as all communities in UPPA II expressed satisfaction with abolition of cost sharing, because they can get free consultations and prescriptions and then buy the right drugs from private clinics or drug shop, it is seen by many community members to have led to deterioration in the quality of health services. Shortages of drugs were reported in all UPPAP II sites and in the NSD survey. In addition, it was reported that when people hear of deliveries of drugs to health units there is a surge in demand, with some patients appearing to stock up with medicines. Communities complained of health staff putting drugs meant for government health units into their private clinics.
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Over 30% of the respondents in the NSD survey reported that they were asked to pay for services and 50% of patients reported paying for services from government facilities despite the free health services policy of government. ANC had the highest number of respondents who reported this practice to pay for services (35%) The biggest percentage of women who did not deliver in health facilities cited high cost as the main reasons. Similar findings were documented in the First Kampala Citizens’ Report Card; 2005 where more than half (57%) of patients who visited a KCC Health Center paid for the medical services (consultancy, drugs, laboratory tests) they received. Much as all services in public facilities should be provided free exept paying wing in hospitals; KCC has had difficulty in enforcing the no user fee policy in its health centres. The average total payment for medical services at government hospitals was reported to be Ush. 18,370 per visit.33 In isolated cases, there appeared to be confusion between legitimate charges in private Class A hospital wards and unofficial payments in public Class B wards.
In the NSD survey, 34% of respondents expressed willingness to pay for services although the cost varied with the type of service. Clients were most unwilling to pay for immunization, but willing to pay for surgery, laboratory and delivery. 66% reported a general improvement on health services delivery compared to 2000. Greatest improvement was in immunization (63% reported improvement) while X-ray services reported to have remained the same
As in the first PPA, UPPA II (December 2002) noted that lack of adequate qualified staff was reported in more than half of the sites. A related problem appears to be short and inconvenient opening hours. Communities often report that the cause of this problem is senior staff moonlighting in their private clinics. In some sites people reported a lack of availability of trained staff, which results in unqualified staff being left in charge of the government health unit. Rudeness by health staff was also reported. Contrary to this, the UNACHO baseline survey showed that trust in health workers was universal amongst patients in Kampala and Bushenyi, while 17% in Luweero expressed signs of lack of trust. Satisfaction rates were generally high among patients, especially in the private health units. Though we note that this study covered only town councils in three districts.
The UNHCO Baseline survey on patient’s rights August 200234 showed that generally respondents reported equal treatment though majority felt treatment offered in the health facilities was not optimum.35 The right to self-determination36 was not respected and patients were unlikely to be offered alternative treatment especially the poor. The right to privacy was generally respected37 and majority of the interviewed patients waited for less than
33 On average, patients who visited private hospitals paid more than four times the cost of medical care at government hospitals. 34 Study not nationally representative: Study was carried out in Kampala City Council, Luwero Town Council and Bushenyi Town Council. 35 The right to optimum treatment was interpreted by investigating whether malaria patients received a blood test during the course of treatment. 36 The right to self determination – was measured by asking patients and health providers whether alternative medication is offered and whether the patients have a say in the choice of medication 37 as measured by asking patients whether they were comfortable with the persons present in the examination room.
121 10 minutes before receiving treatment.38 Less than a third waited for more than 30 minutes. Patients to government health units had longest waiting periods. UPPAP II notes that much as some improvement in access for women was noted, barriers still exist. The time spent at the health unit (sometimes as much as eight hours) has adverse effects on relations in the household.
Feed back mechanisms do not seem to be working effectively as shown in the UNHCO study; August 2003.39 Overall respondents from NGO health facilities were more aware of feedback mechanisms and provided feedback to health facilities than respondents from government and private –FP health facilities. The private-FP health facilities had the least consumer feedback mechanisms in place with only one having a suggestion box and none having written guidelines.
While the majority of consumer respondents are aware of the existence of feedback mechanisms, consumers are not using the intended feedback mechanisms (suggestion box, HUMC). A formal procedure to provide feedback to health providers is not present in most health facilities
Mixed feelings about immunization come out of the research findings of UPPA2. In more than a quarter of sites immunization is generally appreciated and people have noticed the decline in immunisable diseases in their areas. However, in a few sites negative attitudes were expressed especially on National Immunization Days (NIDS). Some people blame immunizations in 1999 for an unspecified number of children’s deaths. In one pastoral community, people think immunization is to finish Africans, so they do not use the services.
Regarding family planning services, a common finding in these sites was that community members lacked sensitization about these services, and both men and women expressed a need for more sensitization on the methods of FP. In addition, FP was reported to be limited by cultural factors, illiteracy and distance to government health units.
This has highlighted a few issues on community perceptions regarding health services. There is a need for a systematic way of getting client satisfaction issues on health services.
5.6 Progress on the Resolutions of the October 2004 National Health Assembly
The Memorandum of Understanding between Government of Uganda and the Development Partners in the health sector provides that, as part of the monitoring and review process for the implementation of the Health Sector Strategic Plan, Government shall organize the National Health Assembly in which districts, urban authorities, central ministries, NGOs and other stakeholders, including development partners will be expected to participate. The Government of Uganda therefore organized the second National Health Assembly on 25th – 26th October 2004. The objectives of the National Health Assembly were
38 This study covers only urban settings where you are likely to have relatively more health workers. 39 Study not nationally representative: Study was carried out in Kampala City Council, Luwero Town Council and Bushenyi Town Council
122 to: review the national health sector performance, share the results of individual district performance assessments, make a contribution to the final draft of HSSP II, lay strategies for improved community participation and health literacy and agree on priority areas for health sector interventions.
The National Health Assembly was attended by over 500 delegates who included Members of Parliament (members of Sessional Committee on Social Services and the Parliamentary Standing Committee on HIIV/AIDS), Chairpersons of District Local Councils (LC V), District Secretaries for Health, Chief Administrative Officers (CAOs), District Directors of Health Services (DDHSs) from all the 56 districts, Medical Superintendents of all the Regional Referral Hospitals, selected General Hospitals and HC IVs, Directors of autonomous health related institutions, Health Development Partners, Non Governmental Organisations (NGOs), representatives of civil society, other line Ministries and government organizations and the private sector organization.
Progress on implementation of 2004 National Health Assembly resolutions At the end of the Nation Health Assembly, stakeholders agreed on a number of resolutions to be implemented and reported on at the 2005 National Health Assembly. The following is the progress report on implementation of the resolutions of 2004 National Health Assembly:
Resolution NHA2: 1 The GoU should increase the share of the budget allocated to health towards a target of 15% of the overall national budget in accordance with the Abuja target.
The proportion of the national budget allocated to the health sector fell from 10.6% in FY 2004/05 to 9.6% in FY 2005/06. There was therefore no increase in the share of the national budget allocated to the health.
Resolution NHA 2: 2 The District Local Governments should prioritise health in the implementation of Fiscal Decentralisation Strategy (FDS) with the aim of attracting additional resources into the health sector
There was no significant re-allocation away or towards the health sector in this Financial Year under the FDS flexible reallocation of the 10%. Preliminary work of budget re- allocations on BFPs for FY 2005/06, shows that of the total allocation of UgShs. 22.466 billion for PHC non-wage grant, LGs allocation to the health sector was UgShs. 22.072 billion, after using the FDS flexibility. A total of UgShs. 393 million or 1.5% was therefore allocated AWAY from the health sector. Most districts left the PHC-non-wage grant as it was or had minor additional allocations to health. There were therefore insignificant reallocations.
Resolution NHA2: 3 The new Local Government structures should be approved as quickly as possible to provide a basis for recruitment of qualified health workers into the district health system.
123 The Ministry of Public Service approved the new Local Government structures and issued implementation guidelines to Local Governments. Ministry of Health is currently working at unresolved structural issues in a consultative manner. Report on the reviewed position will be made at the next review.
Resolution NHA2: 4 The Government, both at Central and District level, should finalise and formalise specific strategies to address recruitment and retention, especially for the hard – to – reach areas
Ministry of Health is planning to conduct a study to determine attrition within the health sector with particular focus on motivation, strategy for targeting hard-to-reach areas. In the meantime Government will continue paying the improved salaries and allowances for medical workers
Resolution NHA2: 5 District staff going for further training in disciplines that make them not applicable to the district human resource needs should be transferred to the centre so as to leave room for the districts to recruit replacements.
The health sector is in final stages of developing a policy on Human Resources for Health which comprehensively addresses issues of training among others. Management and operational guidelines for training and capacity building programmes are being developed. Consultations to seek views of other stakeholders will be undertaken.
Resolution NHA2: 6 Districts should ensure that 50 % and 40 % of PHC CG is allocated by LLUs and hospitals respectively to drugs. The Credit Line resources should be fully (100 %) utilised. The district health managers should prioritise the procurement of Reproductive Health supplies.
Assessment of the FY 2004/05 PHC CG expenditure on Medicines and supplies against the recommended guidance and as agreed with the district leadership show that: 34 (60.7%) districts spent well below the recommended 50% of the non wage PHC CG on medicines and supplies. The range was from as low as 1% spent (both NMS and JMS) by Yumbe district and to 49% by Kisoro district. 22 (39.3%) districts spent 50% or more of the PHC CG non wage on medicines and supplies. Overall 51% of the districts spent 50% or more of the PHC CG non wage on medicines and supplies at the Lower Level Health Units. General and Regional Referral Hospitals performed better in spending the delegated funds (47% and 44% spending respectively). The credit lines expenditure performance was below the 100% mark due to stock outs of some of the items at the NMS during the period. However, the over all spending on credit lines was at 89% for Lower Level Health Units, 75% for General Hospitals and 92% for Regional Referral Hospitals.
124 Total spending (PHC CG and Credit lines) was at 66% for Lower Level Health Units, 60% for General Hospitals and 65% for Regional Referral Hospitals.
Districts therefore did not live up to the commitments on expenditure on medicines, especially at the LLHU where this was most necessary and under their control.
Resolution NHA2: 7 The health sector will continue to prioritise functionalisation of the existing HC IIIs and HC IVs with particular emphasis on maternal and child health services.
During the year, ten (10) HC IV operating theatres have been equipped bringing the total number of equipped theatres to 77. Funds have also been secured for equipping another 23 theatres and 8 HC IIIs. Funds have also been allocated for construction of 12 wards at HC IIIs, 4 wards at HC IVs, 20 staff houses at HC IIIs and 18 at HC IVs. 134 health centre IVs have been provided with multipurpose vehicle / ambulance
Resolution NHA2: 8 At the next NHA, progress on hospital rehabilitation, equipping and provision of hospital services/infrastructure will be provided.
During the year, the following have been undertaken to improve hospital infrastructure: Rehabilitation work on Fort Portal Hospital started and is still ongoing, Rehabilitation work on the sewerage, plumbing and water supply systems of Nakaseke, Abim and Itojo hospital is ongoing Upgrading of Lyantonde Health Centre IV to a 100 bed hospital is ongoing 6 mental health units have been constructed and equipped at selected regional referral hospital Funds have been secured for rehabilitation of Mbale Regional Referral Hospital, Tororo and Bududa General Hospitals and upgrading of Masafu Health Centre to a hospital and 6 hospital ambulances were procured
Resolution NHA2: 9 The political leadership in each district, with technical support from the Area Teams, should organise a conference on Reproductive Health to examine in detail the identified constraints to the provision of Emergency Obstetric Care (EmOC) and utilisation of health facilities for deliveries and child health and come up with immediate and medium term solutions.
7 Regional Reproductive Health Conventions were held with all 56 districts. Constraints and solutions to Reproductive Health implementation were identified. This process will benefit the planning and budgeting at district and lower levels. A report of the RH Conventions is available
Put photo of Minister opening NHA in the middle of text
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Resolution NHA2: 10 More resources should be mobilised to further scale up Anti Retroviral Therapy (ART) and related services so as to improve on the proportion of people accessing ART, taking into account geographical coverage.
Ministry of Health prepared and submitted proposals for ART funding from Global Funds to fight AIDS, TB and Malaria, PEPFAR and other funding institutions. Global Funds and PEPFAR approved and released substantial resources for establishing and supporting of ART and other related services like PMTC, HCT. By June 2005, a total of 60,000 persons living with AIDS had already started treatment with ART, expecting to reach the target of providing ARVs to all who are eligible by end of 2006. A total of 175 health facilities have been accredited to provide ARV and out of these 161 are functional and operating country wide. All the 11 Regional Referral Hospital and 56 General Hospitals are currently providing ARVs. MoH is currently scaling up treatment with ARVs in HC IVs.
Resolution NHA2: 11 Develop appropriate performance assessment tools and regularly assess performance of central level departments and institutions (Ministry of Health Headquarters and autonomous institutions) and within districts (Health Sub-Districts, sub-counties and health units)
Health sector stakeholders reviewed the Quarterly Assessment tools/formats for assessing performance of District Health Services at all levels (district, HSD, Sub-county, and health facility) as part of the HMIS review. Central level assessment tools are still being developed. Performances of different levels have been regularly assessed on a monthly, quarterly and yearly basis. Currently a League Table for comparing performance between districts is preapared every year. Similar League Tables for comparing performance between central level departments, between HSDs, between sub-counties and between health facilities have been proposed although not yet adopted.
Resolution NHA2: 12 The Ministry of Health should continue to take a comprehensive approach in planning and policy formulation for Human Resources to optimise the equitable use of available resources and investing in comparative advantages of the public and private sector
The Ministry of Health continued to work with all stakeholders including Ministry of Public Service, Ministry of Finance, Planning and Economic Development, and the Private Not For
126 Profit (PNFP) to find a lasting solution to the health workers’ salary imbalances. The Ministry of Health continued to provide grants to subsidize the costs of PNFP units and continued to allow flexible use of this grant to pay salary top ups for health workers in the sub-sector. Ministry of Health set up a Task Force to study and propose how to address the issues of salaries for health workers in the PNFP sub-sector. The Ministry of Health is currently using the report recommendations in discussions with Ministries of Finance and Public Service and Development Partners to find additional funding to close the salary gap between PNFP and Public health workers.
Resolution NHA2: 13 The district political and technical leadership to actively mobilise and sensitise communities for health promotion and disease prevention.
District political and technical leadership continued to mobilize and sensitise the communities for health promotion and disease prevention. Due to good mobilization and sensitization of communities, most of the health programmes and services were well utilized. Child Health Days were successfully implemented throughout the country achieving the national coverage of 65% in de-worming with Albendazole and 68% with Vitamin A supplementation. Measles vaccination also increased by 11% during the months of Child Health Days. Coverage for other disease preventive interventions like DPT 3 increased from 84% to 92%.
Resolution NHA2: 14 Deliberate efforts should be made to develop harmonious relations between the district leadership and the Civil Society Organisations in the spirit of transparency and accountability
Health sector stakeholders have put in place mechanisms to streamline the operations of Civil Society Organisations. The revised Memorandum Understanding for HSSP II now includes a section which spells out guidelines and modalities for collaborating with Civil Society Organisations. Planning at district level also emphasis joint planning between District local Governments and Civil Society Orgnaisation such that that plans for all health activities in the district are integrated with the District and HSD Annual Work-plans.
Resolution NHA2: 15 The district should increase on their support for the training of Village Health Teams to effectively mobilise communities for health promotion and disease prevention
The implementation of Village Health Teams is slowly being rolled out in the country. The Support to Health Sector Strategic Plan Project (SHSSPP) supported the training and implementation of VHT in Northern Region. Ministry of Health supported a number of districts in the training of VHT. The districts mobilized stationery, record books and paid allowances for the trainers. In the districts where VHT is being implemented, districts have provided strong political will and commitment in mobilizing the communities for this program. The trained VHT in many districts are now required to attend Local Council meetings and provide status report on health in the village.
Resolution NHA2: 16
127 Information and Communication Technology (ICT) should be promoted to facilitate Continuing Professional Development, health information management, e- Governance, health promotion and education in order to support the development of an integrated and cost effective health system.
Ministry of Health has continued to maintain and upgrade a Local Area Network at MoH Headquarters and has also upgraded the Internet bandwidth from 128 kbps to 256 kbps. Ministry of Health has implemented the concept of Wide Area Network (WAN) between MoH Headquarters and Wabigalo (Health Infrastructure Division). This was an attempt to create/pilot a WAN from the MoH facilities all over the country and share internet resources. The website has been further developed and maintained (i.e. http://www.health.go.ug) which serves as the official internet resource for Ministry of Health. An online data module has been developed aiming at making data available to decision makers at the easiest way possible. The Ministry of Heath has also developed the Information Communication Technology (ICT) policy, only awaiting approval.
5.7 Progress on the Undertakings of the October 2004 Joint Review Mission
The tenth Health Sector Joint Review Mission (JRM) on the implementation of the Health Sector Strategic Plan (HSSP) took place on 27th – 29th October 2004. The Joint Review Mission was preceded by visits to selected districts from 18th – 22nd October 2004 by representatives of Ministry of Health and Development Partners, to assess progress on implementation of the HSSP in the field, identify key constraints faced by districts in service delivery and come up with key issues from the districts to be discussed during the NHA and JRM. The main objective of the JRM was to review progress on implementation of the Health Sector Strategic Plan and to agree on the priorities and Budget Framework for the upcoming Financial Year 2005/06.
At the end of the JRM, Undertakings and actions were agreed upon to be implemented by health sector stakeholders. The undertakings and actions are implemented as part of the Annual Work-plans and are therefore monitored throughout the year and the progress reported at the subsequent JRM. The achievements on the Undertakings of the 10th GoU/DP JRM is summarized in Table -----
128 Table 5.1: Progress report on Undertakings of the October 2004 Joint Review Mission No Undertaking Means of verification Timeframe Progress report 1 Finance Minutes of the Sector Working Throughout the year HSWG been meeting regularly The budget process for FY 2005 /06 to Group Meetings and Minutes available, involve the Sector Working Group in BFP widely discussed and agreed by Throughout the year BFP for FY 05/06 was widely accordance with the Memorandum of all stakeholders discussed and agreed by all Understanding. Finalisation of the Programme of work for stakeholders, recommendations of Tracking Study on implementation of Programme 9 By end January 2005. Draft Programme of Work programme 9 Tracking Study developed and already being implemented 2 Basic Package ToRs for DWSCs developed and Sanitation Terms of Reference for DWSCs By end February 2005 disseminated together with Water By October 2005, all districts have work Minutes of DWSCs Throughout the year Sector Guideline plans, budgets and active District Water and DWSCs Quarterly reports At end of each quarter Circular letter on formation of Sanitation Committees (DSWCs) in place Promotional materials for DWSCs By end May 2005. DWSCs sent to all CAOs and that are integrating and coordinating existing Workshops and support supervision Conducted DDHS resources towards implementation of best reports throughout the year Promotional materials on practice in Hygiene Promotion and Sanitation Promotion Sanitation. disseminated Conducted various sanitation activities. 3 Drug Management Provisional list of additional credit Mid Feb. 2005. Survey done, data analysed and Review the credit line arrangement for drugs line items based on district and shared with facility (hospitals and with the view of expanding the funding for hospital responses to questionnaire, HC IVs) managers and other and number of items procured through it. Estimated needs through stakeholders in May 2005. quantification study, Feb – March 2005. Quantification of needs for new items done simultaneously during Consensus on new list and survey. expanded funding through April 2005. Costing of additional items to the consultative meetings (districts, credit line done and hospitals, MoH programmes, communicated to NMS & JMS funders/HDPs) List of additional items to be part Expanded credit line order forms in of the order form starting two phases. May & Sept. 2005. September 2005. 4. Drugs Management Report on NDA financial review Undertake a review of the operations of the Draft/report of NDA financial Early March 2005. finalised and presented to HPAC
129 No Undertaking Means of verification Timeframe Progress report NDA with the view to ensure future review Report on volume of business financial self sustainability. Report on the volume of business Early March 2005 between NDA and MoH finalised between NDA and MoH and presented to HPAC 5. Human Resources for Health Revised draft report on Human End January 2005 Report was finalised and handed Complete the Human Resource Tracking Resources Tracking Study over to and accepted by MoH. Study and disseminate to a wide stakeholder Final report incorporating By end February 2005 Final report available. group and develop the programme for the comments from stakeholders Two meetings so far held to implementation of the recommendations consultative meeting develop Programme of Work. road map. Programme of work for March 2005 Third meeting scheduled for implementation of study October 05. recommendations 6. Human Resources for health Final report available and Government to utilise the findings of the Final report on PNFP Human By end March 2005 disseminated in HPAC and SWG PNFP Human Resource Task Force to work Resources Task Force Proposal for funding the salary out mechanisms of providing support to the gap for PNFP submitted to MoF Facility Based PNFP health sector to cater Actions taken by Government using By end June 2005 and GFATM but no action has for salary increases within the framework of the report been taken yet. the LTEF and MTEF. 7. Basic Package ART Coordinating Committee HIV/AIDS Minutes of ART Coordination Monthly. been meeting regularly and GoU to work with all stakeholders through Committee, minutes available, the UAC to ensure that the roll out of ART Guidelines and manuals for By end June 2005. Guidelines and manuals for is coordinated and integrated in the National integration of ART services integration ART services available, Health System. Further consultation should Health facilities providing package By May 2005. 173 health facilities have been be undertaken in order to update, that includes ART, accredited to provide ART (of disseminated and implement the existing Reports of ART roll out Quarterly which 160 are now operational), guidelines. Reports on consultation with Report on ART roll out prepared stakeholders on the update, and discussed with stakeholders dissemination and implementation Consultations held with of existing guidelines stakeholders on the update, dissemination and implementation of existing guidelines and report available. 8. Basic Package Reproductive Health Report on Regional Conventions By end of July/August 7 RH Conventions held involving All districts to review the constraints in the summarising the regional specific 2005. all districts. Constraints and
130 No Undertaking Means of verification Timeframe Progress report provision and uptake of maternal and child constraints and solutions adopted solutions identified. A report is health services with emphasis on district for improving maternal and child available specific solutions which should be discussed health services and adopted at the District Conventions. District Annual Work-plans July/August 2005 incorporating recommendations of the Regional Conventions 9. Basic Package A roll out plan for EmOC Reproductive Health developed and disseminated to Develop district plans to operationalise the District roll out plans for EmOC By end April 2005. districts during planning meetings. roll out of the EmOC services on the basis Scale up of EmOC carried out in of the results of the national needs 20 districts. assessment exercise.
10. Health Systems Review the existing Service Standards with Terms of Reference for the review By end January 2005. ToRs being developed the view of establishing Minimum Service of Service Standards, By end August 2005. Sourcing consultant to Standards for specific service delivery Draft report comparing trends in immediately follow after agreeing components, especially those that affect the facility inventory (HR, equipment, the ToRs. health of the poor and vulnerable. The infrastructure) with Minimum required performance assessment tools standards for time period should also be developed. 11 Health Infrastructure Terms of Reference for the study By end August 2005/ ToRs developed and agreed with Undertake a tracking study on the Health Draft report on Health stakeholders Infrastructure and equipment provision to a Infrastructure Development and Contract awarded through representative sample of districts during the equipping of health facilities from competitive bidding process lifespan of HSSP I. Report to be presented FY 2001/02 – 2005/06 Inception report prepared and at October 2005 JRM. presented to MoH. Field surveys and investigations undertaken in the sample 18 districts and draft preliminary report submitted
131 5.8 Future Annual Health Sector Performance Reports and Monitoring for HSSP II
5.8.1 District League table
5.8.2 Monitoring Hospital performance
5.8.3 Performance at the Ministry of Health Headquarters
Review of the annual work-plan by level (this could also be included in section II that reports on activities / experiences with the planned core interventions)
Indicators for performance of central level programmes (to be developed in consultation with departments. If programmes already have indicators, you may include them under this section.
132 Annex I: The District League Table FY 2004/05
133 Annex II: Staffing Situation in General Hospitals Medical Nurses and Allied Health Administrative Support Other Total No. Hospital Officers Midwives Professionals Staff Staff Staff Staff 1 Aber 5 71 27 8 36 0 147 2 Adjumani 4 75 17 6 23 0 125 3 Amai 2 8 8 5 28 0 51 4 Anaka 3 0 0 0 0 0 3 5 Angal St.Luke 4 77 25 4 25 0 135 6 Apac 3 34 24 13 30 0 104 7 Atutur 5 34 18 5 24 0 86 8 Bududa 6 55 25 _ 29 0 115 9 Buluba 4 42 20 12 57 0 135 10 Bundibugyo 3 102 22 8 12 0 147 11 Busolwe 3 52 14 7 20 0 96 12 Bwera 1 38 8 9 38 0 94 13 Comboni 3 32 16 7 33 0 91 14 Entebbe 8 131 17 6 16 0 178 15 Gombe 4 74 11 6 24 0 119 16 Ibanda 4 45 20 14 25 0 108 17 Iganga 7 54 25 7 56 0 149 18 Ishaka 3 29 7 8 66 0 113 19 Itojo 7 68 30 8 85 0 198 20 Kabarole 3 15 6 6 26 0 56 21 Kagando 5 39 17 15 83 0 159 22 Kalongo 8 172 38 19 36 0 273 23 Kambuga 8 67 17 5 22 0 119 24 Kamuli 5 57 19 9 23 0 113 25 Kawolo 5 64 17 8 48 0 142 26 Kayunga 4 52 28 6 46 0 136 27 Kilembe Mines 6 87 35 13 23 0 164 28 Kiryandongo 3 43 21 6 48 0 121 29 Kisiizi 4 38 16 9 22 0 89 30 Kisubi 5 42 25 8 7 0 87 31 Kitgum 4 83 10 22 29 0 148 32 Kitgum St.Joseph 6 141 54 15 45 0 261 33 Kitovu 8 69 29 37 64 0 207 34 Kiwoko 8 65 10 14 191 0 288 35 Kuluva 0 58 10 7 123 0 198 36 Kumi 6 41 26 13 153 0 239 37 Lacor 28 259 72 26 196 0 581 38 Lwala 3 40 16 7 26 0 92 39 Maracha 2 69 12 12 38 0 133 40 Matany 6 92 18 13 146 0 275 41 Mengo 26 196 31 18 169 0 440 42 Mityana 3 55 19 25 33 0 135 43 Moroto 3 27 13 5 3 0 51 44 Moyo 3 49 19 7 13 0 91
134 45 Mubende 3 55 19 25 33 0 135 46 Mutolere 5 73 18 16 69 0 181 47 Naggalama 3 49 17 6 21 0 96 48 Ngora 3 35 10 8 74 0 130 49 Nkokonjeru 2 35 11 5 13 0 66 50 Nkozi 4 52 26 10 38 0 130 51 Nsambya 37 185 50 39 78 0 389 52 Nyakibale 3 57 17 19 24 0 120 53 Nyapea 3 52 38 8 15 0 116 54 Nyenga 3 43 18 10 23 0 97 55 Pallisa 5 48 23 9 20 0 105 56 Rakai 4 37 12 5 22 0 80 57 Rubaga 22 122 62 28 38 0 272 58 St.Stephen 1 4 2 2 5 0 14 59 Tororo St.Antony 4 36 16 8 25 0 89 60 Villa Maria 4 44 24 12 21 0 105 61 Virika 3 87 31 20 62 0 203 62 Yumbe 5 56 11 5 34 0 111
135 Annex III: General Hospital (Facility) Outputs OPD OPD Re- C/S No. Hospital Beds new attend. ANC Immunisations FP Admissions Deliveries Rate 1 Aber 178 10,311 4,345 8,037 37,849 - 7,097 1,033 0% 2 Adjumani 100 36,962 3,469 2,589 740 391 6,517 916 24% 3 Anaka 100 44,423 11,212 1,024 980 351 5,761 478 1% 4 Angal St.Luke 240 19,138 11,893 8,794 13,675 - 10,918 1,675 0% 5 Apac 100 80,186 40,220 8,035 7,518 682 8,739 1,551 5% 6 Atutur 100 51,392 21,917 4,090 10,770 1,207 8,090 1,375 13% 7 Bududa 100 38,475 6,319 7,095 72,818 3,687 _ 921 _ 8 Buluba 160 16,803 1,541 1,023 10,974 - 5,387 311 _ 9 Bundibugyo 114 - - 4,192 108,972 275 8,937 1,346 17% 10 Busolwe 120 42,743 10,827 5,604 13,179 498 8,817 1,205 11% 11 Bwera 75 60,164 1,488 10,706 11,802 1,450 10,322 1,315 23% 12 Comboni 100 25,328 1,717 5,508 7,066 - 8,562 604 34% 13 Entebbe 181 46,148 15,536 12,318 24,554 4,694 8,344 3,243 _ 14 Gombe 144 147,431 1,498 4,020 10,439 731 7,553 1,691 18% 15 Ibanda 178 15,684 1,739 4,795 11,939 - 12,448 1,804 20% 16 Iganga 100 51,169 30,618 11,340 1,952 4,132 15,672 3,241 20% 17 Ishaka 110 _ _ 6,115 9,405 - 12,092 1,467 _ 18 Itojo 110 67,870 2,457 4,712 4,553 1,376 15,131 2,538 21% 19 Kabarole 136 ______20 Kagando 100 ______21 Kalongo 320 42,163 16,296 8,535 44,710 - 13,336 2,789 2% 22 Kambuga 0 44,326 3,240 5,144 14,595 413 - 1,294 _ 23 Kamuli 160 51,318 1,906 9,652 15,283 - 10,205 2,142 _ 24 Kawolo 117 48,033 4,519 4,735 30,749 52,567 8,317 2,814 17% 25 Kayunga 113 68,694 23,600 5,247 5,676 421 9,073 1,714 15% 26 Kilembe Mines 196 16,395 1,554 3,833 11,558 - 17,248 2,890 2% 27 Kiryandongo 104 28,195 14,010 2,398 16,616 335 5,498 1,035 21% 28 Kisiizi 30 ______29 Kisubi 90 15,364 6,593 2,833 8,017 - 4,224 594 0% 30 Kitgum 208 75,030 - 6,824 20,292 545 9,848 2,408 4% Kitgum 31 St.Joseph 350 57,300 5,955 6,966 16,671 - 18,826 964 _ 32 Kitovu 200 25,796 9,137 3,013 8,559 - 12,383 1,377 31% 33 Kiwoko 243 _ _ 3,924 10,728 - 6,330 994 _ 34 Kuluva 182 _ _ 3,117 11,275 - 7,935 591 _ 35 Kumi 291 25,821 2,552 3,721 6,108 564 13,075 802 28% 36 Lacor 474 110,068 63,605 18,111 49,283 - 28,872 1,908 9% 37 Lwala 100 11,024 370 4,498 7,380 - 5,670 596 6% 38 Maracha 200 25,896 1,315 2,761 13,566 - 7,798 779 7% 39 Matany 226 23,745 3,853 4,870 17,607 - 10,940 990 4% 40 Mayanja _ - - 947 1,581 _ _ 278 25% 41 Mengo 320 _ _ 22,559 33,430 - 28,548 4,078 _ 42 Mityana 106 74,182 5,718 7,880 14,152 3,826 8,397 3,021 13% 43 Moroto 101 22,687 11,591 1,194 549 102 3,874 420 3%
136 44 Moyo 104 29,164 24,335 5,122 5,585 719 4,961 1,094 11% 45 Mubende 100 74,182 5,718 7,880 14,152 3,826 6,707 3,021 13% 46 Mutolere 210 27,634 1,177 5,590 12,057 - 9,844 1,575 _ 47 Naggalama 100 28,564 2,550 5,935 14,268 - 8,680 1,912 15% 48 Ngora 180 _ _ 3,630 20,304 - 4,835 2,164 _ 49 Nkokonjeru 120 12,048 1,221 3,833 11,558 - 3,832 2,890 3% 50 Nkozi 100 31,965 5,812 3,208 12,682 - 4,749 985 0% 51 Nsambya 361 _ _ 25,342 46,238 - 17,081 6,173 _ 52 Nyakibale 165 21,287 1,318 2,292 9,682 - 10,797 1,706 23% 53 Nyapea 139 14,362 3,488 5,680 7,793 - 7,688 1,101 23% 54 Nyenga 100 28,668 3,835 2,991 13,224 - 5,939 602 _ 55 Pallisa 100 22,624 8,356 5,892 15,035 918 9,862 2,830 5% 56 Rakai 57 42,537 676 1,217 1,808 428 4,671 1,030 19% 57 Rubaga 275 44,879 69,598 17,556 55,844 - 12,126 3,782 2% 58 St.Stephen 22 _ _ 197 7,499 - 347 48 _ Tororo 59 St.Antony 109 12,368 1,567 1,159 6,430 - 8,661 810 7% 60 Villa Maria 126 26,360 5,084 1,070 11,557 - 6,488 724 7% 61 Virika 160 17,017 - 5,430 12,833 - 18,080 2,119 6% 62 Yumbe 100 32,510 7,632 1,994 12,803 400 6,904 1,676 11%
137 Annex IV: Facility Care Outcomes
Hospital Total Death Rate Maternal Death Rate
Aber _ 0.2% Adjumani 2.4% 0.9% Anaka 1.3% 1.0% Angal St.Luke _ 0.70% Apac 3.4% 0.5% Atutur 1.8% 0.3% Bududa _ 0.3% Buluba _ _ Bundibugyo 2.5% 1.0% Busolwe 2.0% 1.0% Bwera 1.1% _ Comboni 1.8% 0.0% Entebbe 4.1% _ Gombe 2.4% 0.8% Ibanda 3.4% 1.0% Iganga 4.0% 0.8% Ishaka Itojo 2.3% 1.6% Kabarole _ _ Kagando _ _ Kalongo _ 0.1% Kambuga _ _ Kamuli _ 0.9% Kawolo 3.4% 0.9% Kayunga 4.0% 0.8% Kilembe Mines _ 0.0% Kiryandongo 3.9% 0.2% Kisiizi Kisubi _ 0.0% Kitgum 3.9% 2.8% Kitgum St.Joseph _ _ Kitovu 5.4% 1.1% Kiwoko _ Kuluva 5.4% 1.7% Kumi 3.1% 1.9% Lacor _ 0.5% Lwala _ 0.4% Maracha 6.5% 1.0% Matany _ 0.2% Mayanja _ _ Mengo _ _ Mityana 3.3% 0.9% Moroto 2.2% _ Moyo 5.6% 0.1%
138 Mubende 6.0% _ Mutolere _ _ Naggalama 4.6% 0.9% Ngora _ _ Nkokonjeru _ 0.9% Nkozi _ 0.1% Nsambya _ 0.1% Nyakibale 2.3% 0.8% Nyapea 3.0% 0.4% Nyenga 1% Pallisa 1.7% 0.4% Rakai 3.7% 1.8% Rubaga _ 0.3% St.Stephen _ _ Tororo St.Antony _ 8.0% Villa Maria _ 1.0% Virika _ 0.6% Yumbe 4.4% 0.2%
139 Annex Va: Mulago Hospital Service Outputs FY 2004/05
Medical Paediatric Surgical Gen Gynecology ANC Eye ENT Neurology Others Total 03/04 04/05 03/04 04/05 03/04 04/05 03/04 04/05 03/04 04/05 03/04 04/05 03/04 04/05 03/04 04/05 03/04 04/05 03/04 04/05 OPD 13.860 38,046 44,280 13.734 7,412 1,764 4,896 35,124 44,316 15,636 22,168 9,084 6,687 1,539 1,080 222,892 New attendances OPD 33,405 18,093 20,772 17,165 25,441 1,935 4,245 37,902 28,980 5,343 4,294 4,587 5,375 1,683 2,364 253,115 Re-attendances Referral In Admissions 16,257 11,995 19,770 15,835 4,011 3,000 26,337 23,616 28,530 31,368 909 1,164 1,098 1,155 681 754 151,014 (deliveries) Average Length 8 8 8 7 12 7 7 14 12 16 15 14 13 Of Stay (ALOS) Major NA NA 8,772 5,565 5,142 569 89 - Surgical (C/S) Operations Finances (Wage) 11,424,765,240 Finances (Non Wage) 13,036,898,446
Annex Vb: Butabika Hospital Service Outputs FY 2004/05 Female Adm Female Sick Female Kireka Male Male Sick Male Conv. Male LS Kirinya Female Kirinya Total Conv. Adm Muyenga Male OPD New attendances 50,643 OPD Re-attendances 17,951 OPD Referral from Unit 90 Inpatient Referral from Unit 43 Inpatient Referral to Unit 187 Admissions 825 97 32 1707 69 312 462 224 397 4125 Average Length Of Stay (ALOS) 28 56 68 35 61 72 90 32 47.5 44.8 Immunizations done 2,897 Family Planning Contacts 1,904 Finances (Wage) 1,204,981,404 Finances (Non Wage) 1,500,884,823
140 Annex VI: Detailed analysis of health sector projects.40 (Ugshs millions) HR Drugs and Other Capital non Infrastructure Other TOTAL Ugandan medical recurrent infrastructure inputs health staff supplies Public Sector Central level 3,130 64,689 528,951 561,063 80 1,546,235 2,704,149 District level 3,693 33,054 303,475 3,088 187,838 829,927 1,361,075 Sub-total public sector 6,823 97,743 832,426 564,151 187,918 2,376,162 4,065,224
Private Sector PNFP (facility based) 528,717 965,963 835,707 31,018 443 6,453 2,368,301 PNFP (non- facility based) 458 413 248 148 17 97,219 98,503 For Profit Providers 43 0 0 0 0 0 43 Sub-total private sector 529,218 966,376 835,955 31,167 460 103,671 2,466,847 TOTAL 536,042 1,064,1191,668,380 595,318 188,378 2,479,833 6,532,071 PERCENTAGE 8% 16% 26% 9% 3% 38% 100%
40 The Health Sector as defined in the HSSP i.e. preventive and curative health care services. Do not include non health activities in other sectors
141 Annex VII: Programme 9 allocation, releases and expenditure: Approved FUNDS Released FY Expenditure DEPARTMENT amount AVAILABLE AS AT 2004/05 FY 2004/05 FY 2004/05 30 JUNE 2005 Human Resources Division 574,000,000 574,000,000 573,999,999 1 Drugs 15,550,000,000 15,550,000,000 15,547,932,000 2,068,000 Disability Prevention and Rehab 91,000,000 91,000,000 91,000,000 0 Finance and Administration 137,000,000 118,455,924 118,455,924 0 Policy Analysis Unit 46,000,000 39,773,522 39,773,522 0 Blood Transfusion 130,000,000 112,403,432 112,403,432 0 Reproductive Health 182,000,000 157,364,804 157,364,804 0 Environmental Health 73,000,000 63,118,850 63,118,850 0 Health Promotion 413,000,000 357,097,056 357,097,056 0 Sleeping Sickness Programme 91,000,000 78,682,402 78,682,402 0 Disability Prevention and Rehab 33,000,000 28,533,179 28,533,179 0 Health Infrastructure Division 182,000,000 157,364,804 157,364,804 0 Mental Health Programme 22,000,000 19,022,119 19,022,119 0 TB Leprosy 46,000,000 39,773,522 39,773,522 0 Pharmaceutical Section 80,000,000 69,171,343 69,171,343 0 Malaria Control Programme 91,000,000 78,682,402 78,682,402 0 Integrated Disease Surveillence 137,000,000 118,455,924 118,455,924 0 AIDS Control Programme 137,000,000 118,455,924 118,455,924 0 Guinea worm control 201,000,000 173,792,998 173,792,998 0 LF, Schisto & Oncho Control Prog. ( Operations) 91,000,000 78,682,402 78,682,402 0 Nursing 182,000,000 157,364,804 157,364,804 0 Child Health Division 283,000,000 244,693,624 244,693,624 0 Control of Diarrhoeal Diseases (operation 33,000,000 28,533,179 28,533,179 0 Clinical Services Department 73,000,000 63,118,850 63,118,850 0 Veterinary Public Health 33,000,000 28,533,179 28,533,179 0 Community Oral/ Dental Health 73,000,000 63,118,850 63,118,850 0 Public Health emergencies 458,000,000 396,005,936 396,005,936 0 Non Comm. D'ses, (SS, DM ) 91,000,000 78,682,402 78,682,402 0 Quality Assurance Department 78,000,000 67,442,059 67,442,059 0 Resource Centre 410,000,000 354,503,130 354,503,130 0 Planning Department 1,077,000,000 931,219,198 931,219,198 0 NGO's 442,000,000 382,171,667 382,171,667 0 National Drug Authority 71,000,000 61,389,567 61,389,567 0 Chemotherapeutics Laboratory 162,000,000 140,071,969 140,071,969 0 Public Health Laboratories 14,000,000 12,104,985 12,104,985 0 UNHRO 27,000,000 23,345,328 23,345,328 0 UVRI 27,000,000 23,345,328 23,345,328 0 Professional Councils 137,000,000 118,455,924 118,455,924 0 UCBHCA 14,000,000 12,104,985 12,104,985 0 Pathology Services 91,000,000 78,682,402 78,682,402 0 Jinja Children ward contribution 21,000,000 18,157,477 18,157,477 0 Mityana Hospital water supply 30,000,000 25,939,253 25,939,253 0 Labora HC II IDP camp contribution Gulu District-CAO) 76,000,000 65,712,775 65,333,660 379,115 22,210,000,000 21,398,527,478 21,396,080,362 2,447,116 142 Annex VIII: Proposed Recruitment Ceilings for District PHC Health Facilities VOTE District Officers Clinical Medical Officers Dental Surgeons Enrolled Nurses/ Midwives Laboratory Assistants Laboratory Technicians Dispensers Radiographers/Oorth.Off icers/ Dispensers/Anaesth. Tech/PHDA Officers/Lab Officers Anaesth Asst. Anaesth HeaIth Inspectors CN Comp. Nursing Officers/ Nurses PHDA HA Total Allocation
U5 u4 U4 u7 u7 U5 U5 U5 U5 u7 U5 U5 U5 U5 u7
salary/month 461482 693130 693130 305,702 305,702 461482 461482 461482 461482 305,702 461482 461482 461482 461482 305,702
551 Adjumani 3 1 1 7 0 0 0 7 0 0 1 0 5 0 0 25 65,459,316
552 Apac 4 2 10 0 0 0 8 0 0 3 0 5 0 0 32 82,037,520
553 Arua 4 2 11 0 0 0 6 0 0 4 0 0 0 0 27 67,258,380
554 Bugiri 4 2 11 0 0 0 8 0 0 2 0 5 0 0 32 81,102,840
555 Bundibugyo 3 1 11 0 0 0 8 0 0 1 0 5 0 0 29 71,406,276
556 Bushenyi 9 3 1 10 0 0 0 8 0 0 4 0 5 0 0 40 106,968,432
557 Busia 4 2 10 0 0 0 4 0 0 1 0 0 0 0 21 51,579,708
558 Gulu 5 3 10 0 0 0 8 0 0 2 0 0 0 0 28 72,351,840
559 Hoima 4 1 10 0 0 0 4 0 0 2 0 0 0 0 21 50,189,820
560 Iganga 6 2 10 0 0 0 9 0 0 4 0 5 0 0 36 93,113,088
561 Jinja 4 2 10 0 0 0 6 0 0 2 0 2 0 0 26 65,424,168
562 Kabale 5 3 10 0 0 0 6 0 0 2 0 0 0 0 26 66,814,056
563 Kabarole 5 2 10 0 0 0 6 0 0 2 0 0 0 0 25 62,655,276
564 Kaberamaido 5 1 10 0 0 0 4 0 0 1 0 0 0 0 21 50,189,820
565 Kalangala 3 2 4 0 0 0 3 0 0 1 0 0 0 0 13 35,036,652
566 Kampala 0 2 2 10 0 0 0 0 0 0 0 0 5 0 0 19 48,821,700
567 Kamuli 11 5 1 21 3 2 1 12 1 2 4 0 10 0 0 73 186,166,764
568 Kamwenge 4 2 10 0 0 0 5 0 0 1 0 0 0 0 22 54,348,600
569 Kanungu 4 1 10 0 0 0 8 0 0 1 0 5 0 0 29 72,340,956
570 Kapchorwa 4 2 1 10 0 0 0 8 0 0 1 0 5 0 0 31 80,658,516
571 Kasese 5 1 10 0 0 0 9 0 0 3 0 5 0 0 33 83,416,524
143
572 Katakwi 4 2 11 0 0 0 5 0 0 2 0 0 0 0 24 58,951,704
573 Kayunga 4 2 10 0 0 0 8 0 0 1 0 5 0 0 30 76,499,736
574 Kibaale 4 2 1 9 0 0 0 8 0 0 2 0 5 0 0 31 81,593,196
575 Kiboga 4 1 1 9 0 0 0 8 0 0 1 0 5 0 0 29 74,665,524
576 Kisoro 4 1 1 9 0 0 0 8 0 0 1 0 5 0 0 29 74,665,524
577 Kitgum 4 1 14 0 0 0 8 0 0 1 0 5 0 0 33 79,677,804
578 Kotido 4 1 2 14 0 0 0 10 0 0 3 0 8 0 0 42 107,377,608
579 Kumi 4 1 14 0 0 0 8 0 0 2 0 5 0 0 34 82,446,696
580 Kyenjojo 4 1 14 0 0 0 5 0 0 2 0 0 0 0 26 60,295,560
581 Lira 4 3 9 0 0 0 6 0 0 4 0 0 0 0 26 67,748,736
582 Luwero 4 2 1 9 0 0 0 8 0 0 2 0 5 0 0 31 81,593,196
583 Masaka 5 3 9 0 0 0 6 0 0 4 0 0 0 0 27 70,517,628
584 Masindi 5 2 9 0 0 0 10 0 0 2 0 8 0 0 36 94,047,768
585 Mayuge 4 2 9 0 0 0 5 0 0 2 0 0 0 0 22 55,283,280
586 Mbale 5 3 9 0 0 0 9 0 0 4 0 5 0 0 35 92,668,764
587 Mbarara 14 3 9 0 0 0 8 0 0 5 0 0 0 0 39 103,744,332
588 Moroto 5 3 1 9 0 0 0 8 0 0 2 0 5 0 0 33 88,520,868
589 Moyo 5 1 9 0 0 0 8 0 0 2 0 5 0 0 30 76,044,528
590 Mpigi 6 3 1 10 0 0 0 8 0 0 4 0 5 0 0 37 98,661,756
591 Mubende 6 2 10 0 0 0 10 0 0 4 0 8 0 0 40 104,188,656
592 Mukono 9 3 10 0 0 0 8 0 0 4 0 5 0 0 39 102,809,652
593 Nakasongola 4 1 10 0 0 0 5 0 0 1 0 0 0 0 21 50,189,820
594 Napapiripirit 4 1 10 0 0 0 5 0 0 1 0 0 0 0 21 50,189,820
595 Nebbi 5 1 1 10 0 0 0 8 0 0 2 0 5 0 0 32 82,037,520
596 Ntungamo 4 3 10 0 0 0 8 0 0 2 0 5 0 0 32 83,427,408
597 Pader 4 1 10 0 0 0 5 0 0 2 0 0 0 0 22 52,958,712
598 Pallisa 4 2 10 0 0 0 8 0 0 3 0 5 0 0 32 82,037,520
549 Rakai 4 2 2 10 0 0 0 10 0 0 2 0 9 0 0 39 104,199,540
550 Rukungiri 4 3 10 0 0 0 6 0 0 2 0 0 0 0 25 64,045,164
551 Ssembabule 4 3 10 0 0 0 5 0 0 1 0 0 0 0 23 58,507,380
144
552 Sironko 4 2 10 0 0 0 5 0 0 2 0 0 0 0 23 57,117,492
553 Soroti 4 3 10 0 0 0 6 0 0 2 0 0 0 0 25 64,045,164
554 Tororo 4 3 1 10 0 0 0 10 0 0 3 0 9 0 0 40 106,968,432
555 Wakiso 4 2 10 0 0 0 8 0 0 4 0 5 0 0 33 84,806,412
556 Yumbe 4 1 10 0 0 0 8 0 0 2 0 5 0 0 30 75,109,848
751 Arua Mun 1 1 2 0 0 0 0 0 0 0 0 2 0 0 6 16,133,880
752 Entebbe Mun. 0 1 2 0 0 0 0 0 0 0 0 2 0 0 5 13,364,988
753 F/Portal 0 0 0 0 0 0 0 2 0 0 2 5,537,784
754 Gulu Mun. 2 0 0 0 0 0 0 0 2 0 0 4 11,075,568
755 Jinja Mun. 2 2 1 0 0 0 0 0 0 0 0 2 0 0 7 21,227,340 Kampala City 756 Council 0 0 0 0 0 0 0 0 0 0 0
757 Kabale Mun. 2 2 1 0 0 1 0 0 0 0 3 0 0 9 26,765,124
758 Lira Mun. 0 0 1 0 0 0 0 2 0 0 3 8,306,676
759 Masaka Mun. 0 0 1 0 0 0 0 2 0 0 3 8,306,676
760 Mbale Mun. 3 - 0 1 2 6 16,613,352
761 Mbarara Mun. 1 2 3 8,306,676
762 Moroto Mun. 0 2 2 5,537,784
763 Soroti Mun. 2 2 2 0 1 3 10 28,599,336
764 Tororo Mun. 2 - 1 3 6 16,613,352
0
275 120 18 578 3 2 1 403 1 2 125 0 218 0 0 1746 4,481,371,536.0
145 Annex IX: Budget Performance FY 2004/05
FY 2004/05 Budget Projections & Out-turns
TOTAL DONOR WAGE REC. NON-WAGE DOMESTIC DEV. EXCL. DEV. DONORS Budget Budget Budget Budget Budget Out-turn Out-turn Out-turn Out-turn Out-turn % out-turn % out-turn % out-turn
Out-turn Total)
Health 4.56 3.47 76% 27.83 22.35 80% 16.31 15.4 94% 113.46 113.46 48.70 41.17 84.5% Butabika Hospital 1.82 1.22 67% 1.49 1.49 100% 6.92 6.48 94% 13.48 13.48 10.23 9.19 89.8% Mulago Hospital Complex 12.15 12.47 103% 10.29 11.79 115% 1.00 0.76 76% - - 23.44 25.016 106.7% Health Service Commission 0.37 0.37 100% 0.84 0.84 100% 0.04 0.04 100% - - 1.25 1.25 100.0% Uganda Aids Commission 0.54 0.54 100% 0.61 0.61 100% 1.46 1.37 94% 19.79 19.79 2.61 2.52 96.5% District NGO Hospitals/PHC - - - 17.72 17.72 100% - - - - - 17.72 17.72 100.0% District Primary Health Care 68.85 56.07 81% 23.16 22.65 98% 6.09 6.09 100% - - 98.10 84.81 86.5%
District hospitals 0 10.36 10.24 99% 0.00 - - - - 10.36 10.24 98.8% Regional Referral Hospitals 18.09 11.36 63% 6.31 6.31 100% 0.00 - - - - 24.40 17.67 72.4%
TOTAL 106.38 85.50 80.5% 98.6194.00 95.3% 31.82 30.1 94.6% 146.73 146.73 236.81218.79 92.4% Source: Background to the Budget June 2004 Mulago hospital received a supplementary budget for both the wage and non-wage recurrent budgets, which catered for Interns wages and drugs respectively. The worst performing vote was the regional referral hospitals due to under utilization of the allocated wage budget.
146 Annex X: Financial Contribution by different sources at district level
Local District GoU contribution Government Donor projects Total Kayunga 1,537,425,813 34,000,000 528,490,473 2,099,916,286 Kabarole 1,537,398,814 19,516,849 445,654,846 2,002,570,509 Kaberamaido 614,271,498 4,369,876 484,171,787 1,102,813,161 Gulu 2,373,304,564 101,934,341 193,153,100 2,668,392,005 Bushenyi 2,873,609,606 251,019,816 279,104,254 3,403,733,676 Kapchorwa 1,408,489,583 18,000,000 222,950,104 1,649,439,687 Arua 2,987,983,083 73,878,350 1,068,431,710 4,130,293,143 Adjumani 1,395,455,833 57,686,841 387,244,438 1,840,387,112 Kasese 3,583,485,233 90,242,038 172,968,220 3,846,695,491 Wakiso 2,902,294,844 155,000,000 639,359,509 3,696,654,353 Pader 1,240,741,107 276,000 444,561,475 1,685,578,582 Ntugamo 2,036,968,402 2,243,285 193,198,312 2,232,409,999 Kyenjojo 1,129,658,082 25,272,752 501,200,485 1,656,131,319 Mbarara 3,716,322,047 5,120,638 839,082,079 4,560,524,764 Katakwi 1,074,540,191 - 479,998,156 1,554,538,347 Kamwenge 1,021,192,194 19,519,368 137,608,425 1,178,319,987 Iganga 3,006,830,502 43,000,000 382,357,883 3,432,188,385 Jinja 1,298,079,818 26,158,554 443,105,023 1,767,343,395 Yumbe 940,688,807 5,612,000 232,796,617 1,179,097,424 Kanungu 1,648,241,039 - 61,692,768 1,709,933,807 Mpigi 2,079,011,353 36,921,000 1,262,975,000 3,378,907,353 Masaka 2,450,130,943 1,000,000 569,175,504 3,020,306,447 Kalangala 555,157,672 10,673,341 198,535,426 764,366,439 Sembabule 810,080,772 - 51,186,568 861,267,340 Rakai 3,422,236,723 30,100,000 739,650,059 4,191,986,782 Mayunge 1,172,325,108 - 570,252,125 1,742,577,233
147