MPIGI DISTRICT

HEALTH CARE SERVICE STATUS REPORT

August 2016

TABLE OF CONTENTS

LIST OF ACRONYMS ...... ii Chapter One: BACKGROUND ...... 1 1.1 About Us...... 1 1.2 Background ...... 1 1.3 Specific Objectives of the Monitoring Exercise ...... 3 1.2 Methodology ...... 3 Chapter Two: FINDINGS ...... 4 2.1 Human Resources for Health ...... 4 2.2 Leadership and Governance ...... 5 2.3 Medical Services...... 6 2.4 Medical Supplies ...... 9 2.5 Infrastructure and Equipment Management ...... 12 2.6 Vermin Control ...... 16 2.7 Finances and Administration ...... 16 Chapter Three: RECOMMENDATIONS ...... 20

i

LIST OF ACRONYMS ANC – Antenatal Care

CAO – Chief Administrative Officer

DHO – District Health Officer

FY – Fiscal Year

GAVI – Global Alliance for Vaccines Initiative

HC – Health Centre

HMU – Health Monitoring Unit

HSD – Health Sub District

HUMC – Health Unit Management Committee

MRDT – Malaria Rapid Diagnostic Test mTrac – Mobile Tracking

NMS – National Medical Stores

OPD – Outpatients Department

PHC – Primary Health Care

PNFP – Private Not For Profit

SMS – Short Messaging Service

UNICEF – United Nations Children’s Fund

VHT – Village Health Team

ii

Chapter One: BACKGROUND

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

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

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

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

1.2 Background district is a peri-urban district, with a population of 251,512 as of the 2014 population census. The district is divided into two health sub districts (HSDs), namely: Mawokota North and Mawokota South. It has only one hospital ( General Hospital – Mawokota South HSD headquarters) which is a Private Not For Profit (PNFP) facility and one government HC IV (Mpigi HC IV – Mawokota North HSD headquarters), which ought to be upgraded to a general hospital status.

HMU over time received numerous complaints about the status of health care service delivery through various platforms including the mTrac dashboard as shown in table 1 below.

Table 1: Some of the complaints / reports received on the anonymous mTrac dashboard Facility Date Reports Comments Butoolo 13/09/ We don't get medicine at butoro health center HC III 2016 kammengo mpigi the situation is alarming please help DHT, for your attention Butoolo 17/07/ Musawo sekiipi Ku dwaliro a butoolo atujako Sente fe HC III 2015 abalwadde ba pulesa ate tetulina sente Aba VHT EBUWAMA sub County twagema abaana 01/10/ polio nqa 1 ne 2 Dec.216 temwatuwa kantu konna "We VHTs were given any facilitation HC III 2016 yadde entambula lwaki kiri bwekityo when we immunized for polio 1 and 2" Buwama 23/04/ Ssebo abebuwama mutuwa eddagala tonno the drugs supplied to the health center HC III 2016 mutuyambe. are not enough BANANGE TUKUBA OMULANGA KUDWALILO Please come to our rescue as we lack Kibumbir 23/05/ LYEKIBUMBILO TEMULIMUUDAGALA ELYAFFE drugs at Kibumbiro Hc. DHT, for your o HC II 2015 ABALWADDE. immediate action and follow up ENO EMPIGI KIRINGENTE,EKAGEZI,TUBEBAZZA Kiringent OKUWA OMUSAWO AYITIBWA.MUSAWO e Epi SSEBATA.PETER, KUDWALILO KAGEZI Centre 14/08/ EPICENTER. AKOLA.NE KU.WEEKEND, HC II 2016 EKITALIWWO. Good Service Report Kituntu 03/09/ POOR SERVICE KITUNTU HEALTH CNTRE !!! HC III 2015 MPIGI 1

Facility Date Reports Comments Mpigi 22/05/ DHT, for your immediate action and HC IV 2015 No Drugs From Mpigi Health Centre follow up Nze nemulugunya kuba sawo heath center Muduum 10/08/ lll . Batandika okuttuka kuddelwaliro a HC III 2016 sawa (5) ate muddwaliro temuli dagala Muddwaliro Emudduma - Mpigi, Abasawo Batusaba In Muduma HC III we are charged for Sente Okutukebeera Omusayi, N'okutukula Amanyo blood tests and dental services. please Muduum 11/02/ Mutuyambe Tufaa, Bwoba Tolina Sente Tofuuna help us, if you dont have money you a HC III 2016 Bujjanjabi. dont get services Muduum 18/12/ edwalilolyemuduumalyaganvumentnayebatusenteant a HC III 2015 enyinjibatandikirakumitwaloentanomubagambeko. Muduum 13/08/ no drugs in muduuma health centre 3,mpigi district. DHT, for your immediate action and a HC III 2015 why? follow up HEALTH WORKERS AT MUDUUMA HEALTH Muduum 19/05/ CENTER ARE SO CARING THANK YOU BUT THEY a HC III 2015 COME LATE Nabyew anga HC 30/01/ "There are no midwives in II 2016 Edwalilolyenabyewangatemulimubazalisa Nabyewanga health centre" NABYEWANGA HEALTH CENTRE II MUMPIGI There are no drugs in Nabyewanga Hc Nabyew TEMUBEERA DDAGALA KATI NAKU 3O. II in Mpigi district for 30 days now. anga HC 08/09/ ABASAWO BTUUKA SAAWA TAANO KU Health workers reach the facility at 11: II 2015 DDWALIRO MUTUYAMBE TULIBUBI NNYO. am. please help us. banange tusaba mutuyambe bekiikwatako empiji Nabyew mukore orukiiko nga rugata abalwadde nabasowo anga HC 25/06/ muwuriire obuziibu byeturina kubanga tuffa.omwavu II 2015 talwarenga? I was at nabyewanga the other day requesting for health worker to come akora mumateneti nansaba sente nemwegayirira to my rescue and she told me poor Nabyew anyambe nagana nambuza nt'omwavu people donot deliver children or go into anga HC 11/05/ azara?tubegayiride mutukyusizemu on'mukyara ye labor. She refused to help me unless I II 2015 ayagara sente atuyisa bubi. paid her money. There are no drugs at nindye hc3. Nindye 16/08/ DHT, for your immediate action and HC II 2015 NNINDYE H/C III temuli ddagala okumala sabiiti 2. follow up "Please help us. We have very few Nkozi health workers in Nkozi" HOSPIT 28/04/ MUTUYAAMBE KO ENKOZI TULINA ABASAWO AL 2016 BATONO. DHT, for your attention. Nkozi HOSPIT 18/12/ AL 2015 lacks opticians Nkozi There are no health workers on duty at HOSPIT 23/04/ Nkozi Hospital. DHT, for your AL 2015 Nkozi teli basauo kuba feabaluo tuo koye otuola immediate action and follow up Nsamu/ Kyali HC 28/06/ Edwaliro lye mu kwaba mpigi district kyali batunda III 2016 edagala lya goverment There is no services here at ssekiwunga health center Sekiwun 28/06/ 3, in mpigi district, please help us in those warkers ga HC II 2016 thanks DHT, for your attention. Sekiwun 06/10/ MORE PATIENTS NO NURSES IN SEKIWUNGA ga HC III 2016 H/C (111), MPIGI DISTRICT,

2

Facility Date Reports Comments Ssekiwu SEKIWUNGA HEALTH CENTRE 3 MPIGI THEY DO nga HC 28/07/ HAVE ANY MEDICENI EVEN PANADOL OR III 2015 ASPRIN Ssekiwu nga HC 27/07/ i-)SEKIWUNGA TEBALINA DAGALA WANDE NE III 2015 KAPANADO NEKA ASPRIN There are no drugs not even Panadol.

1.3 Specific Objectives of the Monitoring Exercise  To assess the level of effectiveness within the health service delivery systems of the district through direct monitoring of health facilities.

 To identify and rectify any forms of healthcare malpractice, poor administration and mismanagement of healthcare resources.

 To provide feedback to all stake holders involved in health service delivery as well as the public, so as to jointly work-out practical solutions.

1.2 Methodology The HMU team conducted site visits of Public and PNFP health facilities in the district. The evaluation exercise took on the form of on-spot un-announced visits to selected health facilities, where monitoring was conducted with the guidance of an approved data collection tool and observation checklists. Areas of interest were: infrastructure and equipment inventory, medicines management and audit, financial expenditure audit, staffing, administration and effectiveness of health services delivered at the visited facilities.

At every health facility visited, on spot training of health workers was done in case of identified gaps mainly in the areas of drug and records management, sterilization, accountability and mTrac.

Seventeen health centres were visited for assessment of health care service delivery as shown in table two below.

Table 2: Health facilities visited No. Facility Name Level No. Facility Name Level 1. Nkozi (PNFP) Hospital 10. Kampiringisa HC III 2. Mpigi HC IV 11. Ssekiwunga HC III 3. Bunjako HC III 12. Kyaali HC III 4. Buwama HC III 13. Nabyewanga HC II 5. Kituntu HC III 14. Bumoozi HC II 6. Ggolo HC III 15. Bukasa HC II 7. Butoolo HC III 16. DHO’s Clinic HC II 8. Muduuma HC III 17. Kibanda HC II 9. Nindye HC III

3

Chapter Two: FINDINGS The findings of the monitoring visit are presented below in seven sub-sections, which are: (i) Human Resources for Health; (ii) Leadership and Governance; (iii) Finances and Administration; (iv) Medical Services; (v) Medical Supplies; (vi) Infrastructure and Equipment Management; and (vii) Vermin Control.

2.1 Human Resources for Health Staffing Levels: The approved staffing norms are 48 staff at HC IV and 19 at HC III. Fig. 1 below shows the staffing levels at the visited facilities as a percentage of the approved norm.

Generally, the facilities were adequately staffed; Mpigi HC IV the highest level public facility was well staffed with 98% of the approved norm; while Buwama HC III with 116% had the highest staffing levels owing to the high population served by the facility, Muduuma HC III was the third with 95% staffing levels.

Unfortunately, with the exception of Muduuma HC III the good staffing levels were not matched with good service delivery standards as it was curtailed by poor staff attitude and rampant absenteeism as indicated below. It is not clear why Bunjako HC III had an outstandingly low staffing level.

Absenteeism: Despite the adequate staffing levels at the health centres, gross absenteeism was noted at most facilities, which resulted in long patients’ queues and long waiting time. Most health centre in- charges were not found on duty during the monitoring exercise citing that they were attending workshops and carrying out quality improvement in the lower facilities.

Fig. 2 above shows the number of days facility in-charges had attended in the past two months as obtained from staff attendance book (Arrival book). It is evident that only two (Mpigi HC IV and Buwama HC III) had attended at least 30 days in two months, implying that the other seven did not deserve a salary in those two months as they had not worked the minimum of 15 days a month. However, even those with relatively high attendance there were glaring indications of forgery of attendance records as staff could record for their colleaugues. This practice was most evident at Buwama HC III where it was

4 clear that the in charge was never at the facility. It was found that the Askari and cleaner were managing the OPD including updading the dispensing logs.

At Bukasa HC II on the day of the monitoring visit no health worker was found on duty by 11:00AM, yet the duty roster indicated the facility had a total of seven (7) staff. The only person at work was the Health Information Assistant (HIA) who had been newly recruited (5month in service). He was found red- handed clerking patients, carrying out blood tests, prescribing and dispensing drugs to patients.

Mothers and patients stranded at Kampiringisa HC Warning notice against absenteeism at Nindye HC III III without being attended to by 11:00am

Abandonment of duty: A number of staff had abandoned duty and remained on the payroll drawing salaries without rendering any service hence causing financial loss to government. An enrolled nurse at Ggolo HC III had gone on annual leave in April 2016 and not returned for four months by the time of the visit, yet the in-charge had not reported the matter to the DHO’s office.

Staff houses: Most health facilities except Muduuma HC III reported lack of adequate staff accommodation as a reason for late reporting and early departures from duty. Mpigi HC IV with 47 staff had only 16 housing units. Nonetheless the available staff houses however few, should be occupied by the critical clinical staff and commuting to the place of work should never be accepted as reason for late reporting.

At Butoolo HC III, a maternity ward had been turned into staff house.

2.2 Leadership and Governance There was lack of quality supervision from the expected supervisory heads right from the district, to health sub districts and to facility levels. The DHO and the entire DHT last visited Kituntu HC III over three years (on 12th March 2013). Butoolo HC III and Kampiringisa HCIII had been supervised only once in the last five years.

5

Internal audit function does not examine, review and provide feedback to the lower facilities when they submit accountability files, they are instead kept at the DHO’s office. For the last three years facilities had not received feedback in regard to bookkeeping.

Most staff at the various facilities had not been oriented by their supervisors on how to perform their duties for example most nurses that doubled as store keepers are not taught how to fill and update stock cards with their requisition books.

2.3 Medical Services Muduuma HC III was found to be a centre of excellence in the whole district in terms of service delivery and stewardship. The OPD structure was neat one examination room, injection room, laboratories, and mini-store. Staff quarters were very clean and staff were found on duty at the time of our visit. The compound, maternity ward, toilets were all clean. The drug accountability was perfect using issue and requisition books. The maternity ward was well managed with all records available.

On the other hand Kampiringisa HC III was rated the worst facility in terms of service delivery in the whole district. A rift had emerged between the facility in-charge and the Kampiringisa remand home, thus hindering the juveniles from accessing the health care services from the facility. The staff and In- charge were constantly away from the facility and patients often had to wait for long hours to see health workers.

The figures below show the number of OPD attendances and inpatient admissions in one month at the visited facilities.

OPD Functionality: Generally, all health facilities were found running quite busy OPDs as shown in fig. 3 above. This implies a high disease burden in the district. Mpigi HC IV had the highest number of OPD attendances closely followed by Buwama HC III.

General Admission facilities: Figure 4 above clearly depicts that Buwama HC III had the busiest inpatient department even surpassing Mpigi HC IV which is at a higher level. Muduuma HC III inpatient department was also well functional.

6

It can be seen that the inpatient departments at Kampiringisa, Kituntu, Butoolo and Bunjako HC IIIs were non-functional. This is despite the availability of admission facilities i.e. general ward and beds at all these facilities.

Bales of mosquito nets were found heaped at facilities without being issued out and not used by the patients on the wards, hence exposing patients and caretakers to new malaria infections from the health centres.

Filthy admission mattress at Bunjako HC III Torn examination couch – Bunjako HC III

Functionality of Maternity and ANC Services: Figure 5 below clearly depicts a very low proportion of deliveries conducted to total ANC attendances in all visited facilities (less than 30%).

Muduuma HC III had the highest proportion of Deliveries to Total ANC attendances i.e. 227 : 845 (27%) followed by Mpigi HC IV and Ggolo HCIII both with 25%. The worst was Kituntu HC III where only 5% of ANC attendances were delivered at the facility.

This can be attributed to the gross levels of absenteeism and poor attitude of health workers characterised by use of rude language to pregnant mothers. This is worsened by extortion especially at Mpigi HC IV where mothers had to buy a Mama kit at UGX 38,000/=, JIK and detergent. This illegality was approved by the DHO and in-charge of Mpigi HC IV.

7

Mpigi HC IV had 12 midwives and still complained of being understaffed but comparing with the ratio of midwives to deliveries at the lower facilities e.g. Muduuma and Buwama, the complaint ceases to be valid. This implies that there is pseudo-understaffing caused by absenteeism, poor duty roster planning and abandonment of duty by some health workers.

An exceptionally performing Midwife despite the chaos at Ggolo HC III

8

At Ggolo HC III maternity beds in good working condition had been turned into shelter for chicken as shown in the picture below.

Ggolo HC III:

Admission beds in good working condition turned into a chicken house

2.4 Medical Supplies All health centres visited had drug stores and acknowledged regular delivery of essential medicines and other supplies from National Medical Stores (NMS) every two months.

There was general mismanagement of the stores in almost all facilities, which had caused a financial loss in terms of drugs pilferage. This was exacerbated by unauthorised inter-facility transfers of medicines and other medical supplies. The worst case scenarios were at:

 Ggolo HC III: Lacked consistent use of stock cards and issue and requisition vouchers at the facility as there was free entry and exit to the medicine stores;

 Kampiringisa HC III: There was gross mismanagement of the stores. Medicines were oftentimes transferred to the district stores for redistribution yet resident patients were not given priority. Moreover, the redistributions were without proper documentation and authorisation. Some members of the DHT were reportedly involved in directly picking medical supplies from the facility without the required authorisation;

 Kituntu HC III: Lacked accountability for both PHC funds and medical supplies;

 Butoolo HC III: The in-charge and stores in-charge failed to account for medical supplies;

 Bunjako HC III: The medicine store was being managed by VHTs.

 Ssekiwunga HC III: There was total mismanagement of mama kits and general poor accountability of medicines.

9

 Mpigi HC IV: The medicines management focal person collects medicines from lower facilities but they are not received into the HC IV stores records hence could not be traced.

Alterations were noted on stock cards as the quantity in and out and balance on hand figures would not add up.

The following anomalies were common in most of the facilities;

. DHO picking drugs from facilities with no written record for proper tracking of drugs to and from her store at the district. . One requisition book is used in the entire facility for all departments like OPD, Maternity and admission wards. . All laboratories manage their own determine kits. . Authorization control is jeopardized as issues out of the store are not approved by the head in charge of the facility, the issuer and receiver never sign for what is taken and received which makes tracking of drugs out of the store very difficult. . Missing entries in the requisition books and stock cards which made reconciling the two very difficult. . Requisition and issue vouchers were not closed after issuing out items from the store.

Kampiringisa HC III: Unduly signed Butoolo HC III: Medicines transferred to Mpigi HC IV without DHO’s requisition and issue voucher approval (Middle). Unduly signed requisition & Issue voucher (R)

An audit of the district medical stores revealed that essential medicines and other health supplies worth UGX 38,743,175/= could not be accounted for. Worse still, losses through inter-facility transfers that could not be accounted for, amounted to UGX 156,319,397. The total loss is over 195million shillings as shown in the table below.

10

Table 4: Unaccounted for medicines by the district medical stores

Item Total un Pack size Unit Value Monetary value accounted for

Caps Amoxycillin (Tins) 139 1000 43,200 6,004,800 Tabs Paracetamol (Tins) 75 1000 12,420 931,500 Tabs Coartem (1*30*24) 80 30 191,311 15,304,880 Determine Test Kits (1*100) 14 100 293,760 4,112,640 MRDT (1*25) 212 25 40,500 8,586,000 Inj Quinine (Vial) 540 100 61,322 331,139 Inj Oxytocin (Vials) 500 100 20,196 100,980 Surgical gloves (Pairs) 100 50 47,222 94,444 Tabs Cotrimaxazole (Tins) 66 1000 33,232 2,193,312 Tabs Chlopromazol (Tins) 5 Tabs Fansidar (Tins) 5 1000 91,800 459000 Normal Salaine(Botles) 15 24 28,512 17,820 Tabs Metronidazole (Tins) 4 1000 11,971 47,884 Ampicilline (Vials) 150 100 38,336 57,504 Choramphenicol (Botles) 140 1 432 60480 Diazepam (Amps) 240 Diazepam (Tins) 9 1000 12,558 113022 Promethazine (Tins) 1 1000 8,923 8,923 Mebendazole (Tins) 5 1000 27,283 136,415 Maama Kits 3pc 1 21,060 63,180 Syringes (5ml) 300 100 18,507 55,521 Tabs Magnesum (Tins) 2 1000 10,789 21578 Tabs Amitripytillin (Tins) 3 1000 9731 29,193 CAF Eye (Bottles) 20 1 648 12,960 38,743,175 Other inter- facility losses Caps Amoxycillin 56 1000 43200 2,419,200 Tabs Lumartem 477 30 191311 91,255,347 Inj Quinine 140 100 61322 85850 Tabs Paracetamol (Tins) 168 1000 12420 2086560 AZT/3TC 449 60 Determine Test Kits (1*100) 194 100 293760 56989440 MRDT (1*25) 86 25 40500 3,483,000 156,319,397

Expiries: Expired Medicines that had not been collected over a long period were few in most facilities except Nindye HC III.

11

Expired drugs at Nindye HC III Newly constructed lab at Mpigi HC IV

2.5 Infrastructure and Equipment Management Tidiness of health facilities: Most facilities with the exception of Muduuma HC III, Nindye HCIII and Kituntu HCIII were found unkempt.

Muduuma HC III: Well kempt and staff in uniform Ggolo HC III: Dirty OPD patients’ waiting area

Ceiling of Ggolo HC III infested with bats Old and dilapidated ceiling of Kituntu HC III

12

Buwama HC III: New latrines constructed 1 year ago not in use (L); Old latrines still in use (R)

Fencing, Land Titles and Encroachment: Most of the visited facilities were not fenced; thus compromising the security of persons and property of the facilities. Fencing also acts as a deterrent to land encroachment. Land encroachment was reported at Butoolo HC III and Mpigi HC IV.

Ongoing constructions: On-going construction was observed at Nindye HC III where a maternity block was being constructed.

Nindye HC III: Maternity ward under construction Poor medicine accountability at Butooro HC III

Stalled constructions: This was noted in Kampiringisa HC III, where the maternity ward structure had stalled for over four years (since 2012), however, it was being used in spite of lacking any water supply and as a result it was very filthy.

13

Inventory and Equipment engraving: There was total lack of inventory management. Most equipment could not be traced even when the record showed otherwise. Most government equipment in the facilities were not engraved, which predisposes them to theft. The table below shows the status of equipment inventory versus the physical count at the visited facilities.

Staff houses of Muduuma HC III Walkways of Mpigi HC IV

Table 4: Inventory status in health facilities Facility Number PRINTER Maternity General Computers Moto Ambulance Fridges beds ward cycle beds

Stated in - 5 9 1 1 - 1

book

Physical - 4 9 1 1 - 1 count

Kituntu HC III Kituntu HC Variance - 1 - - - - -

Stated in ------

book HC III HC

Physical - - 2 2 1 - 1

count Ggolo Variance ------

Stated in - 5 15 1 1 - - book

Physical - 5 13 1 1 - -

count Butoolo HCIII

14

Facility Number PRINTER Maternity General Computers Moto Ambulance Fridges beds ward cycle beds

Variance - - 2 - - - -

Stated in - 8 7 1 - - 1 book

Physical - 7 4 1 - - 1

count

ekiwunga ekiwunga HC III s

S Variance - 1 3 - - - -

Stated in - 10 14 1 - - 1 III book

Physical - 10 14 1 - - 1 count

mpiringisa mpiringisa HC Variance ------Ka

Stated in ------book

Physical 1 10 - 3 - - 1 count

Buwama HC Buwama III Variance

Stated in 2 31 36 3 3 2 7

book

Physical 2 21 30 3 3 2 7

count Mpigi Mpigi HC IV Variance - 10 6 - - - -

Presence and Functionality of Ambulance: At the time of our visit the district had two functional ambulances.

15

Utilities: At Kampiringisa HC III, the in-charge had not taken trouble to ensure that the newly constructed maternity building is connected to water supply. Other facilities that lacked water supply were: Bunjako, Butoolo and Buwama HC IIIs.

2.6 Vermin Control All health facilities except Muduuma HC III were found heavily infested with bats, which make the facilities filthy and emit a foul smell. The most affected facilities were Bunjako HC III, Ggolo HC III and Kampiringisa HC III. All this is in spite of the fact that, the district an entomology office (vector control).

Ggolo HCIII:

Medicines store taken over by bats

2.7 Finances and Administration An audit covering three financial years namely: FY2013/14, FY2014/15 and FY2015/16 was conducted. The district health sector had received PHC funds both for recurrent expenditure (non-wage) and capital development grants. It was also funded by partners like UNICEF, GAVI and Mildmay.

In FY2015/2016 PHC non-wage grant direct transfers to lower facilities was UGX 396,109,083/=; while district health office PHC non-wage grant was UGX 52,553,803/= and PHC for capital development was UGX 35,548,913/=.

In FY2014/2015 PHC capital development release was UGX 169,920,770/=; while in FY2013/2014 PHC capital development release was worth UGX 189,939,169/=.

The table below shows a summary of queried funds, while a detailed report awaits responses from the responsible officers.

Table 5: Summary of queried funds FY PHC Non-Wage & Unexplained GAVI Funds UNICEF Funds Mild May Funds Capital Development Retention Fees FY2015/16 15,969,000 18,717,034 164,385,642 20,515,908 29,947,928

FY2014/15 14,220,000

16

FY2013/14 230,020,040

TOTAL 260,209,040 18,717,034 164,385,642 20,515,908 29,947,928

In addition the following anomalies were revealed:

Norrkoping (U) Limited received a payment worth 101,286,432/= yet is NOT a prequalified supplier as per the list obtained from procurement.

Retention fees for construction of maternity ward at Nindye HC III had been paid to the contractor (WAMCO), although the building is not complete.

Lack of internal controls: Almost all lower health facilities visited, lacked controls to safeguard the facilities’ assets that is cash and medical supplies. For instance none of the following controls were in place:

 Authorization of documents like requisitions and payment vouchers; money is paid out WITHOUT formal approval from the heads of departments. The in-charge is the principal signatory to the account and he/she can: make requisitions, withdraw money and then pay out.

 There is NO segregation of powers, the in charge is the Accountant at the same time the head of department to approve and make payments. Which raises a query as the in-charge solely controls the cycle.

There was lack of transparency in the utilisation of PHC funds at the lower units as none of the facilities was found displaying PHC releases and accountability for public viewing. It was also noted that management of PHC was the preserve of the in-charge and a top secret.

Undeclared funds: On the 17/11/2015, a total of UGX 24,759,800/= was deposited on the Mpigi HC IV account by UNRA as compensation for the facility’s portion of land encroached upon during the upgrading of Mpigi–Maddu–Ssembabule Road. The health centre uses the same account for PHC funds and other funds. The health centre failed to follow PHC guidelines which require a separate account for PHC funds. By the time of the Audit, funds had already been spent without an approved budget and work plan from CAO.

Variations in PHC releases to HSDs: Out of the DHO PHC non-wage recurrent grant a certain percentage is to be paid to the health sub districts which are: Mawokota North (Mpigi HC IV) and Mawokota South (Nkozi hospital) for monitoring and supervision of the lower Units as per the PHC guidelines section 5.0.

In FY 2015/16 the DHO’s office received UGX 52,523,803 and sent UGX 11,842,712 (23%) to Mawokota South HSD (Nkozi hospital), however, in FY 2015/16 and 2013/2014, Mawokota North HSD (Mpigi HC IV) did not receive any funds. And it was noted that most HSD funds received especially for Mpigi HC IV has been spent on other activities rather than those stated in the PHC guidelines section 5.0. 17

Extraction of funds as contribution to the health assistants: Lower health units were found to be contributing funds to health inspectors and their Assistants as their inspection fee to facilitate their transport. This resolution was passed by the district health team at the district meeting with the in- charges in 2013/14 unfortunately there was no trace of the minutes from the DHO’s office.

18

Table 6: Mawokota South HSD contributions for inspection from October 2014 – June 2015 FACILITY AMOUNT EXPECTED AMOUNT PAID BALANCE

Bukasa HC II 120,000/= 80,000/= 40,000/=

Buwama HC III 180,000/= 120,000/= 60,000/=

Bunjako HC III 180,000/= 120,000/= 60,000/=

Ggolo HC III 180,000/= 60,000/= 120,000/=

HSD referral unit 120,000/= 120,000/= 0

Kituntu HC III 180,000/= 120,000/= 60,000/=

Mitala Maria HC II 180,000/= 0 180,000/=

Nabyewanga HC II 120,000/= 80,000/= 40,000/=

Nindye HC III 180,000/= 120,000/= 60,000/=

TOTAL 1,440,000/= 820,000/= 620,000/=

 Bunjako HC III contributed 50,000/= for April-June 2015/2016.

Mpigi HC IV’s contribution;

QTR AMOUNT

July-Sept15/16 420,000/=

Apr-Jun15/16 417,000/=

Jan-Mar 13/14 417,000/=

July-Sept13/14 417,000/=

TOTAL 1,671,000/=

19

Chapter Three: RECOMMENDATIONS The team recommends that:

 The CAO reprimands errant officers including DHO for Neglect of duty

 The district constitutes a district health monitoring team and develops a comprehensive supervision tool encompassing technical areas of healthcare service delivery and start conducting comprehensive monitoring rather than sporadic monitoring of a few health centres.

 All facility in charges should update and submit to CAO facility inventories of all infrastructure and equipment at the facilities and immediately embark on engraving all equipment and furniture of the facilities.

 Health unit in-charges should be trained on financial management and accounting procedures.

 All entities MUST display funds releases for public viewing.

 Senior Assistant Secretaries (Sub County Chiefs) MUST carry out frequent on-spot checks at the health facilities and regularly close the arrival registers by 9:00AM to deter late coming and absenteeism.

 Internal Auditors at the district should examine the PHC file accountabilities and give feedback to the respective in charges through the management letter.

 HUMCs should be oriented to understand their roles better.

 The DHO’s office MUST coordinate all trainings and workshops because these leave health units devoid critical staff and it has become a common excuse for absenteeism.

 Health unit in-charges, caretakers of medicine stores and all health workers should be mentored on proper medicines management procedures and put in place Standard Operating Procedures.

20