THE REPUBLIC OF UGANDA
MINISTRY OF HEALTH
ANNUAL HEALTH SECTOR PERFORMANCE REPORT
FINANCIAL YEAR
2015/2016
Hon.Dr. Ruth Jane Aceng Minister of Health
Hon. Sarah Opendi Hon. Dr. Joyce Moriku Minister of State for Health/ Minister of State for Health/ General Duties Primary Health Care
Dr. Asuman Lukwago Permanent Secretary
Prof. Anthony Mbonye Ag. Director General Health Services
Dr. Henry G. Mwebesa Director Health Services Planning& Development
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Annual Health Sector Performance Report for Financial Year 2015/16
TABLE OF CONTENTS
TABLE OF CONTENTS ...... iv FOREWORD ...... Error! Bookmark not defined. LIST OF TABLES ...... vi LIST OF FIGURES ...... viii ACRONYMS ...... i FOREWORD ...... v 2 INTRODUCTION ...... 1 2.1 Background ...... 1 2.2 Vision, Mission, Goal and Strategic Objectives of the HSDP 2015/16 – 2019/20 ...... 1 2.3 The Projected Demographics for FY 2015/16 ...... 2 2.4 The process of compiling the report ...... 2 3 Overall Sector Performance and Progress ...... 3 3.1 Health Impact Indicators ...... 3 3.2 Performance against the key Health and Related Services Outcome Targets ...... 7 3.3 Performance against the key Health Investment Output Targets ...... 10 3.4 Health Partnerships ...... 27 3.5 Local Government Performance ...... 34 3.6 Health Facility Performance ...... 38 4 ANNEXES ...... 49 4.1 Annex One:Delivery of the Uganda National Minimum Health Care Package (UNMHCP)...... 49 4.2 Annex Two: Integrated Health Sector Support Systems ...... 74 4.3 Annex Three: Progress in Implementation of the 21st RJM Aide Memoire ...... 100 4.4 Annex Four: Disaggregation of Key Performance Indicators ...... 108
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Annual Health Sector Performance Report for Financial Year 2015/16
FOREWORD
The health of the population is central to socio –economic transformation of the country. In line with statutory requirements, Government reviews the annual performance of the health sector in order to assess progress on agreed outputs and performance of the health sector and come up with strategies and recommendations on how to improve health care service delivery.
The annual Health Sector Performance Report for financial year 2015/16 provides progress of the annual health sector work plan as well as the overall health sector performance against the set targets agreed upon with key stakeholders in financial year 2015/16. The report is the first annual review under the Health Sector Development Plan 2015/16- 2019/2020. This report shall be presented to stakeholders in the 22nd Joint Review Mission in which the sector shall specifically review what has been achieved, what has not been achieved and the reasons why the set targets have not been achieved. The review shall guide future planning and programming and help to refocus priorities towards achieving the National Development plan targets and the Sustainable Development Goals.
The sector will continue to prioritize interventions defined in the five year Health Sector Development Plan with emphasis on efficiency and effectiveness in health service delivery. The Government of Uganda recognizes the contributions of the Health Development partners, the Civil Society Organizations, the private sector and the community in the achievement of progress in financial year 2015/16.
Improvements in performance were made possible by the commitment of health providers and health workers in the public and private sector, working under sometimes difficult conditions especially in the hard to reach districts in the country. I commend the dedicated and productive health workers and implore and appeal to those who are not dedicated to work ethics in the health sector to improve so that the country health indicators improve to acceptable levels.
I wish to thank members of Health Policy Advisory Committee and all partners for their contributions in the preparation of the Annual Health Sector Performance report and co financing the Joint Review Mission. Special gratitude to the MoH Planning Directorate that ensured that this annual report and the accompanying documents are available to all the participants.
For God and My Country
Hon. Dr. Aceng Jane Ruth Minister of Health
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Annual Health Sector Performance Report for Financial Year 2015/16
LIST OF TABLES
Table 1: Population Projections for FY 2015/16 ...... 2 Table 2: Leading causes of Under 5 in-patient mortality ...... 4 Table 3: Trends in Maternal Mortality and Total Fertility Rate ...... 5 Table 4: Leading causes of maternal deaths among maternal deaths audited...... 5 Table 5: Common factors underlying maternal deaths ...... 6 Table 6: Performance against the Health Service Outcome targets ...... 7 Table 7: CYP by method ...... 9 Table 8: Performance against the Health Investment targets ...... 10 Table 9: Persons who fell sick by the first Source where Treatment (%) ...... 11 Table 10: Comparison of source of services based on the HMIS data for 2015/16 FY ...... 12 Table 11: Median Distance (KM) to Health facilities visited by residence (2015) ...... 12 Table 12: Availability Indicator for the 41 commodities ...... 13 Table 13: Progress in Maternal death notification and reporting ...... 14 Table 14: Trends in Government allocation to the Health Sector 2010/11 to 2015/16 ...... 18 Table 15: GOU Budget Performance for FY 2015/16 ...... 19 Table 16: PHC Grants FY 2010/11 - 2015/16 in Ushs billions ...... 19 Table 17: PHC Non-wage Allocation By Service Delivery Strata Within The PHC System ...... 20 Table 18: Human Resource trends in the Public Sector 2010/11 to 2015/16 ...... 20 Table 19: Staffing level at different level of service in public sector fy 2015/16 ...... 21 Table 20: Staffing at RRHs ...... 22 Table 21: Staffing level for health professionals disaggregated by cadres ...... 22 Table 22: Overall staffing level in the public sector versus the PNFP sector ...... 23 Table 23: HPAC Institutional representatives’ attendance ...... 27 Table 24: Progress in implementation of the HSDP Compact during FY 2015/16 ...... 28 Table 25: Top 15 performing districts Table 26: Bottom 15 performing districts...... 35 Table 27: TOP and bottom 10 District ranking for new districts FY 2015/16 ...... 36 Table 28: TOP AND BOTTOM 10 hard-to-reach districts as per the hard-to-reach DLT ...... 36 Table 29: Staffing levels for 10 Top and Bottom Districts ...... 37 Table 30: Health facility outputs and Outcomes by level of care FY 2015/16 ...... 38 Table 31: Budget Performance for National Referral Hospitals ...... 39 Table 32: SUO for National Referral Hospitals FY 2015/16 ...... 39
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Annual Health Sector Performance Report for Financial Year 2015/16
Table 33: Budget performance for RRHs ...... 40 Table 34: Outputs and Outcomes from Regional/large Hospitals ...... 41 Table 35: Cost per SUO in RRHs in FY 2015/16 ...... 41 Table 36: Leading causes of morbidity in RRHs in FY 2015/16 ...... 42 Table 37: Leading causes of death in RRHs in 2015/16 FY ...... 42 Table 38: Leading causes of morbidity in General hospitals in 2015/16 FY ...... 43 Table 39: leading cuases of Death in General Hospitals in FY 2015/16 ...... 44 Table 40: Facility based Maternal Mortality ratio for GHs in 2015/16 FY ...... 45 Table 41: Leading causes of morbidity at HC IVs in 2015/16 FY ...... 47 Table 42:Leading causes of mortality at HC IVs in 2015/16 FY ...... 47 Table 43: Showing Total Number Staff In UCMB Health Facilities From 2011- 2016 ...... 67 Table 44: Showing Annual Outputs of UCMB Health Training Schools for 5 years ...... 68 Table 45: Progress of Renovation of 9 Hospitals ...... 91 Table 46: Infrastructure development projects status ...... 93
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Annual Health Sector Performance Report for Financial Year 2015/16
LIST OF FIGURES
Figure 1: Trends in Newborn, Infant and Child Mortality in Uganda (UDHS & WHS) ...... 3 Figure 2: Households’ Rating of Government Health facilities (%) ...... 15 Figure 3: Distribution of health professionals by employment status ...... 24 Figure 4: Households by type of Toilet facility used (%) ...... 25 Figure 5: Households by Availability of Hand washing Facilities (%) ...... 25 Figure 6: Percentage of HIV+ pregnant women initiated on ART in FY 2015/16 ...... 30 Figure 7: % of pregnant women completing IPT2 by district FY 2015/16 ...... 30 Figure 8: % of Health Facility Deliveries by District FY 2015/16 ...... 31 Figure 9: % of pregnant women attending ANC 4th visit by district FY 2015/16 ...... 32 Figure 10: Latrine Coverage ...... 32 Figure 11: TB treatment success rate by District in 2015 ...... 33 Figure 12:Annual cholera cases in Uganda for the period 2013/14 to 2015/16 ...... 50 Figure 13: Total OPD and Confirmed Malaria Cases in the 14 IRS Districts ...... 59 Figure 14: Percentage of malaria laboratory confirmed cases FY 2015/16 ...... 60 Figure 15: Trends in income for recurrent cost in UCMB network in the last 5 years ...... 65 Figure 16: Hospitals and HC IVs % Income by Source Figure 17: Lower Level Units Income by Class 69 Figure 18: Weekly Surveillance Reporting by Region ...... 84 Figure 19:Reporting rates by region October 2015 to April 2016 ...... 86
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Annual Health Sector Performance Report for Financial Year 2015/16
ACRONYMS
ACT Artemisinin Combination Therapies AHSPR Annual Health Sector Performance Report AIDS Acquired Immuno-Deficiency Syndrome ANC Ante Natal Care ART Anti-retroviral Therapy ARVs Antiretroviral Drugs BFHI Baby Friendly Health Initiative CAO Chief Administrative Officer CCM Country Coordinating Mechanism CDC Centres for Disease Control CDD Control of Diarrhoeal Diseases CDP Child Days Plus CDR Case Detection Rate CEmOC Comprehensive Emergency Obstetric Care CPR Contraceptive Prevalence Rate CSO Civil Society Organization CYP Couple Years of Protection DFID Department for International Development DHO District Health Officer DHMT District Health Management Team DLT District League Table DOTS Directly Observed Treatment, short course (for TB) DPT Diphtheria, Pertussis (whooping cough) and Tetanus vaccine EAC East African Community ECSA-HC East Central and Southern Africa - Health Community EID Early Infant Diagnosis EMHS Essential Medicines and Health Supplies CEmOC Comprehensive Emergency Obstetric Care eMTCT Elimination of mother-to-child transmission of HIV FP Family Planning FY Financial Year GAVI Global Alliance for vaccines and Immunization GBV Gender Based Violence GFTAM Global Fund to fight TB, Aids and Malaria GH General Hospital GoU Government of Uganda HAART Highly Active Anti-Retroviral Therapy HC Health Centre
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HDP Health Development Partners HMIS Health Management Information System HPAC Health Policy Advisory Committee HRH Human Resources for Health HSD Health Sub-Districts HSDP Health Sector Development Plan HSSIP Health Sector Strategic Investment Plan IDSR Integrated Disease Surveillance and Response iCCM Integrated Community Case Management IEC Information Education and Communication IMAM Integrated Management of Acute Malnutrition IMCI Integrated Management of Childhood Illness IMR Infant Mortality Rate IPT Intermittent Presumptive Treatment for malaria IRS Indoor Residual Spraying ITNs Insecticide Treated Nets JICA Japan International Cooperation Agency JMS Joint Medical Stores JRM Joint Review Mission KOICA Korea International Agency for Cooperation LG Local Government MDGs Millennium Development Goals MDR Multi-drug Resistant MIP Malaria in pregnancy MMR Maternal Mortality Ratio MOFPED Ministry of Finance, Planning and Economic Development MoGLSD Ministry of Gender, Labour and Social Development MOH Ministry Of Health MOLG Ministry of Local Government MOPS Ministry of Public Service MOU Memorandum of Understanding MPDR Maternal Perinatal Death Review MTEF Medium Term Expenditure Framework MTR Mid-Term Review NCD Non Communicable Diseases NCRI National Chemotherapeutic Research Institute NDA National Drug Authority NGOs Non-Governmental Organizations NHP National Health Policy NMCP National Malaria Control Program
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NMR Neonatal Mortality Rate NMS National Medical Stores NPHC National Population and Housing Census NSDS National Service Delivery Survey NTDs Neglected Tropical Diseases NTLP National Tuberculosis and Leprosy Control Program OPD Out Patients Department ORS Oral Rehydration Salt PHC Primary Health Care PLWHA People with HIV/AIDS PMI Presidential Malaria Initiative PMDT Programmatic Management of Multi-Drug Resistant TB PMTCT Prevention of Mother to Child Transmission PNFP Private Not for Profit PPPH Public Private Partnership for Health PRDP Peace Recovery and Development Plan RH Reproductive Health RMNCAH Maternal and Child Health RRH Regional Referral Hospital SDGs Sustainable Development Goals SGBV Sexual and Gender Based Violence SLD Second Line Drugs SMC Senior Management Committee SMER Supervision, Monitoring, Evaluation and Research SP Sulfadoxine/Pyrimethamine STI Sexually Transmitted Infection SUO Standard unit of Output SWAP Sector-Wide Approach TB Tuberculosis TFR Total Fertility Rate TMC Top Management Committee TSR Treatment Success Rate TWG Technical Working Group UACP Uganda Aids Control Program UBOS Uganda Bureau of Statistics UBTS Uganda Blood Transfusion Services UCI Uganda Cancer Institute UDHS Uganda Demographic and Health Survey UHC Universal Health Coverage UHSSP Uganda Health Systems Strengthening Project
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Annual Health Sector Performance Report for Financial Year 2015/16
UHI Uganda Heart Institute UNEPI Uganda Expanded Program on Immunization UNFPA United Nations Fund for Population Activities UNHRO Uganda National Health Research Organization UNICEF United Nations Children’s Fund UNMHCP Uganda National Minimum Health Care Package USAID United States Agency for International Development USF Uganda Sanitation Fund UVRI Uganda Virus Research Institute VHT Village Health Team WHO World Health Organization WHS World Health Statistics
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Annual Health Sector Performance Report for Financial Year 2015/16
2 INTRODUCTION 2.1 Background The Annual Health Sector Performance Report (AHSPR) is an institutional requirement compiled to highlight progress, challenges, lessons learnt and propose ways of moving the health sector forward‖ in relation to the National Development Plan (NDP), National Health Policy, the national health strategy. The AHSPR Financial Year (FY) 2015/16 is the sixteenth annual report produced by the Ministry of Health (MoH).This report is the first annual report for the Health Sector Development Plan (HSDP) 2015/16 - 2019/20. The report mainly focuses on the progress of the annual workplan as well as overall health sector performance against the targets set for the FY 2015/16. The report takes into consideration the annual performance in terms of the effectiveness, responsiveness and equity in the health care delivery system, how well the integrated support systems have been strengthened as well as the status of programme implementation and overall development mechanisms. The sector performance will be deliberated upon during the 22nd Joint Review Mission (JRM) slated for September 29th to 30th, 2016. The outcomes of the sector performance review are expected to guide planning and programming for the next financial year.
2.2 Vision, Mission, Goal and Strategic Objectives of the HSDP 2015/16 – 2019/20
2.2.1 Vision The vision of Uganda’s health sector is to have a healthy and productive population that contributes to economic growth and national development.
2.2.2 Mission The mission of the sector is to facilitate the attainment of a good standard of health by all people of Uganda in order to promote a health and productive life.
2.2.3 Goal The sector’s goal as stipulated in theHSDP is to accelerate movement towards Universal Health Coverage (UHC) with essential health and related services needed for promotion of a healthy and productive life.
2.2.4 Strategic Objectives The overall strategic direction for the sector is provided by the strategic objectives of the HSDP namely; i. To contribute to production of a healthy human capital for wealth creation through provision of equitable, safe and sustainable health services.
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Annual Health Sector Performance Report for Financial Year 2015/16
ii. To address the key determinants of health through strengthening intersectorall collaboration and partnerships. iii. To increase financial risk protection of households against improverishment due to health expenditures. iv. To enhance the health sector competitiveness in the region and globally.
2.3 The Projected Demographics for FY 2015/16 The population for the period under review has been projected from UBOS’s National Population and Housing Census 2014 using a growth rate of 3%. The projected figures are shown in table 1 below.
TABLE 1: POPULATION PROJECTIONS FOR FY 2015/16
Demographic Variable Proportion Projected Population (2015) Total population 100% 35,756,800
Males 48.6% 17,377,805 Females 51.4% 17,915,056
Children under 1 year 4.3% 1,537,542 Children under 5 years 17.7% 6,328,954 Children below 18 years 55.1% 19,701,996
Adolescents and youth (young people) (10 – 24 years) 34.8% 12,443,366 Expected pregnancies 5% 1,787,840 Women of reproductive age(15-49 years 20.2% 7,222,874 UBOS Mid-year population projections 2015
2.4 The process of compiling the report The process of drafting the AHSPR was widely consultative with stakeholders from all departments of MoH, Health Development Partners (HDPs) and Civil Society Organizations (CSOs). The initial drafts were done by Technical Working Groups (TWGs) and collated by the secretariate for writing the report i.e. MoH Planning Department.
Information used for compiling the report was both quantitative and qualitative and consisted principally of data generated from the MoH HMIS - District Health Information Software (DHIS)-2 for the FY 2015/16 supplemented by; i. Health Sector Development Plan (HSDP) 2015/16 to 2019/20 ii. Ministerial Policy Statement (MPS) 2015/16 iii. Quarterly progress reports for the FY 2015/16 iv. Output Budgeting Tool reports v. National Population and Housing Census, 2014 vi. Uganda Demographic Health Survey, 2011 vii. National Service Delivery Report, 2015 viii. Uganda Hospital and HC IV survey 2014
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Annual Health Sector Performance Report for Financial Year 2015/16
3 Overall Sector Performance and Progress This chapter highlights an overview of the sector performance of FY 2015/16. It focuses on the performance indicators enshrined in the HSDP 2015/16 – 2019/20, Ministerial Policy Statement of FY 2015/16 and annual workplans from different departments and institutions in the sector.
3.1 Health Impact Indicators The health impact indicators are used to assess the effect of service delivery on the population and these include but not limited to; 1. Neonatal Mortality Rate (NMR) 2. Infant Mortality Rate (IMR) 3. Under five mortality Rate 4. Maternal Mortality Ratio (MMR) 5. Total fertility rate (TFR)
Figure 1 presents the trends in newborn, infant and child mortality in Uganda.The WHO Statistics estimates for 2014 and 2015 have been used since the UDHS 2016 is yet to be undertaken.
FIGURE 1: TRENDS IN NEWBORN, INFANT AND CHILD MORTALITY IN UGANDA (UDHS & WHS)
200 152 158 137 150 89 90 85 76 100 69 66 54 45 44 33 50 29 27 23 22
Per 1,000 live births 0 1995 2001 2006 2011 2014 2015
Neonatal Mortality Infant Mortality Under 5 Mortality
3.1.1 Neonatal Mortality Rate Neonatal mortality rate (NMR) captures newborn deaths occurring in the first 28 days of life and is expressed at the population level as a rate per 1,000 live births. There has been an improvement in NMR from 27 (UDHS 2011) to 22 per 1,000 live births (WHS, 2015). This improvement is due to training programs for skilled birth attendants and other health workers launched by the MoHand availability of life saving commodities which have helped to raise newborn care standards and the diagnosis and management of newborn sepsis including referral of sick babies through the Integrated Community Case Management (iCCM).
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Annual Health Sector Performance Report for Financial Year 2015/16
With three years to go this performance falls short of the HSDP target of 16 per 1,000 live births. Intensification of perinatal deaths surveillance and audits, strengthening community awareness, perinatal health and quality of newborn care services should accelerate further the reduction of preventable newborn deaths.
3.1.2 Infant Mortality Rate and Under Five Mortality Rate The IMR stands at 44 per 1,000 (WHS, 2015) which is a significant improvement from IMR of 54 per 1,000 live births (UDHS 2011). Regarding the Under Five Mortality Rate there has been a significant reduction from 90 per 1,000 live births (UDHS 2011) to 66 per 1,000 live births (WHS 2015).
This significant reduction in both indicators is largely attributed to intensified government efforts to implement high impact child survival interventions. According to MoH HMIS reports, malaria remains the leading cause of death among infants and the under-fives. In 2015/16, the disease was responsible for 43% of hospital-based under-five deaths. But important to note is the significant increase in the number deaths attributed to malaria in this FY against the declining trend in the previous 2 years. According to hospital records in 2015/16, the other leading causes of child fatalities are pneumonia (11%), anemia (10.6%) and neonatal sepsis (6.3%).
TABLE 2: LEADING CAUSES OF UNDER 5 IN-PATIENT MORTALITY
2013/14 FY 2014/15 FY 2015/16 FY Diagnosis No. % Diagnosis No. % Diagnosis No. % Malaria 4,030 28.8 Malaria 3,059 22.6 Malaria 5,295 42.8%
Pneumonia 1,824 13.0 Pneumonia 1,659 12.2 Pneumonia 1,382 11.2%
Anaemia 1,620 11.6 Perinatal Conditions 1,476 10.9 Anaemia 1,312 10.6% (in new borns 0 -7 days) Perinatal 1,105 7.9 Anaemia 1,314 9.7 Neonatal Sepsis 778 6.3% Conditions (in (0-7days) new borns 0 -7 days) Neonatal 611 4.4 Neonatal 712 5.3 Diarrhoea – 430 3.5% Septicaemia Septicaemia Acute Respiratory 441 3.1 Septicemia 457 3.4 Septicaemia 347 2.8% Infections (Other) Septicaemia 388 2.8 Diarrhoea – Acute 404 3.0 Injuries - 275 2.2% (Trauma due to other causes) Perinatal 358 2.6 Injuries - (Trauma 382 2.8 Respiratory 261 2.1% Conditions (in due to other Infections (Other) newborns 8-28 causes) days) Diarrhoea – 337 2.4 Injuries - Road 375 2.8 Injuries - Road 244 2.0% Acute Traffic Accidents Traffic Accidents
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Annual Health Sector Performance Report for Financial Year 2015/16
Severe 294 2.1 Severe Malnutrition 317 2.3 Gastro-Intestinal 185 1.5% Malnutrition (Kwashiorkor) disorders (non (Kwashiorkor) Infective) Others 2,994 21.4 Others 3,399 25.1 Other 1,849 15% Total 14,002 100 Total 13,552 100 Total 12,358 100
Key interventions that have been scaled up include immunization, increased use of Long Lasting Insecticide Treated Nets (LLINs), elimination of mother to-child transmission of HIV (eMTCT), and improved water and sanitation. Training programs for skilled birth attendants and other health workers launched by the MoH have also helped to raise newborn care standards and the diagnosis and management of common childhood illnesses including the iCCM.Also the strengthening and scaling up immunization including introduction of the pneumococcal vaccine, eMTCT, increased use of ITNs and improved sanitation have also contributed to this. More concerted efforts are needed to sustain this and work towards the target at all levels.
3.1.3 Maternal Mortality Ratio (MMR) The MMR has reduced to 320 per 100,000 live births (WHS 2015) from 438 per 100,000 (UDHS 2011). The reduction is attributed to Governments efforts in recruiting critical skilled staff especially Medical Officers and midwives to functionalize HC IVs and IIIs, renovation and equipping of hospitals and HC IVs plus improvements in the roads network, all which have improved access to maternal health services.
TABLE 3: TRENDS IN MATERNAL MORTALITY AND TOTAL FERTILITY RATE
Indicator UDHS 2011 WHO WHO HSDP target (WHS, 2014) (WHS, 2015) 2019/20 MMR 438/100,000 360/100,000 320/100,000 320/100,000 TFR 6.2 - 5.8 (NPHC) 5.1 NB: The WHS will be validated by UDHS 2016
In FY 2015/16, the leading causes of death are still Obstetric haemorrhage and sepsis accounting for 39% and 20% respectively. Hypertensive disease and abortion related death (Table4).
TABLE 4: LEADING CAUSES OF MATERNAL DEATHS AMONG MATERNAL DEATHS AUDITED
Cause 2011/12 2012/13 2013/14 2014/15 2015/2016 Freq % Freq % Freq % Freq % Freq % Obstetric haemorrhage 131 31.5 75 34.7 94 34.9 99 42 96 39 Obstructed labour and 72 17.3 5 2.3 30 11.2 19 8 22 9 uterine rupture Pre-eclampsia and 45 10.8 22 10.2 46 17.1 28 12 23 9 eclampsia Postpartum sepsis 75 18.0 20 9.3 32 11.9 25 11 49 20 Complications of unsafe 63 15.1 21 9.7 35 13.0 7 3 23 9 abortion
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Annual Health Sector Performance Report for Financial Year 2015/16
Other direct causes 30 7.2 3 1.4 32 11.9 35 15 12 5 Indirect causes aggravated 0 0.0 70 32.4 0 0.0 10 4 16 7 by pregnancy Unknown 0 0 0 0 0 0 15 6 5 2 Total 416 100.0 216 100.0 269 100 238 100 246 100
Maternal death review committees also consider what may be the avoidable factors. Delay in seeking care was still perceived as the common reason. Health system factors- especially lack of blood was a major unavoidable factor (Table 5).
TABLE 5: COMMON FACTORS UNDERLYING MATERNAL DEATHS
Delay Underlying factors 2011/12 2012/13 2013/14 2014/15 2015/16 Factors Freq % Freq % Freq % Freq % Freq %
Health 1. Delay of the 112 68 101 65 110 63 46 56 103 60 Seeking woman seeking Behaviour help A. 2. Lack of partner 19 12 26 17 35 20 22 27 41 24 Personal/ support Family/ 3. Herbal 17 10 18 12 17 10 5 6 10 6 Woman medication factors 4. Refusal of 8 5 - - 8 5 5 6 9 5 treatment or admission 5. Refused transfer 8 5 11 7 6 3 4 5 8 5 to higher facility Total 164 100 156 100 176 100 82 100 171 100 Reaching 1. Lack of transport 13 54 19 51 17 49 13 42 18 42 the health from home to service health facilities point 2. Lack of transport 11 46 18 49 18 51 18 58 25 58 B. Logistical between health systems facilities Total 24 100 37 100 35 100 31 100 43 100 Receiving Lack of blood 69 63.3 56 47 44 35 32 33 85 42 adequate products, supplies & health care consumables C. Health service Staff lack of 22 20.1 24 20 20 16 19 20 31 15 expertise D. Health Absence of critical 11 10.1 24 20 25 20 19 20 59 29 personnel human resource problems Inadequate numbers 7 6.4 16 13.3 36 29 26 27 28 14 of staff Total 109 100 120 100 125 100 96 100 203 100 Source: MPDR Report 2011/12, 2012/13, 2013/14, 2014/15, 2015/16
According to the MPDR report, 2014/15 there were 411 perinatal deaths reviewed and the main causes of perinatal deaths include: birth Asphyxia (n=285, 69.3%), Infections (n=57, 13.9%), prematurity (n=44, 10.7%) Birth trauma (n=15, 3.6%), Congenital syphilis (n-8, 1.9%) and tetanus (n=2, 0.5%). The report also identified the commonest avoidable factors as including delay of pregnant women seeking care, lack of transport and staff non-action. Page | 6
Annual Health Sector Performance Report for Financial Year 2015/16
3.1.4 Total Fertility Rate (TFR) The TFR for Uganda stands at 5.8 (NPHC, 2014), which is a decline from 6.2 (NPHC 2000). The general declining trend in TFR is associated with the changed attitude on the size of the family with more preference for small families. This is due to underlying socio-economic determinants like improved education for women, improved economic status combined with improved child survival among other factors.
3.2 Performance against the key Health and Related Services Outcome Targets
The health and related services outcome indicators focus on communicable disease prevention and control, and essential clinical and rehabilitative care. The sector performance is highlighted below focusing on comparison of performance with the previous FY and the HSDP targets for 2015/16 FY. Summary of the performance is in Table 6.
TABLE 6: PERFORMANCE AGAINST THE HEALTH SERVICE OUTCOME TARGETS
Indicator Performance Performance 2015/16 HSDP Target 2014/15 Achievement Disaggregation 2015/16 ART Coverage 56% 88% 57%
HIV+ pregnant women not on 72% (2013/14) 68.3% 85% HAART receiving ARVs for eMTCT during pregnancy, labour, delivery and postpartum TB case detection Rate (all forms) 80% NA 83|% (2014/15) IPT2 doses coverage for pregnant 53.4% 55% 58% women (2014/15) IPT3 doses coverage for pregnant NA NA 93% women In Patient malaria deaths per 30 22 M – 20 13 100,000 persons per year (2013/14) F – 23 Malaria cases per 1,000 persons per 460 408 M - 365 198 year (2013/14) F – 480 Under five vitamin A second dose 26.6% 28% M– 27% 66% coverage (2013/14) F– 28% DPT3HibHeb3 Coverage 102.4% 103% M– 105% 95% (2014/15) F– 99%) Measles coverage under 1 year 90% 96% M – 96% 90% (2014/15) F – 93% Bed occupancy rate NA 83% RRH (Hospitals & HC IVs) 50% (2013/14) 62% GH 62% 59% (2013/14) 52.2% HC IV 55% Average length of stay (Hospitals & NA 4 NRH 4 HC IVs) NA 4 RRH 4 4 (2013/14) 4 GH 4 3 (2013/14) 3 HC IV 3 Contraceptive prevalence Rate 30% 30% 39% (UDHS 2011) Couple year of protection 2,196,713 2,232,225 4,300,000 Page | 7
Annual Health Sector Performance Report for Financial Year 2015/16
Indicator Performance Performance 2015/16 HSDP Target 2014/15 Achievement Disaggregation 2015/16 (2014/15) ANC 4 Coverage 37% 38% 37.5% Health Facility deliveries 53% 55% 54% HC IVs offering CEmOC services 33% 36% 55% HC IVs conducting C/S 51% 62% 55% HC IVs conducting blood transfusion 38.5% 40.4% 55% (75/198)
ART coverage increased from 56% to 88% (898,197/1,196,547) above the HSDP target of 57%.
HIV+ pregnant women not on HAART receiving ARVs for eMTCT during pregnancy, labour, delivery and postpartum was 68.3% (34,357/50,323) in 2015/16 which was below the performance of 72% in 2013/14 and also below the HSDP target.
IPT3 coverage was not assessed this FY because the HMIS tools have not yet been revised to capture this indicator. IPT2 coverage was used as a proxy measure and was at 55% (982,276/1,787,840) in 2015/16 a slight increase from 53.4% in 2014/15.
In Patient malaria deaths recorded in 2015/16 were 22/100,000 persons which is a significant decline from 30/100,000 in 2013/14. This is still far below the HSDP target of 13/100,000 for FY 2015/16. More deaths occurred among females at 23/100,000 compared to 20/100,000 among males.
The number of malaria cases per 1,000 persons reduced from 460 in 2013/14 to 408 in 2015/16 way above the HSDP target of 198 per 1,000 in 2015/16. More females were affected at 480 cases per 1,000 compared to 365 per 1,000 among males. Malaria is still the top most cause of morbidity among all ages.
These indicators didn’t change much due to largely the malaria epidemic in the ten districts in Northern Uganda where indoor residual spraying was conducted and stopped in 2014.
Apart from the malaria epidemic and the high incidence of malaria in a number of districts, non-adherence to test results still remains a major challenge. A proportion of patients with negative malaria tests receive
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ACTs while a small proportion still receive treatment without testing.
Under five Vitamin A second doses coverage was 28% (1,889,053/6,794,599) in 2015/16, with 27% coverage for males and 28% for females. Coverage was far below the HSDP target (66%) for 2015/16. Despite the availability of Vitamin A, there has been a decline in Vitamin A coverage over the last 3 years because the districts no longer conduct Child Days or Family Health Days. A few districts however had picked up the Child Days in their workplans and have continued to allocate some little funds to this activity. There is need to integrate Vitamin A administration with EPI activities.
DPT3 coverage was 103% (1,562,180/1,537,542) compared to 102.4% in 2014/15. Of these 782,600 were males with coverage of 105% (782,600/747,246) among males, and 779,580 were females with coverage of 99% (779,580/790,297).
Measles coverage improved from 90% in 2014/15 to 96% (1,443,015/1,537,542) in 2015/16 FY. Of these 718,100 were males with coverage of 96% (718,100/747,246) among males, and 715,692 were females with coverage of 93% (715,692/790,297). This was above the HSDP target of 90%.
The bed occupancy rate was highest for the RRHs at 83%, general hospitals at 62% (an improvement from 50% in 2013/14) and 52.2% for HC IVs compared to 59% in 2013/14 FY. Bed occupancy rate in HC IVs was below the HSDP target of 55%. The performance level of the various levels shows that there is need to improve the functionality of the HC IVs and general hospitals to decongest the RRHs so that they concentrate on delivering secondary level care.
The average length of stay for hospitals was 4 days and 3 days for HC IVs. All these were within the HSDP target.
There was no new data for contraceptive prevalence rate, however there was a slight increase in the Couple Years of Protection (CYP) to 2,242,225 compared to 2,196,713 in 2014/15. Implants, IUDs and injectables were the highest contributors to the total CYPs at 735,952 CYPs, 727,910 CYPs and 572,342 CYPs respectively.
TABLE 7: CYP BY METHOD Data Total CYP Jul 2015 to CYP Total CYP Jun 2016 Factor Emergency contraceptives 1,078 28,975 0.0143 414 Female condoms 1,196 494,498 0.002 989 IUD 761,005 145,582 5 727,910 Injectable 555,543 2,289,366 0.25 572,342 Male condoms 50,113 40,408,127 0.002 80,816
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Oral micogynon 5,220 319,021 0.0143 4,562 Oral other 435 27,197 0.0143 389 Oral ovrette or another POP 467 27,633 0.0143 395 Oral: Lofeminal 560 35,405 0.0143 506 Tubal Ligation 150,025 6,812 12.5 85,150 Implant Users 647,010 210,272 3.5 735,952 Vasectomy 24,063 2,624 12.5 32,800 Total 2,196,713 2,242,225
Antenatal care (ANC) coverage for the fourth visit was 38% (667,119/1,787,840) in FY 2015/16 which was an increase from 36.6% in 2014/15 and above the HSDP target of 37.5% for FY 2015/16.
Health facility deliveries improved from 53% (958,077/1,787,840) in 2014/15 to 55% in 2015/16 and this was above the HSDP target (54%) for FY 2015/16.
The proportion of HC IVs offering CEmOC services (Caesarean Section and blood transfusion) was 36% (72/198) compared to 33% in 2014/15. The number of HC IVs conducting Caesarean Sections without blood transfusion services also increased significantly to 62% (122/198) from 51% in the previous FY. Similarly there was an increase in the % of HC IVs offering blood transfusion from 38.5% to 40.4% (80/198) in 2015/16.
3.3 Performance against the key Health Investment Output Targets
The key health result areas under healthinvestments are health infrastructure, medicines and health supplies, improving quality of care and responsiveness, health information, financing and human resources. The sector performance is highlighted below focusing on comparison of performance with the previous FY and the HSDP targets for 2015/16 FY. Summary of the performance is in Table 8.
TABLE 8: PERFORMANCE AGAINST THE HEALTH INVESTMENT TARGETS
Indicator Performance Performance FY 2015/16 HSDP Target 2014/15 2015/16 Achievement Disaggregation New OPD Utilization rate 1.2 1.2 M- 1.0 1.1 F - 1.5 Hospital (Inpatient)admissions per 6 7.2 7 100 population (2013/14) Population living within 5km of a 75% 100% 77% health facility Availability of a basket of 64% 87% 86% commodities in the previous quarter for the 6 tracer (% of facilities that had over 95%) medicines Facility based fresh still births (per 16 13 15 1,000 deliveries) (2013/14|) Page | 10
Annual Health Sector Performance Report for Financial Year 2015/16
Indicator Performance Performance FY 2015/16 HSDP Target 2014/15 2015/16 Achievement Disaggregation Maternal deaths among 100,000 118 119 114 health facility deliveries Maternal death reviews 32% 37% 38% Under Five deaths among 1,000 17 19 M - 15.1 17.6 under 5 admissions (2013/14) F - 22.3 ART Retention rate 79% 79% 83% (2014/15) TB treatment success rate 79% 79% 82% Client satisfaction index 69% 46% 71% (UHSSP, survey (NSDS 2015) 2014) Timeliness of reporting (HMIS 105) 88% 79.4% 88% Latrine coverage 77% 75% 74.5% (2014/15)
3.3.1 Utilization of health services The new OPD utilization rate for FY 2015/16 was 1.2 of which per capita utilization for males was 1.0 and females 1.5 indicating that females utilize the OPD services more than males. Hospital (Inpatient) admissions were 7.2 per 100 population, thus achieving the HSDP target of 7 per 100 population. There was an increase from 6 per 100 in FY 2013/14.
During the National Service Delivery Survey (NSD) conducted in 2015, information was collected on the source of treatment sought for the sickness or injury suffered in the last 30 days before the survey. Table 9 shows the percentage distribution of persons that fell sick and where they first sought treatment. At national level, the majority of persons who fell sick first sought treatment from a Government health facility, which has persistently increased from 33% to 51%; followed by private health facilities which, has also increased from 29% to 36% between 2004 and 2015.
There was a notable decrease in the proportion of persons that did not seek treatment from 4% in 2004 to less than 1% in 2015. A similar trend was observed for those that had used self-medication from 11% in 2004 to 1% in 2015.
TABLE 9: PERSONS WHO FELL SICK BY THE FIRST SOURCE WHERE TREATMENT (%)
Source of treatment 2004 2008 2015 Government health facility 33.1 36.7 50.5 Private health facility 28.6 27.1 36.0 Pharmacy / drug shop 17.8 16.1 9.8 Religious / Mission facility 2.7 2.9 0.9 Home / self medication 10.6 8.0 0.6
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Traditional healer 1.1 0.8 0.5 NGO health facility 1.0 0.8 0.5 Community health worker / VHTs 0.4 0.3 0.5 Other 0.9 0.3 0.6 None 3.8 7.1 0.03 Total 100 100 100
Disaggregation of the findings by sub-region, shows the proportion of persons that first sought treatment for illness suffered in the last 30 days from a Government health facility ranged from 26% in Kampala to 74% in Karamoja and West Nile respectively. The reverse was true for private health facilities with 59% in Kampala followed by Central1 (50%) while Karamoja registered the lowest (15%).
Table 10 below shows comparison of source of services in FY 2015/16 which also shows that over 70% of the selected services are sought from the Public Sector
TABLE 10: COMPARISON OF SOURCE OF SERVICES BASED ON THE HMIS DATA FOR 2015/16 FY
Indicator Public PNFP Private Total No. % No. % No. % No. % OPD 35,369,304 79.8% 6,101,314 13.8% 2,826,032 6.4% 44,296,650 100 attendance (New and re- attendance) In patient 1,835,354 69.2% 733,991 27.7 83,985 3.1% 2,653,330 100 admission Deliveries 759,510 79.3% 169,893 17.7% 28,674 3.0% 958,077 100 DPT3 1,191,745 76.3% 317,581 20.3% 52,854 3.4% 1,562,180 100 vaccinations Measles 1,101,223 76.3% 290,891 20.2% 50,901 3.5% 1,443,015 100 vaccinations
3.3.2 Access to health facilities According to the NSDS 2013, 75% of the population was living within 5km of a health facility. The NSDS 2015, found that nationally, the median distance to the Government health facility is 3 km compared to only 1.2 km for other health facilities. The majority of persons who fall sick walk (60%) followed by those that use Public Motorcycle – Bodaboda (21%) to the health facilities. This implies that physical access to health facilities has been addressed with the current health structure.
TABLE 11: MEDIAN DISTANCE (KM) TO HEALTH FACILITIES VISITED BY RESIDENCE (2015) Page | 12
Annual Health Sector Performance Report for Financial Year 2015/16
Sub-region Government health facility Other health facility Rural Urban Total Rural Urban Total Kampala - 2.4 2.4 - 0.9 1.0 Central 1 4.8 3.1 3.0 2.0 0.7 1.0 Central 2 3.2 2.4 1.6 1.0 1.0 1.6 Busoga 3.0 1.6 2.5 2.0 0.8 1.0 Bukedi 3.0 2.0 2.0 1.0 0.6 1.3 Bugisu 2.5 2.5 2.0 1.0 0.5 0.8 Teso 4.0 1.3 3.0 1.6 0.9 1.0 Karamoja 3.0 0.6 3.0 3.0 0.3 0.6 Lango 3.0 2.0 2.0 1.5 1.0 2.0 Acholi 4.8 2.0 4.8 4.8 2.0 2.0 West Nile 3.0 1.6 3.0 3.0 0.5 1.5 Bunyoro 5.0 1.9 3.0 1.6 1.0 1.6 Tooro 3.5 1.5 3.0 1.5 1.0 1.0 Ankole 3.5 1.5 3.0 2.0 1.0 2.0 PDRD Districts Sporadically affected 3.2 2.0 3.0 2.0 0.8 2.0 Severely affected 4.0 2.0 4.0 3.0 2.0 2.0 Spillovers 3.0 2.0 2.0 1.5 0.5 1.0 Mountainous areas 2.0 1.0 2.0 1.0 1.0 1.0 Islands 6.0 1.5 1.0 0.5 0.5 1.5 National 3.2 2.0 3.0 1.6 0.9 1.2
3.3.3 Medicines and Health Supplies In this period (2015/16), availability of health commodities as measured by a basket of 41 commodities was available 87% of the time and an average of 52% of health facilities that reported had over 95% availability of the basket of commodities. ARV's and RMNCAH baskets had the highest availability however more than a quarter of health facilities still experienced a stock out of EMHS. In spite of the high availability, funding for EMHS through GoU did not increase from 2014 stagnating at UGX 219 billion with a greater proportion of ARV, TB and RMNCAH commodities funded by donors.
On the other hand average lead time for commodities to be delivered to the health facility significantly reduced over the years from 59 days (ranging from 20 to 215 days) in 2010/11 to 35 days (range 0 to 120 days) in 2015. The National Medical Stores (NMS) set the maximum lead time from receipt of facility order to delivery at the facility as 60 days. Adherence to the order and delivery schedule and last mile delivery have played a critical role in improving the lead time.
TABLE 12:AVAILABILITY INDICATOR FOR THE 41 COMMODITIES
Indicator 1: Average %age availability of the basket of 41 Jan-Mar Apr-Jun Overall Average Break down % n % N % EMHS (15 items) 84% 3,305 89% 3,686 86% ARV (8 items) 86% 1,586 91% 1,318 89% TB (2 items) 80% 1,125 85% 1,135 83%
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LAB (7 items) 85% 2,853 88% 3,423 87% RMNCAH (9 items) 87% 3,162 90% 3,583 89% Overall Average 85% 89% 87%
Indicator 2: % age of facilities with over 95% availability Jan-Mar Apr-Jun Overall Average Break down % n % N % EMHS (15 items) 44% 3,305 55% 2,015 49% ARV (8 items) 43% 1,586 58% 755 50% TB (2 items) 53% 1,125 67% 759 60% LAB (7 items) 47% 2,853 61% 2,078 54% RMNCAH (9 items) 38% 3,162 56% 1,994 47% Overall Average 45% 59% 52%
Adherence to treatment guidelines is monitored for three common illnesses namely malaria, mild or moderate upper respiratory tract infections and diarrhoea. Adherence to treatment guidelines improved for all conditions with the greatest improvement for malaria at (82%), diarrhoea (60%), Upper Respiratory Tract Infections (37%) respectively.
3.3.4 Improving Quality of Care
Facility based fresh still births (per 1,000 deliveries) reduced from 16 per 1,000 in 2013/14 FY to 13 per 1,000 in 2015/16. This surpassed the HSDP target of 15/1,000 for 2015/16.On the contrary the number of maternal deaths among 100,000 health facility deliveries slightly increased to 119 from 118 per 100,000. This could be attributed to the improved reporting.
In 2015/16 FY a total of 1,136 maternal deaths were reported through the MoH HMIS and of these only 246 (22%) maternal deaths were notified and only 419 (37%) reviewed/audited.
The MoH policy guidelines on maternal and perinatal deaths categories maternal and perinatal death as a notifiable event that has to be notified to the Ministry within 24 hours of occurrence. It thence calls for a maternal- perinatal review within seven (7) days. It mandates the existence of death registers where all deaths to women of reproductive age and perinatal children who die should be recorded.
TABLE 13: PROGRESS IN MATERNAL DEATH NOTIFICATION AND REPORTING
Item 2010/11 2011/12 2012/13 2013/14 2014/15 2015/2016 Total number of deaths notified 13 45 129 371 238 246 Number of maternal deaths reported 1,005 1,206 1,169 1,147 1,019 1,136 through HMIS
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% of maternal deaths notified compared 1.3% 3.7% 11.0% 32.3% 23.4% 21.7% to reported in HMIS
The rate of under five deaths among 1,000 under 5 admissions was high at 19 per 1,000 which was an increase from 17 per 1,000 in 2013/14 FY. The HSDP target was 17.6 per 1,000. ART retention rate stagnated at 79% in comparison with last FY and was below the HSDP target of 83%. TB treatment success rate also stagnated at 79% in comparison with last FY, and below the HSDP target of 82%. According to the NSDS Report 2015, the proportion of households that reported that the overall quality of services provided at Government health facility was good increased from 41% in 2008 to 46% in 2015. There was no change in the percentage of households that indicated the responsiveness of the staff in Government as good in 2015 compared to 2008. On the other hand, the proportion of households that rated the availability of drugs as good declined between 2008 and 2015 by four percentage points.
FIGURE 2: HOUSEHOLDS’ RATING OF GOVERNMENT HEALTH FACILITIES (%)
mTrac is a government led national program that focuses on strengthening the Health Management Information System (HMIS), and more specifically identifying supply side bottlenecks, monitoring response, and improving communication channels among health care Page | 15
Annual Health Sector Performance Report for Financial Year 2015/16
providers at all levels within the health system in Uganda. The primary motivation is to improve data collection and transmission from frontline health facilities using structured SMS reporting, which in turn provides timely and more disaggregated data on health service quality in health systems. Currently over 35,000 health workers from 4,000 health facilities in all 112 Districts are enrolled in mTrac. About, 2,000 District Health Team members are registered in the system.
Additionally, a health service delivery complaints hotline is functional and provides a platform for health workers and community members to report on any issues they face within the health system. Progressively the system is being used for communication between national and district staff and conversely with front line health professionals and as a survey tool to gather other non-routine information that can support assessing quality of health service delivery.
By June 2016, national health facility reporting rates was at 75.7%, with northern region at 85.4%, western region at 82.3%, eastern region at 73.6% and lastly central region at 65.2%. Facilities sendthe timely reports by Phone every Monday and average national timeliness of reporting is at 75%. The Information on the Health facility Weekly Surveillance Report (HMIS 033b) aims at improving reporting on disease surveillance and stock tracking for medicines in all health facilities in Uganda. Data reported via SMS through mTrac is immediately made available within DHIS2 for further analysis.
Supporting the HMIS component is an anonymous SMS Service Delivery Complaints toll free hotline through which any community member can report health service-related issues, including health centers closed during working hours and stock outs of essential drugs in hospitals, Drug theft, Negligence,Malpractice, extortion, Fraud,Extortion and Absenteeism. This information is available to the DHT on a dashboard who are the first action center. Further analysis is done at MoH for filter out unclosed reports and any reports requiring further investigations. mTrac has been used for communication throughout all levels of stakeholders i.e. Various departments, MoH, RRHs, DHTs and healthfacilities. Forexample the EPI Program used the polling functionality to run rapid surveys on the vaccine stock levels throughout Uganda. Over 95% responses were provided within 24hours providing data that is used in restocking health facilities countrywide.
For the FY 2015/16, a total of 7,048 actionable reports were received through the MoH’s anonymous SMS Service Delivery Complaints hotline from all 112 districts. Among the reports received 3,091(43.8%) were actionable. Districts investigated and resolved 25% (769) of the total actionable reports whereas 29.1% (899) high priority reports of the total were forwarded to the Medicines and Health Services Delivery Monitoring Unit for further follow up. Page | 16
Annual Health Sector Performance Report for Financial Year 2015/16
• Although the national HMIS system has been rolled out countrywide and generating information from the lower level facilities, health facility reporting has not attained the desired 80% of the national HMIS target in most health facilities. Timeliness of monthly HMIS reporting declined from 88% in 2014/15 to 79.4% in 2015/16. This is mainly attributed to the introduction of the new HMIS tools in July 2015. Some other issues that are attributed to low reporting patterns which include; poor attitude of the health workers, network irregularities in many rural parts of the country, poor training of lower facilities by some DHTs, irregular supervision and follow-up to lower facilities.
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3.3.5 Health Financing The health system, including service delivery was financed by a multiplicity of stakeholders namely; Government, Private firms, Households and Health Development Partners (HDPs). Service delivery and developments in public facilities were mainly financed through Government grants, concessional loans and grants from HDPs. Government continued to support service delivery in the PNFP facilities by way of grants and seconding personnel.
• The MoH undertook the 5th round of the National Health Accounts expenditure tracking for the FY 2013/14. The per capita health expenditure stands at an average of $56. The five-year Health Sector Development Plan (HSDP) recommended a minimum of $73 per capita in the year 2015/16. Public health financing represents 17% of the total health expenditure, HDPs 41% and the private sector including the households contribute 42% of the total health expenditure.The key message from the findings is that the country still has 40% out of pocket expenditure which is still high. The maximum recommended level of household out of pocket spending on health is 15% according to WHO. This is in line with World Health Assembly resolution of 2005 on universal coverage and sustainable health financing and as well as revisiting the Paris Declaration that calls for greater Investments in the Health Sector. • General Government allocation for health as percentage of the total Government budget has been averaged at about 8% from 2010/11 to 2015/16, which is 1.8% short of the HSDP target of 9.8%. This translates into a Government contribution of US $ 12 per capita expenditure on Health.
The trend in allocation of funds to the health sector shows that there has been a steady increase in Government allocation to the health sector over the last five years. The increments are majorly on account of the rising wage bill and the ongoing Development Partner supported projects in the sector.
TABLE 14: TRENDS IN GOVERNMENT ALLOCATION TO THE HEALTH SECTOR 2010/11 TO 2015/16
Year GoU Donor Total (Ushs Per capita Per capita GoU health Funding Projects bns) public health public expenditure as (Ushs bns) and GHIs exp (Ushs) health exp % of total (Ushs bns) (US $) government expenditure 2010/11 569.56 90.44 660 20,765 9.4 8.9 2011/12 593.02 206.10 799.11 25,142 10.29 8.3 2012/13 630.77 221.43 852.2 23,756 9 7.8 2013/14 710.82 416.67 1,127.48 32,214 10 8.7 2014/15 748.64 532.50 1,281.14 37,130 13.5 8.5 2015/16 818.86 451.94 1,270.8 36,830 11 6.4
The figures above are MTEF figures and exclude Non-Tax revenue collected by the sector institutions
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Annual Health Sector Performance Report for Financial Year 2015/16
3.3.5.1 GoU Budget Performance for FY 2015/16 The overall GoU budget performance for the sector for FY 2015/16 was 100% even when some sector institutions did not receive all their budgets. This is majorly on account of supplementary funding received during the FY for Hepatitis B response (Ushs 11bn) and payment of VAT arrears for the JICA rehabilitation works inKabale,Hoima and Fort Portal RRH (Ushs 2.4bn). Supplementary funding was also received for procurement of blood collection supplies, test kits and heart services among others.
TABLE 15: GOU BUDGET PERFORMANCEFOR FY 2015/16
Institution Approved budget Release %of budget released Health 101.04 105.89 105% Uganda Aids Commission (Statutory) 7.75 8.53 110% Uganda Cancer Institute 13.12 13.33 102% Uganda Heart Institute 11.55 11.55 100% National Medical Stores 218.61 216.61 99% Health Service Commission 4.37 4.66 107% Uganda Blood Transfusion Service (UBTS) 8.65 8.58 99% Mulago Hospital Complex 41.77 42.58 102% Butabika Hospital 9.33 7.21 77% Regional Referral Hospitals 83.19 82.78 100% District NGO Hospitals/PHC 17.19 17.19 100% District PHC 283.14 283.14 100% District Hospitals 14.14 14.14 100% KCCA Health Grant 5.00 5.00 100% TOTAL HEALTH 818.86 821.20
3.3.5.2 PHC Allocations (PHC NWR for FY 2015/16) There was minimal increase in the PHC wages between FY 2014/15 and FY 2015/16 and this explains the slight increase in staffing levels from 69% to 70% during the FY. The increase in PHC Non wage from UGX 15.84 bn in FY 2014/15 to UGX 20.54 bn in FY 2015/16 was to increase funding for operationalization of the HSDs. All the additional funds weretherefore allocated to HSD/Constituency Health Assembly activities.
TABLE 16: PHC GRANTS FY 2010/11 - 2015/16 IN USHS BILLIONS
FY PHC PHC PHC General PHC Sanitation Total Wages (Non- NGOS Hospitals (Dev't Grant wage) (PNFP) Grant) 2010/11 124.5 17.4 17.7 5.9 15.3 - 180.8 2011/12 143.43 18.5 17.19 5.94 44.43 - 229.49 2012/13 169.38 15.84 17.19 5.94 34.81 - 243.16 2013/14 228.69 18.05 17.19 5.94 30.08 4.16 304.11 Page | 19
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2014/15 250.61 15.84 17.19 5.94 30.08 4.16 327.02 2015/16 248.06 20.54 17.19 5.94 26.41 4.68 322.82
From table 17 below, above, 22% of the NWR-funds go to administration at the DHO, Municipal Health Office and HSD, 38% to General hospital services and only 40% to the lower level health units. Furthermore a HC II has only Ushs 9,000 a day while a HC III has on average Ushs 16,500 a day to deliver the package of health services required at that level of care. It is therefore difficult to offer the desired level of service with so little a budget.
TABLE 17: PHC NON-WAGE ALLOCATION BY SERVICE DELIVERY STRATA WITHIN THE PHC SYSTEM
Level of health service Number of Total annual NWR Annual average Monthly average delivery units. allocation per level allocation per per facility/ office individual facility/ office District Health Office 111 4,516,509,026 40,689,271 3,390,773 Municipal Health Office 22 235,160,769 10,689,126 890,760 Health Sub Districts 199 4,700,000,000 23,618,090 1,968,174 General Hospitals 100 16,662,087,057 166,620,871 13,885,073 HC IVs 192 4,276,194,936 22,271,849 1,855,987 HC IIIs 1,173 6,963,935,644 5,936,859 494,738 HC IIs 1,952 6,322,786,006 3,239,132 269,928
3.3.6 Human Resources for Health It can be noted that health sector staffing improved slightly to 71% (42,530/60,384) in 2015/16 from 69% in 2014/15. This was a net increase of 747 health workers during the year. The objective of the HSDP is to fill the current staffing norms in the public sector to at least 80% of the current staffing norms by 2019/20, by which time the structure of the whole health workforce should have been reviewed.
TABLE 18: HUMAN RESOURCE TRENDS IN THE PUBLIC SECTOR 2010/11 TO 2015/16
Indicator 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 HSDP Target 2015/16 % of approved posts filled 56% 58% 63% 69% 69% 71% 69% by health workers (public health facilities) Number of health workers Doctors 0.03 0.04 (doctors, midwives, 0.02 nurses) in public service Midwives 0.25 0.25 per 1,000 population 0.13 Nurses 0.46 0.5 0.48 Doctors, 0.74 0.75 nurses & midwives Page | 20
Annual Health Sector Performance Report for Financial Year 2015/16
The number of health workers per 1,000 population in Uganda is still far below the WHO threshold of 2.3 doctors, nurses and midwives per 1,000 population. In 2015/16 FY the number of doctors, nurses and midwives per 1,000 population was 0.74/1,000, of which doctors were 0.03/1,000, midwives 0.25/1,000 and nurses 0.46/1,000.
3.3.6.1 Staffing by level of service Central level institutions are better staffed (74%) than health institutions at Local Government (LG) level. However, LGs have registered a marginal increase in staffing level from 69% in 2014/15 to 70% in 2015/16; while there was a decline in staffing level at central level, from 77% in 2014/15 to 74% in 2015/16. Overall staffing level in central level institutions has been trending downward in the past three years (it was 79% in 2013/14).
Of the central level institutions, Uganda Virus Research Institute, Uganda Cancer Institute and Uganda Heart Institute are the least staffed with levels of 38%, 67% and 57% respectively.Of health facilities at LG levels, HCIIs and general hospitals are currently the service levels with the most severe shortage, at 52% and 68% respectively.
TABLE 19: STAFFING LEVEL AT DIFFERENT LEVEL OF SERVICE IN PUBLIC SECTOR FY 2015/16
Cost Centre # of Units Approved Filled % Filled positions Central Institutions 1 MoH Headquarters 1 810 728 90% 2 Mulago NRH 1 2,339 1,933 83% 3 Butabika NRH 1 424 376 89% 4 Regional Referral Hosp 14 5,430 3,728 69% MOH's Specialized Institutions: 5 Uganda Virus Research Institute 1 227 86 38% 6 Uganda Cancer Institute 1 272 183 67% 7 Uganda Heart Institute 1 192 110 57% 8 Uganda Blood Transfusion Services 1 251 236 94% Sub-total: Central Level 21 9,945 7,380 74% Local Governments 18 DHOs Offices 112 1,232 1,039 84% 19 General Hospitals 47 8,930 6,057 68% 20 HC IV 172 8,256 6,931 84% 21 HC III 920 17,451 13,753 79% 22 HC II 1,628 14,651 7,720 53% 23 Municipal Councils 28 224 193 86% 24 Town Councils (Big) 3 21 11 52% 25 Town Councils (Small) 121 605 193 32% Sub-total LGs 3,031 51,370 35,897 70% Total National Level 3,052 61,315 43,277 71% Source: MoH HRH Biannual Report December 2015 Page | 21
Annual Health Sector Performance Report for Financial Year 2015/16
Staffing in the Regional Referral Hospitals (RRHs) has fallen dramatically, from 79% in 2014/15, to 69% in 2015/16. One main reason for the decline is massive retirement of health workers, not backed timely replacement recruitment. RRHs with the most severe shortage are Moroto (40%), Soroti (56%) and Hoima (59%).
TABLE 20: STAFFING AT RRHS
Hospital Total Filled % Hospital Total Filled % Norms Filled Norms Filled Arua RRH 319 238 75% Mbale RRH 441 363 82% Fort Portal RRH 475 348 73% Soroti RRH 439 247 56% Gulu RRH 450 309 69% Lira RRH 357 270 76% Hoima RRH 382 225 59% Mbarara RRH 341 230 67% Jinja RRH 418 362 87% Mubende RRH 346 210 61% Kabale RRH 377 248 66% Moroto RRH 384 155 40% Masaka RRH 352 239 68% Naguru RRH 349 284 81% Total 5,430 3,728 69% Source: MoH HRH Biannual Report December 2015
3.3.6.2 Staffing in the public sector by cadre Table 20 below shows an analysis of the staffing level in the public sector for health professional cadres, disaggregated by type of cadre. It should be noted that these numbers are aggregates for both central and LG institutions.
Overall, the total number of clinical officers and laboratory cadres appear adequate, relative to the HSDP targets, although these numbers may be skewed towards the larger health facilities. Other cadres are short of the HSDP target of achieving 80% staffing level by 2019/20. Of the essential cadres required to deliver the RMNCAH package, the cadres which are severely short in number include theatre assistants (57%), doctors (49%), pharmacists (40%), dispensers (40%) and anesthetic officers (27%).
TABLE 21: STAFFING LEVEL FOR HEALTH PROFESSIONALS DISAGGREGATED BY CADRES
Total % No. Cadre Norms Filled Vacant Filled 1. Clinical Officers 2,821 2,598 223 92% 2. Lab Technologists/Technicians/ Assistants 3,020 2,447 573 81% 3. Nursing Staff (Registered and Enrolled) 21,328 16,490 4,838 77% 4. Public Health Dental Officers 365 276 89 76% 5. Midwives (Registered and Enrolled) 11,706 8,815 2,891 75% 6. Orthopedic Officers 346 227 119 66% 7. Psychiatric Clinic. & Psych Social Workers 174 106 68 61% 8. Theatre Assistants 421 238 183 57% 9. Health Inspectors 3,683 1,925 1,758 52% 10. Doctors (Consultants, MOSG, MOs) 2,156 1,047 1,109 49%
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11. Radiographers and Imaging Staff 248 121 127 49% 12. Physio. & Occupational Therapists 253 114 139 45% 13. Health Educators 298 123 175 41% 14. Pharmacists 112 45 67 40% 15. Dispensers 423 169 254 40% 16. Ophthalmic Clinical Officers 290 104 186 36% 17. Anesthetic Officers 878 238 640 27% Source: MoH HRH Biannual Report December 2015
3.3.6.3 Comparing staffing in the Public and PNFP sectors 21 belowcompares the total staffing levels in the public sector with the combined health work force in the PNFP sector. Typically, staffing requirement in the PNFP sector is determined on the basis of workload rather than a fixed standard norm. For comparison sake, this analysis assumes that the public sector staffing norms also apply to similar institutions in the PNFP sector. The analysis considers only health facilities affiliated to Uganda Catholic Medical Bureau (UCMB), Uganda Protestant Medical Bureau (UPMB) and Uganda Muslim Medical Bureau (UMMB). It does not include health workers deployed at the bureau and regional coordination offices. Further, it also excludes one of the hospitals affiliated to one of the bureaus, which declined to submit the requisite data for the analysis. The result of the analysis is summarized in Table 21 below.
TABLE 22: OVERALL STAFFING LEVEL IN THE PUBLIC SECTOR VERSUS THE PNFP SECTOR Cost Centre No. of Total Filled % Filled Units Norms Total health work force Public Sector (central and DLG combined) 3,052 61,315 43,277 71% PNFP (UCMB, UPMB and UMMB) 596 18,191 13,188 73% Total HWF 3,648 79,506 56,465 71%
Total of registrable health professionals Public Sector (central and DLG combined) 3,052 48,522 35,083 72% PNFP (UCMB, UPMB and UMMB) 596 8,945 5,887 66% Total registrable health professionals 3,648 57,467 40,970 71% Source: MoH HRH Biannual Report December 2015
Thus assuming the Ministry of Public Service structure applied to the PNFP sector, then the current staffing in the PNFP sector would represent 73% of the filling rate of approved positions for those health institutions, compared to 71% in the public sector. However, the staffing level within the PNFP sub-sector varies widely between the bureaus, ranging from 28% to 88%. When compared on the basis of the number of registrable health professionals, the PNFP sector comes out worse off than the public sector, at 66% of the required number (ranging from 34 to 85%); compared to 72% filling rate in the public sector. Thus, sections of the PNFP sector may be reliant on support staff as a coping mechanism for failing to attract qualified health professionals. Page | 23
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3.3.6.4 Availability of Health Professionals in the Labour Market Total number of health professionals registered in the country (Doctors, Nurses, Midwives, Pharmacists, AHP) during 2015/16 stood at 83,000. This number represents health professionals who appear in the Health Work Force registry kept by the 4 Health Professional Councils. It excludes administrative, other support cadres and health professionals hitherto unregistered. Figure 3 displays the number of registered health professionals by employment status. FIGURE 3: DISTRIBUTION OF HEALTH PROFESSIONALS BY EMPLOYMENT STATUS
Other Public 42% (35,083) of registered health s , , 42% professionals are currently employed in the 51% public sector, and at least 7% (5,887) are employed in the PNFP sector. About half of the registered health professionals (42,030) PNFP , 7% are either private practitioners, employed by NGOs, unemployed or have emigrated. Thus it is reasonable to conclude that there is a large pool of health professionals in the labormarket, many of whom may not be in full-time employment.
3.3.6.5 Reasons for staff shortage The major limitation to filling the staffing gaps in both the public and PNFP sector is inadequate and unpredictable wage. Other commonly cited factors include;
• Limited capacity for systematic HRH planning • Inadequate advocacy for wage and HRH support • Limited capacity to attract and retain qualified staff • Difficult working conditions – no accommodation, inadequate social amenities, • Inadequate supply of some priority cadres: pharmacists, dispensers, lab. technologists, lab technicians in critical shortage. • Poor quality of graduates affecting their employability • Unattractive compensation (PHN, Anesthetist, Dispensers) • Limited capacity of some districts to recruit • Dynamics in the labor market – rapid private sector growth, causing variation in terms and conditions of service
3.3.7 Health promotion and environmental health The NSDS 2015 results show that, four in every ten households in Uganda used a covered pit latrine without a slab compared to only 2% that used flash toilets. The proportion of households using a covered pit latrine without a slab in rural areas (45%) is twice that reported for urban areas (22%). On the other hand, 30% of households used covered pit latrine with a slab - with the majority in the urban areas (47%) compared to only 25% in rural
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areas. Overall, 6% of households do not have toilet facility. Variations at sub-regional levels show that the majority of households in Kigezi used covered pit latrines with a slab (68%), 67% in West Nile used covered pit latrines without a slab while 44% in Karamoja and 28% on the islands had no toilet facilities. High costs are the major factor limiting construction of toilet facilities (45%) while ignorance is the major factor limiting the use.
FIGURE 4: HOUSEHOLDS BY TYPE OF TOILET FACILITY USED (%)
Though proper hand washing after toilet use is a hygienic practice, which is highly recommended for good health rarely is it practiced. Close to eight in every ten households (78%) did not have any functional hand washing facilities while only 8% had hand washing facilities with both water and soap. This pattern is similar across sub-regions although Ankole (19%) had the highest percent of household with hand washing facilities with water and soap.
FIGURE 5: HOUSEHOLDS BY AVAILABILITY OF HAND WASHING FACILITIES (%)
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Like the previous FY, during 2015/16 there was no significant investment in building the capacity of Village Health Teams (VHTs) whichremained at 75% of the villages in the country having trained VHTs. Much effort was towards finalizing the Community Health Extension Workers (CHEWs) policy and strategy.
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3.4 Health Partnerships 3.4.1 Progress in implementation of the HSDP Compact This section assesses performance of the HPAC and progress in implementation of the partnership commitments made in the HSDP Compact.
During the year under review, the MoH and health partners developed the Compact for Implementation of the HSDP 2015/16 – 2019/20. The purpose is to maintain policy dialogue, promote joint planning, and effective implementation and monitoring of the HSDP through a sector wide approach.Implementation of the Compact is monitored by the MoH Health Policy Advisory Committee (HPAC). HPAC is a stakeholder coordination mechanism which supports the functions of the MoH Top Management in policy related issues and meets monthly.
In terms of meetings, HPAC was able to hold 11out of the 12 scheduled meetings during FY 2015/16. Membership attendance of the meetings varies with remarkable decline in representation from the MoH, HDP representatives. There is need to assess the functionality of the HPAC and recommend strategies for improving attendance by the eligible representatives.
TABLE 23: HPAC INSTITUTIONAL REPRESENTATIVES’ ATTENDANCE Representatives Average Annual Attendance Rate 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 MoH (11) 45% 45% 41% 37% 65% 38% HDP (4) 88% 109% 138% 161% 108% 42% CSO (3) 48% 67% 44% 67% 50% 64% Private (1) NA 66% 58% 72% 33% 25% NMS (1) 58% 42% 92% 72% 67% 67% Medical Bureaus(2) N/A N/A N/A 73% 46% 54% NRH (2) 0% 4% 4% 0% 17% 13% Line Ministries (5) 0% 2% 8% 11% 7% 5% Source: HPAC Minutes
According to the M&E framework for implementation of the Compact there was compliance to 8 out of the 15 indicators assessed this FY, no compliance to 3 of the indicators and partial compliance to 4 indicators as shown in table 24.
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TABLE 24: PROGRESS IN IMPLEMENTATION OF THE HSDP COMPACT DURING FY 2015/16
No Indicator Performance Comments Compliant / Non compliant 1 Planning and Budgeting 1.1 MoH Comprehensive Annual Workplan MoH annual report not comprehensive. reflecting stakeholder contribution A number of Partner supported activities and budgets not reflected in the inannual sector workplans 1.2 All new sector investments are appraised Not all projects appraised were by SBWG submitted to HPAC 1.3 Comprehensive procurement plan Procurement plan developed but not developed and adhered to fully adhered to mainly due to delays in initiation of procurements 1.4 Response to Auditor General's report Response to AG report presented to HPAC 1.5 Implementation of harmonized TA Plan Guidelines for TA were not available and there was no harmonized TA plan. Guidelines to be disseminated during FY 2016/17 2 Monitoring Programme Implementation and Performance 2.1 Quarterly Area Team Visits Only 2 Area Team visits were conducted due to inadequate funds 2.2 MoH Quarterly Performance reviews Reviewed quarter 1 & 2 only. Constraint of funds 2.3 Technical Review Meeting No TRM held 2.4 Technical Working Group meetings Irregular TWG meetings 2.5 Annual Health Sector Performance Timely compilation of report Report 2.6 Submission of Annual Report to OPM Timely reporting to OPM 2.7 Joint Review Mission Annual Reviews held timely 2.8 MTR of HSDP 2.9 End of HSDP Evaluation 3 Policy Guidance and monitoring
3.1 Senior Management Committee Meetings held monthly 3.2 Health Policy Advisory Committee Attendance of at least 3/4 of meetings by all members 3.3 Country Coordination Mechanism Attendance of at least 3/4 of meetings by all members
3.4.2 Key Sector Challenges a) Despite the achievements, the sector still faces several challenges in ensuring newborn and child survival among which are; b) Huge disease burden owing to mainly Malaria, Pneumonia and diarrhea in children. c) Inadequate staffing at the levels a significant number of posts most are not filled. d) Inadequacy in the maintenance of medical equipment nationwide. e) Monitoring of various disease outbreaks is not equitably funded. f) Stocks outs of key commodities at facility level owing to incorrect quantification
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g) Influx of refugees into the country puts pressure on existing resources and is a risk of importation of vaccine preventable diseases. h) During this period, Uganda was hit by a malaria epidemic in the ten former i) Districts in the north where indoor residual spraying had ceased. The affected districts experienced and upsurge in the number of malaria cases as reflected in the incidence map below and this upsurge has reversed some of the gains in malaria control that had been achieved in these areas. j) Funding gaps for ARVs, Antimalarials and chemistry and haematology laboratory reagents in the public sector. k) There is inadequate funding for sector activities especially PHC Services. l) There is a challenge of the alignment of off-budget funding to sector priorities. m) There is skewed input mix in financing health facilities, for instance there have not been commensurate funding for recurrent costs for utilities and/or maintenance arising from the construction of new buildings and equipment especially for hospitals. n) Unsatisfactory level of support supervision from districts to the lower level health facilities. Many district lack capacity in terms of man power, transport and other logistical requirements to conduct regular and effective support supervision.
3.4.3 Conclusion and Recommendations • Improve district storage facilities for EMHS
• Encourage and buttress the referral system in accordance with levels of care from the lower facilities to reduce on the influx of patients at the National Referral Hospital and RRHs.
• The Government and HDPs need to increase investment in health towards meeting recommended per capita health expenditure of minimum $84 per capita for low income countries, if the country is to increase access to health care and improve quality of services. With the current epidemiological profile, relative to our desired level of health status, the per capita expenditure of Shs 148,000 ($56) may not move the country towards achieving the Sustainable Development Goals (SDGs).
• The Country needs to address high levels of Out-of-Pocket expenditure (40%) in order to protect households from catastrophic. The country needs to explore alternative ways of mobilizing domestic resources to improve financial sustainability including the improvement of efficiency in resource use. Social Health Insurance and community based health insurance and medical savings would enhance domestic resource mobilisation efforts.
• The MoH needs to strengthen its stewardship role in coordinating donors and ensuring alignment to country strategies to the Paris Declaration principles for more aid
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effectiveness. In this regard, the development of strategic partnerships which allow for predictability of funds over a longer period will ensure sustainability of funding.
• The sector should committee resources for strengthening health (and community) systems to engage in care and prevention of TB and leprosy. There is also need to strengthen tools such as the intensified case finding guide and build capacity of health workers to suspect and diagnose TB & leprosy cases.
FIGURE 6: PERCENTAGE OF HIV+ PREGNANT WOMEN INITIATED ON ART IN FY 2015/16
FIGURE 7: % OF PREGNANT WOMEN COMPLETING IPT2 BY DISTRICT FY 2015/16
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FIGURE 8: % OF HEALTH FACILITY DELIVERIESBY DISTRICT FY 2015/16
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FIGURE 9: % OF PREGNANT WOMEN ATTENDING ANC 4TH VISIT BY DISTRICT FY 2015/16
FIGURE 10: LATRINE COVERAGE
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FIGURE 11: TB TREATMENT SUCCESS RATE BY DISTRICT IN 2015
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3.5 Local Government Performance The Uganda District League Table (DLT) was launched 2003 with a primary purpose of comparing performance of districts to determine good and poor performers; providing information to facilitate understanding of good and poor performance and to enable application of corrective measures, increasing local government ownership of achievements, and encouraging replication of documented good practices. Over the years the use of DLT has gained importance in the overall health sector monitoring and it is an important tool for managers and policy makers as a starting point for a comprehensive review of national and individual district performance.
The DLT is composed of input, process and output indicators – e.g.deliveries in health facilities, Out Patient Department attendance, latrine coverage, among others; in line with the HSDP.The composite index employed is computed by weighting the agreed upon indicators, ranking districts from best to worst performer.
3.5.1 District League Table (DLT) Performance In this report, the 111 districts are used as the units of analysis with key objectives ofcomparing performance between districts; provide information to facilitate the analysis forgood and poor performance at districts and thus enable corrective measures which may range from increasing the amount of resources (financial resources, human resources, infrastructure) to the LG or more frequent and regular support supervision.
The DLT is not meant to embarrass LG leaders of poorly performing districts, but rather to make them question why their district is performing poorly, and consider ways in which that performance can improve.
The objectives of the DLT are; To compare performance between districts and therefore determine good and poor performers. To provide information to facilitate the analysis for good and poor performance at districts thus enable corrective measures. Appropriate corrective measures which may range from increasing the amount of resources (funds, human resource, infrastructure) to the LG or more frequent and regular support supervision. To increase LG ownership for achievements – the DLT to be included in the AHSPR to be discussed at the NHAor JRM with political, technical and administrative leaders of districts. To encourage good practices – good management, innovations and timely reporting.
For the FY2015/16, 14 indicators were used to evaluate and rank district performance: 6 coverage accounting for 45%, 4 quality accounting for 20%, 1 human resource accounting for Page | 34
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10% and 3 HMIS reporting accounting for 15 % totaling to 90%. The final percentage performance was then computed by the formula % score (total score)/90*100 this is because one of the 15 indicators (average district quality of care score) approved for assessing district performance was not included in this year’s DLT.
The 111existing districts excluding KCCA in FY2015/16 are used as the units of analysis for LG performance.
Routine HMIS data was the primary data source for majority of the indicators (Pentavalent Vaccine 3rd Dose coverage, institutional deliveries, outpatient visits, Sulfadoxine / Pyrimethamine (SP) 2nd dose for IPT, 4thANC visits, HMIS timeliness and completeness of reporting, and submission of inventory data; some of the indicator data were provided by MoHprograms such as HIV/AIDS, TB, human resources, Environmental Health Division.
The top ten best performing districts in FY2015/16as ranked by the percentage (%) score computed by (total score)/90*100 are; Lyantonde, Rukungiri, Mpigi, Gulu, Amuria, Lamwo, Katakwi, Serere, Kabarole and Buyende. The lowest performance levels were noted in Wakiso, Sembabule, Bulambuli, Kotido, Koboko, Moroto, Napak, Sironko, Amudat and Buvuma
Tables 25 and 26 show the top and bottom 15 performing districts with their total scores andranks. The full DLT can be seen in the Annex.
TABLE 25: TOP 15 PERFORMING DISTRICTS TABLE 26: BOTTOM 15 PERFORMING DISTRICTS
DISTRICT % SCORE RANK DISTRICT % SCORE RANK Lyantonde 77.2 1 Luuka 60.3 98 Rukungiri 77.0 2 Kibaale 60.2 99 Mpigi 74.2 3 Pader 60.1 100 Gulu 74.1 4 Buliisa 59.8 101 Amuria 73.5 5 Otuke 59.2 102 Lamwo 73.3 6 Wakiso 58.9 103 Katakwi 72.8 7 Sembabule 58.9 103 Serere 72.7 8 Bulambuli 58.5 104 Kabarole 72.6 9 Kotido 57.8 106 Buyende 72.5 10 Koboko 57.7 107 Buikwe 72.5 11 Moroto 57.1 108 Dokolo 72.3 12 Napak 57.0 109 Iganga 72.2 13 Sironko 54.2 110 Bushenyi 72.2 14 Amudat 51.3 111 Soroti 72.0 15 Buvuma 50.7 112
There is reasonable contrast between the district performance in FY2014/15 and current FY2015/16. For instance the top performing district last FY was Gulu district with a score of 89% while this year the top performing district is Lyantonde with a score 77.2% indicating a decline in total district performance of 11.8 percentage points. In terms of individual districts,
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7 districts (Lyantonde, Rukungiri, Gulu, Lamwo, Serere, Kabarole, and Bushenyi) have sustained their presence in the top 15 performing list while 7 districts including Jinja, Butambala, Lira, Mityana, Mbale, Luwero and Masaka have dropped from the list. New entrants on this list in FY2015/16 include; Mpigi, Amuria, Buyende, Buikwe, Dokolo, Katakwi and Iganga districts. The list appears to be a mixture of old, new and even hard-to- reach districts, implying that it is possible for all districts to achieve improved performance by being in the top 15 performing list.
TABLE 27: TOP AND BOTTOM 10 DISTRICT RANKING FOR NEW DISTRICTS FY 2015/16
% National % National District Score Rank Rank District Score Rank Rank Lamwo 71.8 1 7 Kyegegwa 61.0 22 79 Serere 71.4 2 9 Kyankwanzi 60.6 23 84 Buyende 70.8 3 11 Buhweju 60.1 24 94 Mitooma 70.7 4 17 Bukomansimbi 59.5 25 95 Buikwe 70.3 5 12 Luuka 59.1 26 98 Ngora 70.0 6 18 Otuke 57.2 27 102 Ntoroko 69.2 7 22 Bulambuli 56.4 28 105 Agago 67.5 8 38 Napak 54.8 29 109 Butambala 67.2 9 28 Amudat 49.9 30 111 Kole 66.7 10 41 Buvuma 47.8 31 112
In the new districts LT, only Lamwo, Serere and Agago maintained their presence in the top 10 performing districts in this category from FY2014/15. Districts which have joined the top 10 performing new districts in FY2015/16include Buyende, Mitooma, Buikwe, Ngora, Ntoroko, Butambala and Kole.
TABLE 28: TOP AND BOTTOM 10 HARD-TO-REACH DISTRICTS AS PER THE HARD-TO-REACH DLT
District Total Score Rank National Rank
Gulu 73.4 1 5 Lamwo 72.7 2 7 Ntoroko 70.2 3 22 Mukono 69.6 4 27 Agago 68.2 5 38 Namayingo 67.9 6 37 Kitgum 66.5 7 48 Mayuge 66.2 8 44 Bundibugyo 65.8 9 49 Nwoya 65.8 10 57 Abim 62.3 17 85 Amuru 61.9 18 90 Kisoro 61.4 19 93 Kaabong 60.6 20 97
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Pader 59.3 21 100 Kotido 57.1 22 106 Moroto 56.4 23 108 Napak 56.1 24 109 Amudat 50.7 25 111 Buvuma 49.5 26 112
Regarding the hard-to-reach category performance for FY2015/16, Gulu remained the top most performing with 73.4% which lower than it score (89.0%) in the same position last FY. Other districts in this category FY2015/16 include Lamwo (72.7%) Ntoroko (70.2%), Mukono (69.6%), Agago (60.7%) among others. Like last FY the bottom performing districts in the hard-to-reach category are dominated by districts of the northern and Karamoja region including Amuru (61.9%), Pader (59.3%), Abim (62.3%) Kaabong (60.6%), Kotido (57.1%), Napak (56.1%), Moroto (56.4%) and Amudat (50.7). Others are Buvuma (49.5%), and Kisoro (61.4%). There seems to be a consistent relationship between hard-to-reach districts and poor performance. This implies that special attention should be given to these districts in order to tackle the unique challenges in the districts. Although affirmative action has been applied, it seems as a sector we need to review these strategies.
There appears to be a slightly positive relationship between district staffing levels (% of approved posts that are filled qualified personnel in public health facilities) and the overall score. For instance majority of the top 10 performing districts have staffing levels of over 70% with the other 3 having staffing levels of 60% and above. High staffing is a major advantage but it must be quickly added that other factors like motivation, requisite skills, equipment and accommodation are equally relevant. However, 5 districts in the low performing category reported similar staffing levels of over 70%. This calls for an in-depth assessment of the factors associated with staffing levels and general service delivery. Such studies can also capture factors that influence attraction, retention and productivity of health personnel.
TABLE 29: STAFFING LEVELS FOR 10 TOP AND BOTTOM DISTRICTS
Staffing National Staffing National District Level Rank District level Rank Lyantonde 82.6 1 Wakiso 71.3 103 Rukungiri 82.2 2 Sembabule 54.4 104 Mpigi 73.6 3 Bulambuli 86.8 105 Gulu 81.2 4 Kotido 70.8 106 Amuria 82.3 5 Koboko 31.1 107 Lamwo 54.3 6 Moroto 78.1 108 Katakwi 65.5 7 Napak 41.3 109 Serere 69.1 8 Sironko 75.4 110 Kabarole 60.8 9 Amudat 19.7 111 Buyende 78.8 10 Buvuma 65.9 112
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In conclusion as earlier indicated the DLT has primary purpose of comparing performance of districts to determine good and poor performers; providing information to facilitate understanding of good and poor performance and to enable application of corrective measures, increasing LG ownership of achievements, and encouraging replication of documented good practices.In order to improve the quality and power of the DLT there is need for better availability of accurate data on district characteristics, which may have significant influencing on performance. It is therefore necessary for all stakeholders to actively participate in supporting better data collection, transmission and use the information from the DLT to make the necessary decisions at the various levels.
3.6 Health Facility Performance
The health facility performance was measured in terms of budget utilization (inputs) Standard Unit of Output (Outputs), Faculty based Fresh Still Births, Maternal Mortality ratio, in-patient fatality rate and Perinatal Mortality rate (Outcomes) as well as Bed Occupancy rate, average length of stay and cost per SUO (efficiency).The overall performance of the different levels of care is shown in table 30 below. 31.7% of the outputs as measured by standard unit of output are produced by HC IIIs while 22.2% are produced by HC IIs
TABLE 30: HEALTH FACILITY OUTPUTS AND OUTCOMES BY LEVEL OF CARE FY 2015/16
National Level RHs RRHs GHs HC IVs HC IIIs HC IIs Clinic Admissions 88,427 43,2064 804,850 52,6206 704,968 76,217 25,303 1,710,4 3,121,75 1,294,58 1,568,89 Patient Days 330,645 41 5 2 2 151,316 32,480 Beds 2,115 5,665 13,985 6,788 15,138 1,788 419 2,731,1 4,180,52 4,274,02 15,137,5 16,082,8 1,195,2 Total OPD 219,574 70 2 8 18 66 09 Deliveries 23,674 85,814 204,702 170,670 359,228 104,857 9,132 2,265,19 Total ANC 41,113 195,659 445,389 662,512 3 758,484 32,181 Postnatal Attendances 1,928 119,217 214,728 232,474 783,293 302,514 17,521 3,004,23 FP 6,588 35,487 118,183 240,838 730,797 9 110,538 3,238,01 2,874,56 Immunization 40,931 221,742 640,203 856,086 2 0 50,849 Caesarian Sections 519 30,352 52,552 12,755 1,578 329 168 Major Operations 1,027 59,608 92,087 23,780 5,249 931 594 IPD Deaths 4,452 12,710 24,657 3,228 5,594 748 229 Fresh Still births 892 1,874 3,303 2,076 2,850 988 175 Macerated still births 561 1,527 3,147 1,792 3,067 739 101 Newborn deaths 547 1,179 3,718 1,971 3,581 955 39 Page | 38
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Perinatal Death Rate 2,000 4,580 10,168 5,839 9,498 2,682 315 Maternal Deaths 92 360 391 163 68 42 5 BOR 82% 82% 61% 52% 28% 23% 21% ALOS 33 4 4 3 2 2 1 Maternal Death Risk 803 343 212 93 123 107 61 FSB Risk 78 18 18 12 7 4 21 9,956,0 17,692,0 13,780,7 30,149,3 21,159,5 1,705,9 SUO 2015/16 1,636,255 65 58 82 72 82 69
3.6.1 Performance of the National Referral hospitals
The country still has two national referral hospitals; Butabika and Mulago. Butabika is a specialized hospital for mental health services. The budget performance for the National referral Hospitals is shown in table 31.
TABLE 31: BUDGET PERFORMANCE FOR NATIONAL REFERRAL HOSPITALS
Hospital APPROVED BUDGET (Bn) RELEASES (Bn) EXPENDITURE (Bn) Wages Non- Dev’t Wage Non- Dev’t Wage Non- Dev’t Wage Wage Wage
Mulago 20.04 16.07 5.02 20.04 17.5 5.02 20.04 17.34 5.02 Butabika 3.79 3.71 0.07 3.13 4.0 0.07 3.13 3.98 0.07 Total 23.83 19.78 5.09 23.17 21.5 5.09 23.17 21.32 5.09
The performance of these hospitals is summarized below.It is worth noting that Mulago HMIS reporting was at only 50% during FY 2015/16 thus the low performance for a National Referral Hospital.
TABLE 32: SUO FOR NATIONAL REFERRAL HOSPITALS FY 2015/16
Unit Butabika NRH Mulago NRH Admissions 2,486 85,941 Patient Days 76,101 254,544 Beds 550 1,565 Total OPD 54,852 164,722 Deliveries 11,455 Total ANC 41,113 Postnatal Attendances 1,928 FP 179 6,409 Page | 39
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Immunization 639 40,292 Caesarian Sections 519 Major Operations 0 1,027 IPD Deaths 59 4,393 Fresh Still births 892 Macerated still births 561 Newborn deaths (0-7days) 547 Perinatal Death Rate 174 Maternal Deaths 92 BOR 37.9 44.6 ALOS 30.6 3.0 Maternal Death Risk 803 FSB Risk 77.9 SUO 2015/16 92,359 1,543,895 Source: MoH DHIS-2 2015/16
3.6.2 Regional Referral Hospital Performance The RRHs are meant to provide specialized services for a region of approximately 2,000,000 people in additional to general services for the host districts. The budget performance of the public RRHs is shown in table 33 below. This excludes the value of medicines supplied to these hospitals by the NMS.
TABLE 33: BUDGET PERFORMANCE FOR RRHS
Vote RRH Wage Nonwage Development Total Approved budget Release Actual Approved budget Release Actual Approved budgetRelease Actual Approved budgetRelease Actual 163 Arua 3.10 2.798 2.80 1.775 2.747 2.295 0.750 0.729 0.729 5.62 6.27 5.82 164 Fortportal 3.55 3.078 3.07 1.894 2.232 1.92 0.600 0.520 0.519 6.05 5.83 5.51 165 Gulu 2.96 2.617 2.60 2.700 2.648 2.258 1.470 1.426 1.405 7.13 6.69 6.26 166 Hoima 2.86 2.230 2.22 2.115 2.253 2.065 1.400 1.224 1.224 6.37 5.71 5.51 167 Jinja 3.74 3.576 3.58 2.279 2.250 2.25 0.600 0.598 0.598 6.62 6.42 6.42 168 Kabale 2.50 2.359 2.36 1.824 2.317 2.317 0.600 0.533 0.533 4.92 5.21 5.21 169 Masaka 2.69 2.689 2.34 1.998 1.994 1.928 1.200 1.079 1.079 5.89 5.76 5.35 170 Mbale 3.95 3.494 3.49 3.135 2.904 2.91 0.600 0.539 0.538 7.68 6.94 6.94 171 Soroti 2.78 2.522 2.52 2.065 2.036 2.021307 0.900 0.812 0.812 5.75 5.37 5.35 172 Lira 2.68 2.621 2.62 1.838 2.455 2.32776 0.600 0.538 0.538 5.12 5.61 5.49 173 Mbarara 3.39 2.942 2.66 2.186 3.411 2.830827 1.328 1.184 1.184 6.91 7.54 6.67 174 Mubende 2.54 2.071 2.07 1.386 1.345 1.363 1.800 1.800 1.800 5.72 5.22 5.24 175 Moroto 2.13 1.943 1.44 1.310 1.807 1.51 0.664 0.597 0.597 4.11 4.35 3.54 176 Naguru 3.76 3.337 3.02 1.235 1.222 1.221671 1.394 1.307 1.307 6.39 5.87 5.55 Total 42.63 38.28 36.79 27.74 31.62 29.22 13.91 12.89 12.86 84.27 82.78 78.87
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The performance of RRHs is shown in table 34 below. The regional referral and large PNFP hospitals contributed 10.5% of the SUOs produced by health facilities in Uganda. The total SUOs from Regional referral and Large PNFP Hospitals increased from 8,727,281 in FY 2014/15 to 9,956,065 in FY 15/16. Mbale RRH continues to produce significantly higher SUOs that other RRHs mainly owing to a relatively higher population being served by the hospital.
The bed occupancy rate in excess of 100% observed in Moroto, Soroti and Lira RRHs is explained by the relatively high average length of stay (6.2, 5.1 and 8.8 days respectively). Given that the average length of stay for these hospitals is higher than that of Mulago NRH emphasis should be placed on reducing average length of stay to reduce bed occupancy rate. Mubende RRH however has a bed occupancy rate of 100.4% and an average length of stay of 2.9 days it therefore probably requires an increase in the bed capacity.
TABLE 34: OUTPUTS AND OUTCOMES FROM REGIONAL/LARGE HOSPITALS
The cost per SUO in RRH is shown in table35 below. If you combine the three efficiency indicators namely: Bed occupancy rate, Average Length of Stay and Cost per SUO, Mbale RRH hospital stands out as the most efficient RRH in the country.
TABLE 35: COST PER SUO IN RRHS IN FY 2015/16
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Health facility Health 2015/16 SUO 15/16FYExpenditure (Bn) (UGX) SUO Per Cost Mbale REGIONAL REF HOSPITAL 1,000,426 6.94 6,937 Masaka REGIONAL REF HOSPITAL 709,114 5.35 7,545 Fort Portal Regional Referral Hospital 692,127 5.51 7,961 Gulu Regional Referal Hospital 759,313 6.26 8,244 Mbarara REGIONAL REF HOSPITAL 718,777 6.67 9,280 Mubende RR HOSPITAL 544,106 5.24 9,630 Arua REGIONAL REF HOSPITAL 584,993 5.82 9,949 Lira REGIONAL REF HOSPITAL 531,113 5.49 10,337 Hoima REGIONAL REF HOSPITAL 527,436 5.51 10,447 Soroti REGIONAL REF HOSPITAL 498,721 5.35 10,727 Jinja Regional Ref HOSPITAL 590,719 6.42 10,868 Kabale REGIONAL REF HOSPITAL 375,236 5.21 13,885 Moroto Regional Refferal HOSPITAL 254,298 3.54 13,921 Naguru Hospital - China Uganda Friendship 387,102 5.55 14,337 St. Mary's Hospital Lacor 646,574 - Mengo HOSPITAL 424,556 - Lubaga HOSPITAL 396,050 - St. Francis Nsambya HOSPITAL 315,406 - Total 9,956,065 78.86 7,921
TABLE 36: LEADING CAUSES OF MORBIDITY IN RRHS IN FY 2015/16
While malaria remains the leading cause of morbidity in RRH NCDs like Diabetes Mellitus and Epilepsy have also emerged as leading causes of morbidity reflecting the epidemiological transition.
The inpatient fatality rate for RRH was 2.94% with inpatient fatality rates above 4% being observed in Mbarara, Arua and Fort portal RRHs while inpatient fatality rates below 2% were observed in Moroto, Naguru and Gulu RRH. The leading causes of mortality in RRH are shown in table 37 below. Over 90% of the deaths among children under five years and 60% of the deaths among patients above 5 years were due to treatable/preventable infections.
TABLE 37: LEADING CAUSES OF DEATH IN RRHS IN 2015/16 FY
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Condition 5 and % 5 and Under 5 % Under 5 above above Condition Deaths Death deaths death Malaria 625 31.1 Anaemia 377 9.4 Neonatal Sepsis 0-7days 304 15.1 Malaria total 329 8.2 Pneumonia 293 14.6 Injuries: (Trauma due to other causes) 298 7.4 Anaemia 288 14.3 Pneumonia 292 7.3 Septicemia 100 5.0 Other Types Of Meningitis 290 7.2 Diarrhoea - Acute 51 2.5 New TB cases diagnosed: Bacteriologically confirmed 202 5.0 Injuries: (Trauma due to other causes) 36 1.8 Injuries: Road Traffic Accidents 175 4.4 Injuries: Road Traffic Accidents 32 1.6 Hypertension (Old cases) 148 3.7 Gastro-intestinal disorders (non-infective) 25 1.2 Other Cardiovascular Diseases 133 3.3 Neonatal tetanus 21 1.0 Septicemia 124 3.1
Maternal Mortality continued to be a major challenge in RRHs. The Facility based MMR for RRHs in FY 2015/16 was 343.2 per 100,000. Hoima, Fort Portal and Mubende RRH had high MMR of 805, 737 and 683 per 100,000 respectively while Naguru and Kabale had low MMR of 83 and 95 per 100,000. Fresh Stillbirths and Perinatal Mortality rates at RRHs also continued to be a major challenge with rates of 17.9/1000 and 34.3/1000 respectively. Masaka RRH had the lowest FSB rate at 5.7/1000 while Mubende RRH had the highest FSB rate at 43 per 1000. Naguru RRH had the lowest PNM rate at 12.2/100 while Jinja RRH had the highest PNM rate at 85.7/1000. 3.6.3 General Hospital Performance General Hospitals provide general hospital services to their host district and neighbouring districts without hospitals. The general hospitals are financed under their respective District local governments and their inputs are thus to some extent merged with the inputs of HCs. The General Hospitals were however allocated UGX 5.94 billion for recurrent non wage and UGX 8.2 billion for Capital development in FY 2015/16. Both their budget performance and expenditure were 100%.
The general hospitals produced 18.6% of the health facility outputs as measured by the SUO. The detailed performance of each general hospital is shown in Annex. The total SUO from General Hospitals increased from 16,256,818 in FY 2014/15 to 17,692,056 in FY2015/16. Iganga Hospital had the highest SUO 600,244 followed by Kitgum Hospital with 493,981 while 14 hospitals had SUOs less than 20,000 including Aber NGO Hospital with only 1,098 these should probably be re-classified to a lower level.
TABLE 38: LEADING CAUSES OF MORBIDITY IN GENERAL HOSPITALS IN 2015/16 FY
Condition Under 5 Condition 5 and above years No. % No. % Malaria 251,624 31.6%% Malaria 601,699 28.0% No pneumonia – cough or 196,227 24.6% No pneumonia – cough or 399,088 18.6% cold cold
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Tooth extractions 120,576 15.1% Urinary Tract Infections 169,927 7.9% Diarrhoea – acute 45,966 5.8% Tooth extraction 145,921 6.8% Pneumonia 36,938 4.6% Other eye conditions 90,904 4.2% Skin diseases 32,010 4.0% Skin diseases 87,894 4.1% Other eye conditions 15,392 1.9% Injuries (trauma due to other 65,772 3.1% causes) Intestinal worms 15,262 1.9% Pelvic Inflammatory Diseases 59,429 2.8% Other types of anaemia 13,749 1.7% Intestinal worms 59,052 2.7% Urinary Tract Infections 11,354 1.4% Diabetes Mellitus 50,785 2.4%
The leading causes of morbidity in General Hospitals are shown in table 38 above. Malaria and Cough or cold without pneumonia remain the leading causes of attendance at general hospital outpatients for both patients below and above 5 years. These may however reflect a broad categorization of several disease entities and the sector should consider introduction of the international classification of diseases to improve both diagnosis and reporting as well as comply with international standards. Dental diseases injuries, eye diseases and Diabetes Mellitus now appear among the leading causes of morbidity probably reflecting the epidemiological transition to a mixture of communicable and non-communicable diseases.
TABLE 39: LEADING CUASES OF DEATH IN GENERAL HOSPITALS IN FY 2015/16
Condition Under five Condition 5 years and above cause of death cause of death No. % No. % Malaria 1,390 30.0% Malaria 748 11.1% Anaemina 670 14.4% Pneumonia 555 8.2% Pneumonia 655 14.1% Anaemia 551 8.2% Neonatal sepsis 389 8.4% Other cardiovascular 328 4.9% diseases Septicaemia 160 3.5% Hypertension 295 4.4% Diarrhoea – acute 151 3.3% Septicemia 287 4.3% Injuries – trauma due to other 145 3.1% New TB cases 234 3.5% causes Injuries - RTAs 134 2.9% Injuries – RTA 229 3.4% Respiratory infections 101 2.2% Gastro-intestinal disorders 206 3.1% Asthma 93 2.0% Injuries – Trauma due to 197 2.9% other causes
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The overall Facility based Maternal Mortality ratio for general hospitals was 369/100,000. While more than 40 hospitals reported no maternal deaths during the FY the hospitals in table below had very high maternal mortality ratios which require urgent attention.
TABLE 40:FACILITY BASED MATERNAL MORTALITY RATIO FOR GHS IN 2015/16 FY
Hospital Maternal Mortality Ratio per 100,000 Lugazi Scoul 2,239 Nakasongola Military 1,563 Senta Medicare clinic 1,170 Novik Hospital 830 Ishaka Adventist 784 St Francis Nagalama 735 Villa Maria 665 Adjumani 660 Nyapea 659 Ibanda 579
The fresh still birth rate for General hospitals was 17.8/1000. Murchison Bay hospital and Gulu Military Hospital reported the highest fresh still birth rates of 106/100 and 97/1000 respectively. The Perinatal Mortality rate for general hospitals was 54.5/1000. Murchison Bay Hospital and Senta Medicare clinic reported the highest perinantal mortality rates 334/1000 and 228/1000 respectively.
15 general hospitals reported bed occupancy rates above 100%, with Iganga Hospital reporting the highest bed occupancy rate of 177%. The hospital has, with support from World Bank, been renovated and expanded. The bed capacity will be revised upwards effective FY 2016/17. Some general hospital had high average length of stay notably Adjumani Hospital 7.7 days and Maracha Hospital 7.9 days which need to be addressed.
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3.6.4 Health Centre IV Performance The HC IV serves as the first referral facility providing comprehensive obstetric and newborn care services in HSDs where there is no Hospital. HSDs on average cover a population of 100,000 people. The main objective of the HSD concept was to reduce maternal and perinatal mortality by increasing access to comprehensive obstetric and newborn care services. Of the 206 recognized HC IVs in the country 194 submitted reports to MoH on a regular basis. 63% of the HC IVs reported having carried out caesearian sections during FY 2015/16 and are thus considered to have been providing comprehensive obstetric and newborn care services. This shows a significant increase from 51% reported in FY 2014/15. However 83% of the HC IVs reported having carried out a major operation implying that they may have capacity to provide caesearian sections. 80 HC IVs (41%) provided blood transfusion services rising from 38% in FY 2014/15. The trends in percentage of HC IVs providing caesearian section and blood transfusion are shown below. There is a positive trend that clearly demonstrates the impact of salary enhancement for medical officers.
The HC IVs are financed under their respective District LGs and their inputs are thus merged with those of other lower level HCs.
The detailed outputs and outcomes from HC IVs are provided in the Annex. HC IVs generated 13,780782 SUOs equivalent to 14.5% of the total sector outputs. Mukono Town Council HC IV with 216,116 SOUs had the highest number. 41 HC IVs had SOUs above 100,000 and if resources allow could be considered for upgrading to Hospitals. The bed Page | 46
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occupancy rate for HC IVs was 52.3% while the average length of stay for inpatients was 2.5 days. 13 HC IVs had a bed occupancy rate above 100% and may require expansion given that their average length of stay was less than 3 days. PAG mission HC IV had an average length of stay of 6.4 days which may need to be explored further.
TABLE 41: LEADING CAUSES OF MORBIDITY AT HC IVS IN 2015/16 FY
Condition Under 5 Condition 5 and above years No. % No. % Malaria 338,238 39.0% Malaria 945,463 33.7% No pneumonia – cough or 275,945 31.8% No pneumonia – cough or 686,751 24.5% cold cold Diarrhoea – acute 62,334 7.2% Urinary Tract Infections 173,358 6.2% Skin diseases 36,858 4.3% Tooth extraction 123,752 4.4% Pneumonia 36,459 4.2% Intestinal worms 112,110 4.0% Intestinal worms 32,254 3.7% Skin diseases 94,591 3.4% Other eye conditions 13,963 1.6% Pelvic inflammatory disease 70,116 2.5% Urinary Tract infection 12,004 1.4% Other sexually transmitted 69,346 2.5% infections Injuries (trauma due to 7,115 0.8% Injuries (trauma due to other 56,975 2.0% other causes) causes) Other types of anaemia 6,001 0.7% Diarrhoea – acute 54,511 1.9%
The leading causes of morbidity in HC IVs are shown in table 42 below. While infectious diseases still dominate the list, the emergence of dental diseases and trauma as leading causes of morbidity is worth noting. The leading causes of mortality are shown in table 43. Treatable infections including malaria in pregnancy are still the major cause of mortality though injuries due to road traffic accidents have also emerged as a major cause of mortality.
TABLE 42:LEADING CAUSES OF MORTALITY AT HC IVS IN 2015/16 FY
Condition Under five Condition 5 years and above cause of death cause of death No. % No. % Malaria 972 47.3% Malaria 306 16.3% Pneumonia 224 10.9% Malaria in pregnancy 150 8.0% Anaemina 205 10.0% Pneumonia 102 5.4% Diarrhoea – acute 73 3,6% Anaemia 95 5.1% Respiratory infections 66 3.2% HIV related 67 3.6% Septicaemia 55 2.7% Urinary Tract Infection 66 3.5% Neonatal sepsis 52 2.5% Abortions 66 3.5% Gastro-intestinal disorders 47 2.3% New TB cases 63 3.4% Injuries (trauma due to other 37 1.8% Hypertension (old cases) 59 3.1%
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causes) Injuries – Road traffic accidents 31 1.5% Injuries – Road traffic 52 2.7% accidents
The facility based Maternal Mortality ratio for HC IVs was 106/100,000. Rhino camp, Namatala and Amolator HC IVs had high MMR of 2,578/100,000, 1,600/100,000 and 1,004/100,000 respectively and need support. More than 50% of HC IVs did not report any maternal death. The fresh still birth rate for HC IVs was 11.9/1000. St Ambrose charity and Busia HC IV reported the highest Fresh still birth rate of 132.2/1000 and 111.6/1000 respectively. 12 HC IVs reported no fresh stillbirth. The perinatal mortality rate for HC IVs was 33.4/1000. Namatala and St Ambrose charity reported the highest perinatal mortality rates i.e 424/1000 and 282/1000 respectively. HC IVs with high fresh stillbirth and perinatal mortality will be supported to improve functionality and outcomes.
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4 ANNEXES
4.1 Annex One:Delivery of the Uganda National Minimum Health Care Package (UNMHCP). This section details the progress on implementation of priority activities under the UNMHCP.
4.1.1 Health promotion, disease prevention, and community health initiatives The key objectives of the division are Prevention and control of communicable and non - communicable diseases (NCDs), capacity building of service providers, policies, laws, guidelines dissemination and plans and strategies, technical support supervision monitoring and supervision.
The following outputs were achieved;
i. Raised awareness on cholera, teenage pregnancy, measles, HPV, Polio and safe motherhood through radio spot messages and press conferences. ii. Reviewed IEC materials on measles, HPV, and nutrition for Karamoja region. iii. Developed Social behavior Change (SBCC) guidelines on Sexual and Reproductive and HIV/AIDS. iv. Technical support supervision and monitoring in 10 districts in western region.
4.1.2 Environmental Health This component aims at contributing to the attainment of a significant reduction of morbidity and mortality due to: poor sanitation and hygiene, indoor pollution, poor food hygiene and supply, unsafe water accessibility and other environmental health related conditions. This was done through implementation of activities supported by the GoU, UNICEF and the Uganda Sanitation Fund (USF) Program.
Emphasis was put on Improved Hygiene and Sanitation (ISH) and Kampala Declaration on Sanitation (KDS +) strategies. The communities are reached through Community Led Total Sanitation (CLTS) approach, Participatory Hygiene and Sanitation Transformation (PHAST).
The following were the achievements: • Training and capacity building: Trained 25 Health Inspectorate staff from Kayunga, Buikwe, Soronko, Manafwa & Bududa in Community Led Total Sanitation (CLTS) approach with support from UNICEF, 35 Community Extension Workers, 25 VHTs in CLTS in the districts of Hoima, Kiboga, Buikwe with support from (World Vision) and Bukwo with support from Catholic Relief Services and 12 MoH staff in Sanitation Wealth approach under the support of WHO. • Other out puts included; commemoration of National Sanitation Week with apex celebrations held in Mbale district. • Developed the Environmental Health Strategy 2015/16 – 2019/20, Page | 49
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• Supported six districts with 6 motorcycles from UNICEF. • Supported 2 districts (Ntungamo and Kiruhura) in conducting Open Defecation Free Verification. • The division also supported districts of Mbale, Soronko, Manafwa, Bududa, Budaka, Kibuku, Pallisa, Butaleja Bulambuli and Namayingo during the outbreak of cholera. • Supervised 14 districts in Busoga and Karamoja Sub Regions for jiggers eradication programme. • Monitored and evaluated Health care waste management in the 14 districts of Kitgum, Lamwo, Padero, Agago, Gulu, Oyam, Otuke, Lira, Kole, Dokolo, Soroti, Katakwi, Moroto and Kotido.
4.1.3 Control of Diarrheal Diseases (CDD) The mandate of CDD division is to prevent and control diarrheal diseases through promotion and use of strategies that will reduce morbidity and mortality.
The following outputs were achieved;
• Supported districts to prevent and control cholera outbreaks. Thirty one districts were identified and equipped with skills for cholera outbreak prevention and control. Cholera outbreaks were reported and controlled in 22 out of 112 districts. • Provided logistical and financial support to the districts with severe cholera outbreaks namely; Bulambuli, Butaleja, Namayingo, Busia, Mbale, Sironko, Hoima, Nebbi, Bukedea, Mayuge, Kayunga, Wakiso and Kampala. • Other districts with minor outbreaks were also supported with medical supplies for cholera control. These districts were: Bududa, Manafwa, Budaka, Kapchorwa, Zombo, and Arua, Buliisa, Buvuma and Palisa.
Though several gains were registered during the year 2015/16, there were a number of challenges as well notable among them were:
• Adverse weather condition namely El Nino rains whose effects were mitigated but pronounced in the districts of eastern Uganda (Figure 12). As result of these rains, the country recorded an upsurge of cholera cases in which 2,913 cases with 79 deaths and Case fatality rate of 2.7% were reported during the FY.
FIGURE 12:ANNUAL CHOLERA CASES IN UGANDA FOR THE PERIOD 2013/14 TO 2015/16
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Source: MOH, CDD reports • Poor sanitation and hygiene in affected communities especially the island communities and on the landing sites. • Inadequate participation of other key sectors in promotion and preventive activities (Local Governments, Water and Environment, etc) for cholera.
4.1.4 Maternal and Child Health MCH cluster is composed of five sub programs: Sexual and Reproductive Health (SRH), Newborn Health, Integrated Child Survival and Development, Immunization and Nutrition.
4.1.4.1 Sexual and Reproductive Health and Rights The sexual and reproductive health rights interventions are aimed at reducing maternal mortality, perinatal mortality, and total fertility rate, and improving sexual and reproductive health of the people which are all key elements for achieving the SDG3.
The health sector and its development partners have continued to prioritize SRH services during resource allocation as shown in table below. The sector was also able to recruit additional critical cadres 59 doctors, 174 midwives, 26 Nursing officers midwifery and 148 Enrolled midwives, and 8 anesthetic officers to offer RH services among other cadres that were recruited. As a consequence 100% of hospitals were able to offer comprehensive emergency obstetric and neonatal care (EmONC) while all HCIIIs offer basic EmONC.
4.1.5 Newborn and Integrated Child Survival and Development The sector’s major strategy is to end preventable newborn and the under five deaths by increasing equitable coverage of high impact evidence based interventions in order to accelerate the attainment of SDG 3, and to promote appropriate nutrition and proper growth and development of children and adolescents.
The child survival strategy focuses on the following;Newborn care,infant and young child feeding, prevention of malaria, management of new childhood illness, expanded program on immunization, care of HIV exposed children, EMTCT, promotion of safe water access and use, and safe sanitation.
The following outputs were achieved;
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• Revision of the sharpened plan for RMNCAH. • UNEPI successfully conducted mass polio campaign (SNIDS in October, 2015, February 2016 and NIDS in April 2016) so as to increase the population immunity. Uganda was certified polio free after conducting mass polio and measles vaccinations. • UNEPI successfully introduced Inactivated Polio Vaccine (IPV) into routine immunization schedule. UNEPI successfully switched from oral trivalent Oral Polio Vaccine (tOPV) to bivalent Oral Polio Vaccine (bOPV) as part of meeting the Polio Eradication and Endgame strategic plan 2013-2018 • The child day’s strategy to provide supplementary packages in October and April each year continued and countrywide the proportion of children covered was 79% and 85% in October 2015 and April 2016 respectively. Increased community access to child survival interventions and commodities • Increased capacity of facility-based staff to manage common childhood and newborn illness through training in IMCI. This improved health worker skills in assessment and management of common childhood illness and has a component for Emergency triage and treatment for Hospital and HC IV based health workers. • Integrated Community Case Management (ICCM) expanded to 75 districts.Trained 2,350health workers in newborn resuscitation in order to improve newborn health and survival bringing the percentage of health workers trained to 39 % within the last two years.
4.1.6 Tuberculosis and Leprosy control During the FY 2015/2016 the following tuberculosis control interventions were prioritized, a) Early diagnosis of TB cases b) Drug susceptibility testing and systematic screening for drug resistance among the previously treated patients and high risk groups. c) Treatment of all TB patients including emphasizing childhood TB management and integration in Reproductive, Maternal, Child, and Adolescent Health (RMNCAH). d) Collaborative TB/HIV activities and management of co-morbidities.
The following outputs were achieved;
• National situation analysis were carried out and childhood TB guidelines and training manuals were developed. • A total of 250 national trainers have been trained and they conducted mentorships on peadiatric TB in 72 health facilities.
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• Capacity building of health workers to improve peadiatric TB surveillance was initiated and together with the ongoing facility mentorships is expected to improve case detection, contact tracing and treatment success for childhood TB cases. • During the year, the sector extended capacity building for private health practitioners beyond Kampala to Wakiso, Mukono, Jinja and Buikwe districts. Trained over 220 clinicians and 108 laboratory personnel from 150 private health facilities who in turn detected and enrolled over 1,370 TB patients on treatment. • The country has a network of 1,349 peripheral TB laboratories and 112 with PCR TB machines in 106 Diagnostic and Treatment Units in 78 districts. During the FY, 88% of peripheral labs participated in External Quality Assurance for smear microscopy using the blinded rechecking method. The High False Negative rate country wide has progressively reduced from 22% in 2006 to the current <5% rate. During the FY, only 6% and 4% of Diagnostic and Treatment Units assessed had more than 1% High False Positive and 1% High False Negative respectively.
Key outcomes • The overall TB case notification rate for FY 2015/16 was 121/100,000 indicating a slight decline when compared to 124/100,000 in FY 2014/15. The overall number of patients started on TB treatment continued to decline (45,268 in FY 14/15 compared to 43,858 in FY 15/16) probably as a result of improved TB/HIV collaborative activities. Bacterialogically confirmed TB cases declined from 29,288 to 28,326. Pulmonary TB constituted 91% of TB cases notified while extra-pulmonary TB made up 9% as opposed to the expected 15-20%. Clinically diagnosed TB continues to be under-notified with 1 case for every 2.5 Pulmonary Bacteriologically confirmed cases notified against a national target of 1 clinically diagnosed for every 1 pulmonary bacteriologically confirmed case. • The treatment completion rate for the cohort of 2015 was 89.4% while the treatment success rate was 79.3% and 51.2% were declared cured. Up to 5.4% of the patients died while on treatment and 1% had treatment failure. The records of 3.7% of the patients were incomplete mainly due to transfers out to other health facilities and their records had not reverted back to the original health facility. In comparison of the 41,509 new patients notified in the year 2014/2015, a total of 74.7% were successfully treated, 7.4% died, and 0.7% failed while 11.7% were lost to follow up and the
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treatment outcomes of 5.5% were not recorded. Furthermore, retreatment patients had improved outcomes with 71% success rate compared to previous years. • During the FY 2015/16, 3,079 (41% of the expected) childhood TB cases were notified; and 10.1% under five years old had infectious Pulmonary TB. The treatment success rate for childhood TB (2015 cohort) was 72% falling below the national target of 85%. Due mainly to a shortage of medicines only about 5.7% (791/13,798) of the documented under five years old contacts of infectious TB patients were initiated on Isoniazid Preventive Therapy (IPT). • 295 MDR-TB patients were enrolled on treatment; and 74% (target 70%) of the MDR-TB patients enrolled in 2013 were successfully treated. However, low cure rates and high unfavourable outcomes among drug susceptible TB cases, low DR-TB case finding (20% against target of 50%), weak surveillance systems, poor flow of GeneXpert test data, inadequate provision of patient adherence enablers (food and transport refund), and low contact tracing remain a challenge to management of multi drug resistant TB in the country.
4.1.7 Leprosy Leprosy remains an endemic disease in Uganda. During FY, 266 new leprosy cases were detected, 31% of them with grade 2 disabilities (against 5% target) and 6% of whom were aged less than 15 years; a 90% MDT treatment completion rate was attained; and contact surveillance remained the best screening strategy, yielding 13.1 new leprosy cases per 1,000 individuals screened. NTLP plans to maintain a national surveillance system, institute systematic contact surveillance, map out leprosy hot spots and intensify case finding in them; and sustain partnerships as well as urgently build the capacity of clinicians to suspect and diagnose leprosy early so as to minimize disability and stop transmission. There is need to include leprosy among neglected tropical diseases so that it benefits from the support coming through for the neglected tropical diseases. Uganda has not prioritized leprosy among neglected tropical diseases so far.
4.1.8 Prevention and Control of STI/HIV/AIDS The AIDS Control Program of the MoH is mandated to spearhead the implementation of the Public Health response to the HIV and AIDS epidemic in Uganda. This mandate is part and parcel of the multi-sectoral HIV and AIDS response that is coordinated by the Uganda AIDS Commission. In the implementation of the Public Health response, the AIDS Control Program focuses on interventions that reduce the occurrence of new HIV infections, mitigate
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the impact of the epidemic through the provision of prevention, care and treatment; and to develop capacity for service delivery. The 2011 AIDS Indicator Survey (AIS) established an HIV prevalence that was estimated at 7.3% in 2011. At the end of 2015, the number of people in the country living with HIV was estimated at 1,461,756 (Adults 1,366, 107 and pediatric 95, 649). The epidemic disproportionately affects certain geographical areas, women, urban residents and Key populations. The main risk factors for HIV transmission in Uganda are multiple concurrent sexual partnerships, mother-to-child transmission, and non-use of condoms, non- circumcision, and a high median viral load in HIV infected population. The following outputs were achieved;
• In partnership with Communication for Health Communities (CHC) project, HIV messages were developed and disseminated through a variety of channels. The messages were aired on 45 radio stations, 4 Television stations, and Road-side bill boards in 112 districts and 200,000 posters and 300,000 leaflets on different themes. • The Program also conducted 4 IEC/BCC coordination meetings to review performance of work plans. The stakeholders included Communication for Health Communities, Uganda Health Marketing Group (UHMG), Reproductive Health Uganda (RHU), AIDS Information Centre (AIC), Baylor College, UAC and Strengthening TB and HIV/AIDS Eastern Uganda Project (STAR E). • In support of programs for eMTCT, the MoH in partnership with the office of the First Lady and other stakeholders launched eMTCT campaigns year in four regions namely Teso, South Western, Mid-Western, and Central 1& 2 regions. Through these campaigns the uptake of EMTCT services were improved, and political and civil leadership was mobilised for onward social mobilization for eMTCT services in respective regions. • During 2015, 89 million male and female condoms were procured distributed in the public and private sector. This represents a decline of 49% compared to the previous year, and 85% short of projected annual need. This gap was compounded by delayed deliveries from the Global Fund and National Drug Authority (NDA) post shipment testing and clearance. Condom for the public sector are distributed to peripheral outlets by National Medical Stores (NMS), while the Uganda Health Marketing Group (UHMG) is an alternate distribution mechanism to implementing partners and private not for profit (PNFPs) facilities. In addition, UHMG, the Program for Accessible
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Health, Communication and Education (PACE), and Marie Stopes International (MSI) Uganda also distributes condoms through social marketing. • An assessment of the comprehensive condom programming was conducted with support from the Global Fund in conjunction with the Makerere University School of Public Health. The assessment revealed significant achievements in supply and commodity security; improved availability, access and utilization. Furthermore there was better public trust in condoms supplied by government and the public sector brand ―Hot Pink‖ was one of the most preferred. • In 2015,HIV testing services were provided to a total of 11,742,311 individuals including10,292,539 adults and 1,449,772 children. The target of testing 9,523,170 during the year was surpassed. The sero-positivity rate among adults and children was 3.0% which continued the trend observed from previous years. Based on the number of people in chronic HIV care, it is now estimated that about 945,752/1,461,756 (64.7%) of People Living with HIV (PLHIV) by the end of 2015 know their status (the first 90 of the 90-90-90 targets, of whom 834,931(54.1%) were on ART by end of 2015. • The Program revised the HIV Counseling and Testing Policy. • During 2015, a total of 556,546 young men were circumcised in facilities across the country bringing the total number of circumcised males since 2012 to 2,604,823 or 62.0% of the initial target of 4.2 million young men to be circumcised by 2015. These services were provided in 851 facilities (10 referral facilities, 103 hospitals, 150 HC IVs, 273 HC IIIs, 212 HC IIs, 84 clinics, 18 and specialized clinics. • By the end of 2015, all districts in the country were implementing Option B+. PMTCT services were offered in 3,637 health facilities of all levels by July 2015. These were comprised of 16 referral hospitals, 133 general hospitals, 191 HC IVs, 1,186 HC IIIs, and 2,327 HC IIs. • Out of 1,654,222 women that attended the first antenatal care visit during 2015, 1,522,367 (92%) had an HIV test, of whom 45,206 (3.0%) tested HIV positive, and 60,190 already knew and had their documented HIV sero-status before the current pregnancy. In addition, 236,003 women were tested in other settings including the post-natal clinic (PNC) (117,476), Family Planning / maternity (118,527) etc. Therefore, the number of women who were counselled and tested and received test
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results for PMTCT were 1,758,370 and overall, women with known HIV sero-status in ANC, labour and postnatal were 1,818,560. • Out of the 1,818,560 who knew their sero-status, 126,961 were HIV sero-positive, i.e. 38,749 who tested HIV-positive in ANC, 60,190 who had a documented HIV-positive sero-status prior to first ANC visit, 2,672 who tested HIV positive in maternity, 2,018 who tested HIV positive in PNC, and 3,785 who tested positive in ANC upon retesting. About 97% of the HIV-positive women received ARVs for PMTCT namely: 70,207 who were on HAART before first ANC visit, and 47,680 who started on Option B+ during antenatal, labour and delivery. • The Country is at the verge of virtual elimination of mother-to-child transmission. Our data indicate that the number of children born with HIV infection in Uganda declined by 86% between 2011 and 2015. At the end of 2015, only 3,487 new pediatric HIV infections occurred in the Country. • During the reporting period, the AIDS Control Program continued to expand the Care and Treatment portfolio. There were 1,461,756 HIV-infected adults in the country at the end of 2015, of whom 1,196,547 were eligible and in need of ART according to the 2013 WHO national treatment guidelines. The Country is in advanced stages of adapting the 2016 WHO Prevention and Treatment guidelines, and when their implementation begins in October 2016 all HIV infected individuals will be eligible for treatment based on a policy known as "Test and Treat". • By end of 2015, there were 834, 931 individuals including 774,902 adults and 60,029 children on ART in 1,664 facilities across the country, having grown from 750,896 (694,627 adults and 56,269children) at the end of 2014. A total of 160,484 new adult clients were enrolled during the year. By June 2016, the number of individuals on ART had further increased to 898,197 (836,947 adults and 61,260 children). The number of ART service delivery outlets increased modestly from 1,658 to 1,664 during the year through accreditation of ART services. The pace of accreditation of new facilities slowed down due to the need to be more cost-efficient, taking into account current patient loads in each facility. • Viral load monitoring of ART clients was rolled out further during the year. About 970 facilities sent samples for viral load tests at Central Public Health Laboratory (CPHL) through the sample transport system. A total of 270,556 samples were tested.
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Overall, 89.8% of samples had viral suppression; the detailed data can be found in the laboratory section. • In the reporting period, the MoH, together with partners have been planning for a large scale Uganda Population based HIV Impact Assessment Survey (UPHIA). The Survey is being implemented with the support from ICAP at Columbia University as well as the U.S. Centre for Disease Control and Prevention (CDC). The other partners include Uganda Virus Research Institute (UVRI), Uganda AIDS Commission, Uganda Bureau of Statistics, World Health Organization, UNAIDS, Westat and ICF Macro. The Survey Field Work has currently commenced after being flagged off by the Honorable Minister of Health and the US Ambassador to Uganda on the 23rdAugust 2016.
4.1.9 Malaria Control and Prevention The Malaria Control Program spearheads malaria control in the country and in the pursuit of this endeavor, it has conducted activities under Case Management and Integrated vector management. These have been supported by Monitoring, Evaluation, Epidemic Response and Surveillance and BCC activities.A number of these activities have been implemented as presented below;
• Rapid diagnostic kits for testing malaria and anti-malarial medicines have been procured. • Overall from the HMIS, over the current reporting period, there were 408 malaria cases per 1000 persons, 18 deaths per 100,000 persons and 93% of women received 2 IPT doses in this period. Despite the interventions, these indicators didn’t change much due to largely the improved reporting and epidemic in Northern Uganda. A survey to assess factors contributing to over consumption of artemisinin-based combination therapy (ACTs) against low numbers of malaria cases was conducted. In collaboration with PMI, The Global Fund, TASO and other partners, routine LLIN distribution was done throughantenatal clinics and EPI. Besides, the country has procured LLINs for mass distribution. A total of 24 million nets have been mobilized and distribution is expected to commence in the last quarter of 2016. During this FY, NMCP together with PMI and DFID continued with indoor residual spraying in a total of fourteen (14) Districts. Out of these, nine districts are in the
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eastern part of the country. These include; Namutumba, Tororo, Bugiri, Mayuge, Serere, Pallisa, Budaka, Butaleja, Kaberamaido and Kibuku. The rest are in the north and these include; Amolator, Dokolo, Lira, Otuke and Alebtong. The Total Malaria cases and the Confirmed OPD Malaria cases in the 14 IRS districts in Eastern Uganda decreased from the last FY as shown below;
FIGURE 13: TOTAL OPD AND CONFIRMED MALARIA CASES IN THE 14 IRS DISTRICTS
2000000
1500000 Total OPD Malaria 1000000 Cases Confirmed Malaria 500000 Cases
0 2014/15 2015/16
• In the bid to continuously ensure that staff at service delivery points have the requisite skills for diagnosis and management of malariaand that they are updated on the malaria control policies, integrated management of malaria (IMM) training has been conducted in 50 districts and a total of 1,250 persons trained. • Quarterly supervision was done by the central team in 60 districts across the country, routine data quality assessments were conducted across the country, integrated management of malaria was done in 50 districts across the country. • The malaria communication strategy was finalized and launch. • Data quality audits were conducted in a number of districts and with focus on the high level and high volume health facilities. More facilities will be covered in the next FY. • With support from DFID, UNICEF and WHO, under its capacity building plan, NMCP received three technical staff. • Mapping of breeding sites has been done and currently Baseline entomological studies are undergoing in two sub counties in Nakasongola. • The program renewed efforts to strengthen the Test, Treat and Track policy. Figure 14 shows the distribution of percentage malaria lab confirmed cases across the country. • The program mobilized resources from various partners, most especially Global Fund, UNICEF, WHO, DFID, AMFM, and PMI. Funds for critical activities such as Malaria
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commodities (ACT’s and RDTs), mass (countrywide) LLIN distribution, IIRS in the 10 Northern Epidemic districts have been secured. The Global fund awarded the country a costed-extension of the malaria grant under which numerous activities are funded.
FIGURE 14: PERCENTAGE OF MALARIA LABORATORY CONFIRMEDCASES FY 2015/16
4.1.10 Mental Health and Control of Substance Abuse Key outputs during FY 2015/16 • Following the enactmentof thetobacco control Act 2015, the program initiated the development of regulations for the different sections of the Act for effective enforcement and implementation. • During the FY the program begun the process of finalizing the Alcohol Control Policy. • Commemorated the National Mental Health day, the World No Tobacco Day and International day on drug abuse and illicit trafficking. During these days the program has raised public awareness through radio and television talk shows on tobacco control drug abuse and Mental illnesses. • Provided support supervision to Mbale, Gulu, Lira, Jinja, Fort Portal, Kabale and Soroti Regional Referral Mental Health units. From all these visits it was found that the number of patients with Mental, Neurological and Substance use disorders has
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substantially increased and all the units were challenged by stock out of all relevant medicines. • 75 health workers were trained in Inter Personal Psycho Therapy for Groups and also with support from World Vision International begun the training of general Health workers in Mental Health using the WHO-MHGAP interventional guide. • The program participated in research on integration of mental health into PHC by various researchers and in management of depression among people with HIV in Kitgum, Pader and Gulu in collaboration with Makerere University. • Disseminated the findings from the global adult tobacco survey conducted in 2013 at regional level with an aim of stimulating districts to made plans for tobacco control.
4.1.11 Community Oral Health Outputs for Oral Health during the FY 2015/2016 were as follows; • Support supervision was done in 12 dental units in RRHs. • Equipped 13 dental units with an assortment of dental materials for school oral health program, two hospitals equipped with X- ray machines, 10 schools per 1 RRH screened for oral disease, • Marked World Oral Health Day with dental camps in KCCA clinics, RRHs and at Mulago dental school. • Developed guidelines on SOPs in Dental units, Hepatitis B, Injection Safety and Palliative care, • Capacity building for 15dentistsfrom national and RRHs, 20 Technicians, and 60 Public Health officers.
4.1.12 Central Public Health Laboratories In the FY 2015/16 with support from CDC, the CPHL building in Butabika was completed and commissioned at a cost of 29bn Uganda Shillings.The laboratory was set up to carry out hepatitis B and HIV viral load tests.
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4.1.13 Epidemiological Disease Surveillance (ESD) The following activities were achieved during the FY 2015/16;
• Capacity building for integrated diseases surveillance and response was conducted in 97 districts • 2 districts for DTRACBEP supported Surveillance training. • 26 weekly surveillance bulletins were published • 3 monthly IDSR/IHR meetings were held • 2 standard operating procedures for VHTs were developed • 13 health workers from 8 eight regions were trained on the clinical management of Viral Haemorrhagic Fevers (VHFs) • Typhoid disease outbreak was controlled in Kampala and Wakiso districts. • Investigations were carriedout on Podoconiasis disease outbreak in Kamwenge district. • Funds were transferred to the districts of Agago, Amuru, Apac, Gulu, Kitgum, Kole, Lamwo, Nwoya and Pader to support their respective district response plans to malaria epidemic in Northern Uganda. • Technical support supervision was carriedout and conducted. • A stakeholders meeting with the district leaders on malaria epidemic in the districts of Agago, Amuru, Apac, Gulu, Kitgum, Kole, Lamwo, Nwoya, Oyam and Pader in northern Uganda was held to forge a way forward for the epidemic. • Investigated the suspected Viral Heamorrhagic Fever, (VHF)/yellow fever in Napak district, strange disease (linked to Viral Heamorrhagic Fever), Rubella/Chicken pox outbreak in Wakiso district, Measles in the districts of Kiruhura, Kamwenge, Kyegegwa, Poisoning in Buikwe, Iganga and Tororo and cholera outbreaks in Hoima, Buliisa, Mbale,Wakiso, Kampala and Masindi districts.
4.1.14 Clinical services • Conducted technical support supervision in the 13 RRHs as well as the following general Hospitals; Tororo, St Anthony,St Francis Buluba, Maracha, Kuluva, Masafu, Mityana and Kawolo Hospitals. • Support supervision was also provided to the following HC IVs -Mukuju, Busia, Nagongera, Mulanda, Olii, Mukono Kilembe, Kagando, Rwesande, St Paul, Nyamirami and Kotomor HC II. • Five mentoring and coaching sessions were conducted. • The world Hepatitis day was celebrated in Ngora. • Developed the Public Health Protocols which were launched in Sheema by H.E the President of the Republic of Uganda.
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4.1.15 Palliative Care Palliative Care is an approach that improves the quality of life of patients and their families facing the problems associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.
Main achievements
• Palliative Care policy was presented to Top management and endorsed for presentation to Cabinet. • The communication strategy was developed up and is ready for presentation to the TWG. • Consultative meetings were held on the Drug and Narcotic act with stakeholders. • Two stakeholders/multi-sectoral on UNGASS was held. • 4 quarterly stakeholders meeting on Morphine were held. • 2 Hospitals were trained on Palliative Friendly Initiative (Mbale Hospital & Gulu Hospital). • Improved reconstitution and distribution of oral morphine.
4.1.16 Nursing Department In the FY under review the following were achieved;
• Three technical Support Supervision visits conducted in Northern and central region • Two Nurses, Midwives leaders Assistant District Health Officers (ADHO) meetings were held with a total of 45 Nurses, Midwives and ADHOs • Q1& Q2 Students interviewed and Nurses and Midwives students supervised in their final examinations. • Participated in the development of EAC Nurses and Midwives curriculum.
4.1.17 Uganda National Health Research Organization
The following were the key outputs from UNHRO during the FY 2015/16; • 7th (ANREC) Annual Conference on Research was held • A strategic Plan for 2016-2021was finalized and approved • Research findings on Eflornithine, Nifurtimex, and melasporol, Suramin were reviewed • Knowledge translation workshop held to disseminate and review indigenous health adaptation to climate change. • The Annual Traditional conference (ANTRAMEC) was held in August 2015 under the Theme ―Traditional medicine to generate partnership between scientists, practitioners, and entrepreneurs”
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• Reviewed the establishment of the EAC Health Research Commission in Kigali, Sept 2015 • UNHRO hosted a national stake holders conference on EAHRC in March 2016 • Jointly launched the East African Health Research Commission in Nairobi, Mar 2016.
4.1.18 Uganda Blood Transfusion Services (UBTS)
The UBTS registered the following out puts; • Continued supervision and coordination of operations of the 7 RBBs including maintenance/ replacement of transport logistics and laboratory equipments. • 232,331 cumulative units of blood were collected, Repeat blood donors were maintained at 60% and all collected blood units were tested for TTIs and the safe blood units were issued to all transfusing heath care facilities in the country. • The discard rate for blood units collected was reduced to 5.3% against a target of 8%. • Conducted quarterly audits of the seven Regional Blood Banks and blood collection centres
4.1.19 Uganda Aids Commission Uganda Aids Commission achieved the following outputs; • It convened 4 National Policy Coordination meetings about the Modes of transmission study to guide planning and HIV response • Finalized the MARPS priority action plan 2015-2017 and the MARPS programming and accountability framework • Disseminated the National Strategic Plan and all accompanying documents in 18 Local Governments • Joint Aids Review was convened and an Aide memoire was signed with 12 undertakings. • 47 districts and13 Municipalities were supported in planning, resource mobilization and sustaining the recently rejuvenated HIV and AIDS Coordination Structures. • They mapped partners operating in Uganda using the E-data base. • An electronic NADIC portal has been established hosting, the HIV Research Database, NADIC Catalogue, Stakeholder Emapping Database and M&E Database • Video conferencing Equipment and ACs, Computers, all in one Printers procured installed. • Commemorated World AIDS day, Philly Lutaaya and Candle light.
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4.1.20 Uganda Catholic Medical Bureau (UCMB) performance The UCMB is a health department of the Catholic Church in Uganda and plays the principal roles of advocacy and lobby, coordination, mentorship & supervision and regulation of catholic health services in Uganda—which entail a broad range of initiatives and activities aimed at building and strengthening national health systems within a framework of complementarily. The Bureau coordinates, represents and supports 294 registered health facilities and 13 health training institutions. The health facilities comprise of 32 hospitals, 6 HC level IV, 178 HCs at level III and 77 HCs at level II.
4.1.20.1 Health Financing in UCMB Network in the FY 2015/2016 The financial contribution from the UCMB facilities amounted to 172.9 billion shillings in the FY 2015/2016 an increase by 16% from the FY 2014/15 of network’s total income. The increase was mainly due to increase in support from external aid and user fees collections, which increased by 26% and 14% respectively in the period. The Government subsidy, which was in form of PHC Conditional Grant to UCMB health facilities, and health training institutions accounted for 9% of the budget in the FY 2015/2016, while user fees accounted for 49% and donations accounted for 42% of the budget. The introduction of the Straight Through Processing (STP) of PHC Grants to UCMB health facilities improved on timeliness of receipt of the Grant and therefore the implementation of the primary health care services in the previous two financial years. Figure 15 below shows the proportionate contribution of the 3 major sources of income of UCMB health facilities over the last 5-year period. Over the period within the UCMB network health facilities, the proportion of External Aid to total income has increased while user fees have remained fairly stable and the proportion of government subsidies reducing.
FIGURE 15: TRENDS IN INCOME FOR RECURRENT COST IN UCMB NETWORK IN THE LAST 5 YEARS
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Source: Bureau databases
4.1.20.2 UCMB Contribution to the HSDP Outputs The output from the UCMB hospitals and Lower Levels depict the performance on the most important health indicators used for monitoring the HSDP performance for the FY 2015/2016. The cumulative values for the 3 of the 4 main services offered in the Hospitals and LLU registered positive gains. New and Re-attendances decreased to 2,911,231 in FY 2015/16 from 3,212,863 in FY 2014/15 a decrease by 9.4% in the period.
The total number of deliveries increased to 99,818 in FY 2015/16 up from 94,356 (2014/15) an increase by 6% in the period under review.Significant maternity increases were noted in lower level units, which reported a 17% increase in deliveries in the period while hospitals, registered a slight increase of 3%.
The number of immunizations increased to 2,147,856 in FY 2015/16 from 2,105,887 in FY 2014/15 an increase by 2% in the last one year.The increase was significant in UCMB hospitals which registered an increase by 18% in the period while lower level health facilities increase was 4%.
Total number of admissions increased to 494,096 in FY 2015/16 from 460,006 FY 2014/15 an increase by 7% in the period under review.
UCMB facilities counseled, tested and gave HIV results (HCT services) to a total of 677,553 individuals—an increase by 29% from FY 2014/15, 157,944 pregnant and lactating women attending antenatal, postnatal and maternity services and 4,756 couples were also counseled, tested and received results for HIV—an increase by 26.6% from the last FY. UCMB contributed 9% of the entire country HIV counseling and testing outputs during the year.
A total of 91,687 individuals (8% of whom were children below 15 years) were provided with comprehensive HIV services through the UCMB network of hospitals and Lower Level Units across the country. Of these HIV patients, 85,017 (92% of total in HIV care) were given antiretroviral therapy (ART). UCMB facilities contribute 10% of the total number of individuals on ART in the country.
In its efforts to enhance TB/HIV co-management, UCMB got an award through a WHO funding mechanism to support the national TB program to scale up case finding and treatment for TB using the GeneXpert diagnostic technology. Currently 2- 2 modular GeneXpert machines are running these services in the districts of Tororo, Busia and Mpigi, not only serving the host hospitals of Nkozi and St Anthony’s, but the entire districts. Over the year, more than 1,482 patients were identified and put on treatment in addition to identifying and referring 5 MDR cases to MoH managed MDR treatment center. The Page | 66
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biggest challenge to UCMB during the year under review was the inconsistent supply of TB medicines and INH prophylaxis.
4.1.20.3 Status of Human Resource for Health in UCMB 2015/2016 The total workforce in the UCMB networks as at June 30th 2016 was 8,870 as compared to 8,527 as at June 30th 2015. This was a rise of about 4% over one year as shown in the table below.
TABLE 43: SHOWING TOTAL NUMBER STAFF IN UCMB HEALTH FACILITIES FROM 2011- 2016 Years 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 HOSPITALS 5,068 5,355 5,435 5,502 5,618 5716
LLUs 2,522 2,688 2,790 2,920 2,909 3154 Total 7,590 8,043 8,225 8,422 8,527 8,870 Data Source: UCMB facility annual staffing report
Out of the 8,870 total staffing, the health facilities employed 61% of the qualified clinical workforces, 5% were not clinically qualified and 34% were the non-clinical staff which are administrative staff, and support.
4.1.20.4 Health Worker Support to the UCMB Facilities The GoU through the MoH and DLGs supported UCMB health facilities with 8% of the total clinical staff in 2015/16; this is a slight decline from the 9% support of last FY. Four hundred and fourteen (414) clinical staffs were seconded to UCMB hospitals and lower level units in FY 2015/16 by the GoU. However, Kilembe Mines hospital alone has 121 HRH seconded, which accounts for 29.2% of the total seconded staffs to UCMB health facilities. Other significant secondment of HRH ranging between 20 and 30 staff are also observed in Buikwe, Lacor St Mary's, Maracha, and Lubaga Hospitals mainly also supporting HSD activities. The bureau greatly appreciates this support.
The UCMB HRH partnership support by USAID/Strengthening Decentralization for Sustainability (SDS), Mildmay Uganda, and Walter Reed, recruited and deployed to selected UCMB health facilities 118 health workers in FY 2015/16, totaling to 355 supported qualified clinical staffing in 89 UCMB health facilities in 92 districts of Uganda. The key cadres supported include, Clinical Officer, Midwife, Nurse, Lab Technician, Medical Officer Anaesthetic Assistant, Anesthetic Officer, Lab. Technologist, Laboratory Assistant, Pharmacy Assistant, and Pharmacy Technician.
One of the HRH challenges in the high attrition rate.During the FY 2015/2016, most of the departures were nurses at 34%, followed by midwives at 25%, 20% for administration and support staff and to a lesser extent the medical officers and paramedical staff.
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4.1.20.5 UCMB Health Training Institutions Contribution to Health Work Force UCMB coordinates 13 Health Training Institutions (HTIs), with the objective to train an optimal range of health care personnel of high moral and professional standards for PNFP health care facilities and national health care institutions. The contribution of UCMB HTIs to the National health work force in both Certificates and Diploma programs over the range of 5 years is shown in the table below.
TABLE 44: SHOWING ANNUAL OUTPUTS OF UCMB HEALTH TRAINING SCHOOLS FOR 5 YEARS
Programs 2010/11 2011/12 2012/13 2013/14 2014/15 Cumulative % share No.of by Graduates Program Certificate Nursing 80 148 176 230 349 983 24.4% Certificate Midwife 97 137 250 292 401 1,177 29.2% Certificate Comprehensive Nursing 255 145 131 33 39 603 15% Certificate Clinical Laboratory 44 85 109 48 91 377 9.4% Diploma Nursing 46 29 37 43 56 211 5.2% Diploma Midwifery 39 0 0 0 0 39 0.97% Diploma Nursing-Extension 49 39 67 55 50 260 6.45% Diploma Midwifery-Extension 54 62 35 49 39 239 5.93% Diploma Medical Clinical Laboratory 28 22 9 27 39 125 3.1% E-Learning (EM) 14 0 14 0.35% Total 692 667 814 791 1,064 4,028
In the last 5 FYs there has been a significant progressive reduction in the output by UCMB HTIs of Certificate in Comprehensive Nursing cadres. This has been mainly due to increased attention and focus to Midwifery cadres consistent with national policy on Maternal & Child Health. The certificate midwifery outputs by UCMB Training Institutions has increased from 97 Enrolled midwives annually to 401 Enrolled midwives in FY 2015/16. This significant increase has been largely attributed to GoU support in partnership with agencies including mainly Baylor-Uganda, and UNFPA.
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4.1.21 Uganda Protestant Medical Bureau (UPMB) Performance FY 2015/2016 The UPMB is a national umbrella organization and Technical Organization registered as a charitable, faith-based Non-Governmental Organization (NGO) founded in 1957 by the Anglican Church of Uganda and Seventh Day Adventist Church Uganda Union and serves as the technical arm of the Churches.UPMB has a Network of 290 health facilities with the majority (80%) of the health facilities located in rural and remote areas and include 18 hospitals with 15 Health Training Institutions; 10 HC IVs; and 262 LLH facilities.
4.1.21.1 Health Financing in UPMB Facilities During the FY 2015/16, UPMB facilities achieved a total income of Uganda Shillings 50,249,744,345 with Hospitals and HC IV’s contributing 73% of the annual income and Lower level units contributing 27% of the annual income.
Some of the key interventions to improve health financing were community Health Insurance initiatives led by Kisiizi, Bwindi Community and Kiwoko Hospitals which posted significant enrolment of clients in their Community Health Insurance schemes. Trends have shown that these facilities are reaching break even (sustainable) points. With this experience UPMB has started scaling up Community Health Insurance Schemes across its entire Network facilities in a phased manner.UPMB will therefore seek to engage with key partners and Government in this endeavor.
FIGURE 16: HOSPITALS AND HC IVS % INCOME BY SOURCE FIGURE 17: LOWER LEVEL UNITS INCOME BY CLASS
External Others Aid PHC 14% 2% 16% Training fees 19% User fee Pull 38% System (Credit Donations Line) User 32% PHC Fees Credit 8% 43% line 3%
Hospitals and HC IVs raised UGX 36,434,567,736 in annual income during the FY with user fees, Donations and Training fees providing the highest source of revenue for the facilities. PHC funds contribute 8% of the total income for hospitals.
Lower Level Units (HC IIs & HCIIIs) obtained an annual income of 13,815,176,609 Uganda Shillings during the FY. User fees, In-kind Medical suppliesand PHC funds being the highest source of resources for lower level units.
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staffing levels. The achievement has been attributed to UPMB’s effort to support implementation of the integrated Human Resource Information System (iHRIS) across the network that has enhanced tracking of the health work force.
Partnerships with the GoU through the District LG and HDPs like USAID, CDC and BTC through implementing agencies such as the SDS Program and Mildmay to name but a few, UPMB facilities have been supported to recruit and second key staff to its facilities through provision of salary support and equipment.
Although UPMB reported an increase in staff productivity and staffing levels, staff turnover across the facilities remained a major concern. The network is affected by frequent staff turnovers for especially critical positions like medical officers, clinical officers and nurses which has affected service delivery.As the government embarks on recruitment of staff in the public sector, there is need to address the HRH challenges across the entire health sector including the PNFP health facilities.
4.1.21.3 Health Service Delivery in UPMB facilities Bed capacity: UPMB Registered 4% increase in bed capacity from 3,624 during FY 2014/15 to 3,770 during FY2015/16 OPD Attendances increased by 108%. This has been attributed to Interventions like Community Health Insurance, Improved staffing rates, new facility registrations and technical support to improve in reporting using HMIS tools and DHIS II In-patient admissions increased by 60.2% during the FY. The increase in staffing rates, improved documentation and reporting. First ANC attendances and deliveries at the facilities also improved by 40% and 78% respectively. Capacity for facilities to provide ANC and maternal services has greatly improved as more human resources for health are being recruited. The role of PMTCT interventions have also been critical in improving MCH services at the facilities. Immunizations increased by 360%. There was a slight drop in utilization of family planning by 2.6% this financial year. The drop is attributed to a number of Family planning projects at UPMB that came to an end during the FY. UPMB is working with a number of partners to scale up access to HIV care, treatment and support services. By the close of the FY, the network was supporting 5.4% of the People Living with HIV/AIDS (PLHIV) in Uganda with HIV care, treatment and support services. A total 78 facilities were providing ART services and 102 providing PMTCT services. o Number of Individuals counselled, tested and received their results - 431,466 o %of Individuals who tested HIV Positive and linked to Care - 10,580 o Number of Pregnant women who received HTC at ANC - 60,193 o Number of Pregnant women initiated onto ART for PMTCT - 1,249 o Number of Individuals newly enrolled in HIV Care - 8,957 o Number of Individuals newly enrolled on ART - 7,145 Page | 70
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o Number of Individuals Active on ART - 46,995
4.1.22 Uganda Muslim Medical Bureau Performance 2015/16 FY
Uganda Muslim Medical Bureau (UMMB) is a national organization established by the Uganda Muslim Supreme Council (UMSC) in 1999 to coordinate activities of Muslim non- profit health facilities. The Bureau is the main link between these facilities, the government and other stakeholders. By the end of the FY 2015/16 the membership of the bureau consisted of 52 health facilities, one Nurses and Midwifery training institution and one Medical Laboratory training institution. The bureau is in the process of establishing another health training institution in Yumbe district. Increased technical support supervision of the member facilities especially in FYs 2013-14, 2014/15, and 2015/16 which saw a tremendous increase in reporting rates to 62%, 78% and 90% respectively in LLUs. The UMMB network continued providing Maternity services in year 2015/16, and there has been a progressive increase since 2013/14 FY with 15.5% increase in 2014/15 and 19.5% increase in 2015/16. This is attributed to the availability of full time qualified midwives at the units through support from HRH project of SDS and Mildmay Uganda in the East, Central and Western regions. Training of midwives and support supervision by UMMB secretariat has built the capacity of these service providers and improved the quality of maternity departments in the network. HIV + exposed infant rate reduced from 3.6% in 2014/15 to 3.4% in 2015/16. All this is attributable to improvement in management of patients especially the HIV+ mothers by the qualified midwives. The prevalence rate in ANC in hospitals was at 1.8%. Hospitals initiated 100% of their HIV+ mothers permanently into HIV/AIDs chronic management clinics for life. Post-natal cases increased to 1,957 in hospitals in 2015 compared to 1,533 post-natal mothers for hospitals in 2014/15. The prevalence rate in ANC in LLUs was at 2.4%. LLU initiated 100%, of the HIV+ mothers permanently into HIV/AIDs chronic management clinics for life. Total immunization increased to 154,124 in 2015/16 compared to 124,679 in 2014/15 representing 2.5% increase. 14.8% of 154,124 children were fully immunized by June 2016. HCIIIs had the highest number of children reached for immunization contributing 43% of the total Immunization across the network. The UMMB network facilities continued providing reproductive health services to all age categories in terms of FP. OPD utilization in hospitals increased by 99.7%. This is attributed to the improvement in reporting, data management and training in HMIS for the hospitals.
Facility level Total FP users Total immunization Total ANC Attendance HCT services Hospitals 1,454 48,763 9,525 18,612 HC IIIs 8,545 66,306 8,869 38,395
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HC IIs 8,682 39,055 3,802 11,315 TOTAL 18,681 154,124 22,196 68,322
Both Hospitals and LLUs continued to provide inpatient services in the communities. The performance is shown in the table below for inpatients. In-patient episodes had an increasing trend in the year under review. The total number of clients during the year increased by 40.4% across all network facility. The average length of stay (ALOS) approximately measured at 3 days. The Bed occupancy Rate (BOR) was established at 25.2% at all levels. On the already 12 ART sites that were in existence for 2014/15, Mityana UMSC HC III was accredited as a full ART site in 2015/16, bringing the total to 13 ART sites.
Service 2014/15 2015/16 Children Male (15 yrs. Female Children Male (15 yrs. Female under 15yrs &above) (above 15yrs) under 15yrs &above) (above 15yrs) Pre 49 1,037 1,800 65 1,077 1,925 ART ART 96 864 1,845 124 983 2,066 Total 145 1,901 3,645 189 2,060 3,991 Overall number of clients in chronic care and management 6240 to date (June 2016) Source: UMMB Health Facilities’ HMIS106a 2015-16.
The 13 ART sites continued seeing and enrolling new clients on ART. A comprehensive and holistic package is given including psycho-social support, family planning, treatment, adherence counseling and support, CD4 monitoring, TB assessment and co-infection management, HBC and follow up of bedridden clients, cohort analysis, STIs screening and treatment, opportunistic infection management and nutrition supplements. As seen above there was an increase in the number of clients reached in Pre-ART from 2,805 clients in 2014/15 to 3,179 clients in 2015/16 across all network Art sites representing a 13.3% increase. A total of 220 children below 15yrs were active on ART treatment by June 2016. In order to ensure that the member health facilities maintain the minimum required qualified health workers, the bureau recruited and managed payroll of 56 health workers in 17 health facilities. This support was from SDS and Mildmay Uganda. UMMB also recruited on request 10 qualified health workers for deployment in other health facilities. Two HC IIIs, namely Lugazi Muslim HC and Crescent Medical Centre, have started to put up additional structures in order to upgrade to HC IV level. 8 other facilities have renovated their buildings. The bureau trained eight medicines monitoring supervisors in implementation of SPARS. The supervisors were provided with motorcycles and laptops courtesy of USAID/Uganda Health Supply Chain.
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4.2 Annex Two: Integrated Health Sector Support Systems
During HSDP 2015/16 –2019/20 the Ministry will focus on health systems strengthening through its core functions of health investments, information management, supervision and monitoring to ensure there is improved access to health services. .
4.2.1 Policy, Planning and Support Services Under this function, the MoH is responsible for general strategic planning and policy framework, resource mobilization, coordination of projects and development assistance, Information management,Human Resource Management and Development, Public Private Partnerships, international engagements among others.
During the FY 2015/16 the following outputs were delivered;
• Annual work plan for MoH 2016/17 • Annual Health Sector Performance Report 2014/15 • Budget framework paper FY 2016/17, • Ministerial Policy Statement 2016/17 • Health Financing Strategy 2015/16 – 2024/25 • National framework for the RBF and its implementation manual • Health Planning guidelines for planning at LGs • PHC grant utilization guidelines. • Finalized the Design for the Health sector Basket Fund framework • Quarterly technical support supervision and monitoring to LGs and hospitals • Conducted the Private Sector Assessment.A draft PSA report is available and is undergoing validation by a consultant before submission for review by the sector governance organs • Developed a 5-year PPPH strategy with support from the Belgian Technical Agency in Uganda. • Enrolled facilities to the Uganda Reproductive Health Voucher Scheme, supported by the World Bank through a SIDA Grant of US $ 12 million. • Policies and guidelines finalized included; Palliative Care Policy, Rehabilitative and Health Care Policy, Medical Internship Guidelines and Uganda Immunization Policy • Bills Submitted to Cabinet include; Uganda Human Organ Transplant and Tissue Bill and the Uganda Health Service Management Institute Bill
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Bills passed into Acts by Parliament were; Uganda Allied Health professionals Regulation, Uganda Cancer Institute Bill, 2015, Uganda Heart Institute Bill, 2015 and Uganda Immunisation Act, 2016.
A number of Memoranda of Understanding (MoUs) were developed and signed.
The sector organized a Joint Review mission in October 2015 and agreed on several undertaking in the Aide memoire progress on implementations is attached in the annex. Subsequently the sector organized the Annual DHO’s meeting to review the district health services as to make resolutions which will input in the JRM 2015/2016.
As part of efforts to enhance global health partnerships, the sector participated in the following engagements; WHO World Health Assembly,East Central and South Africa meetings, EAC TWG on health and climate change and African Union.
4.2.2 Human Resource Management and Development In human resource management and development, the following were achieved; • Sponsored 59 continuing students in various health training institutions • Held 9 HRH stakeholders policy and planning meetings {(2) IST National meeting, 2 accreditation Joint Committee meeting, 2 HRHTWG meeting at MoH, 2 Training Committee Meeting at MoH, 1 HRDD staff joint meeting (at Mbale HMDC)}. • Conducted only 2 Hosp. Boards Mgt training at Jinja and Gulu RRH and 43 HUMCs in Mayuge district with Intrahealth-Uganda Partner support • 127 Health Managers from Regional Performance Monitoring Teams, DHTs, General Hospitals and HSDs trained in Governance, Leadership and Management. • 71 Clinical Instructors from in Health Training Institutions were trained to improve on their competencies in teaching at the practicum sites and Classrooms. • The Principles and the Cabinet Memo for transforming HMDC Mbale into a semi autonomous institution are being developed. • Support supervision to 30 health institutions, • Sponsored training of 41 post-basic and post-graduates
4.2.3 Finance and Administration The political leadership supervised the following outputs in Various Districts, • Launchedof iCCM in full in Sheema, • Administrative Monitoring & Supervision of sector activities in the districts of Mbale, Lira, Jinja, Ntungamo, Kabarole,
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• Provided policy guidance through HPAC meetings to national and LG levels • Policy briefs to Cabinet and Parliament were developed, • Increased Global Health partnerships in Washington, Korea, Turkey and Indonesia. Advocacy meetings with key stakeholders / Development partners within the country & abroad were held in China, Japan and UK.
4.2.4 Bilateral Cooperation FY 2015/2016 Memorandum of understanding have been signed between MoH, through inter institutional level MOUs, and through Joint Permanent Commissions (JPCs) as well as through Regional Forum where agreed upon signed commitments are made for implementation such as through Intergovernmental Government Regulatory Authority, East African Community, African Union as well as through international Forum such as China Africa Health Ministers’ Meetings, and India Africa Health Forums. Preparation for and participation in India Africa Summit of Heads of State October 2015 Preparation and participation in the 2nd China Africa Health Ministers’ Meeting in Cape town October 2015, the delegation led by the Minister of Health Bilateral Cooperation talks were held between the MoH of Uganda and South Africa in October 2015; which lead to the eventual finalization and signing of the MOU on health in Cape town in December 2015 by the Minister of Foreign Affairs on behalf of GoU. A delegation of MoH led by the Minister of Health participated in the Global Health Security Agenda (GSHA) 2015 in Seoul September 2015; and visits made to Donga A – ST Industry A donation of Hepatitis B screening diagnostics was received from Donga – A ST, a South Korea Pharmaceutical Company was by the MoH in October 2015. These have been used for screening rural communities for Hepatitis B in various districts including Bushenyi district in, Kanungu and Tororo Districts Memorandum of understanding between Uganda and Republic of Korea was signed on 29th May 2016 during President Park’s State Visit by the Ministers of Health in attendance of the two Heads of Sate. A Memorandum of Understanding was signed between Uganda Cancer Institute and Korea Cancer Institute and Korea Foundation for International Health Care during President Park’s Visit by the Institution heads in attendance of the Ministers of Health of both countries on 28th May 2016 A project on Mobile health services to enable services reach the rural hard to reach focusing on reproductive health with special emphasis on the adolescent girls. A project on better girl health is now being implemented in Kamuli and Buyende districts by KOICA in collaboration with MoH and the District LG health workers.
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A donation of two ambulances and a medical mobile medical Van with in built diagnostic facilities was donated to MoH during President Parks’s Visit A donation of an antimalarial medicine, Pyramax, which of high quality and effective against both Plasmodium falciparum and plasmodium Vivax worth USD500.000 was received by the Ministry of Health of Uganda; donated by Shin Poong Pharmaceutical Industry in Korea through the Ministry of Health and Welfare of Korea during President Parks’s State visit equivalent to 187,000 doses. The K - Project on Reproductive Health with focus on adolescent girls launched the Uganda National Leaders’ Centre;Kampiringisa in Mpigi District. The Better Girl Health Project is being implemented in Uganda in the districts of Kamuli and Buyende in partnership with Korea International Agency for Cooperation (KOICA). The Memorandum of Understanding was signed with between Uganda Supra National Reference Laboratory and the Korea Foundation for International Health Care (KOFHI) on 28th May 2016. The Memorandum of Understanding was signed between Uganda Cancer Institute and Korea Cancer Institute and KOFHI on 28th May 2016. Preparation for and participation in the Joint Permanent Commission Meeting between Uganda and Kenya in Eldoret in March 2016. Preparation for and participation in the IGAD Meeting of Health Ministers in August 2015. Preparation for and participation in the India Global Exhibition of Services April 2016. Preparation for and participation in India Global Exhibition of Services April 2016. Participation in preparations and field activities for hosting of Delegation from Ethiopia on Food Fortification July 2015. Preparations and hosting of delegation from Egypt on assessment of health facilities for renal dialysis May 2016. Requirements for support to Mulago Hospital and China Uganda Friendship Hospital - Naguru Hospital were quantified and Ministry of Health awaits Arab Republic of Egypt to provide more renal Dialysis Machines for Mulago Hospital and to eventually support capacity building for Renal Dialysis Health Workers. Preparation for and participation in the second IGAD Regional Pharmaceutical Regulatory meeting April 2016 in Khartoum. Preparation for and participation in ongoing dialogue and preparations for Serbia Pharmaceutical Investors to invest in Local production of pharmaceuticals in Uganda May – June 2016 (still ongoing) through diplomatic channels). Development of MOU for collaboration with India is ongoing through diplomatic channels and consultations are still ongoing. Capacity building was offered to Health Works by the Arab Republic of Egyptfor 2 Health workers.
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Capacity building of Health workers has taken place in Egypt on safety and infection control (beneficiary program was Aids Control Program for 2 Health Workers through the Bilateral Cooperation agenda. Involvement of Regional Hospitals, Private Sector, Professional Associations is on - going where required by invitations on bilateral cooperation activities abroad. The State of Israel support towards rehabilitation of Mulago National Referral Hospital was ceremoniously plaque unveiled on 4th July 2016, during the Prime Minister of Israel State Visit; by the two heads of state during the 40th anniversary of ―Operation Jonathan‖ when Israel rescued her nationals at Old Entebbe airport that had been hijacked by terrorists on 4th July 1976 Participation in dialogues/consultations with Egypt, Israel, Turkey, India and Serbia are still ongoing. Participation in National Organization Committee (NOC) and Ministry of Foreign Coordination meetings for technical officers for Head of State Visits for State of Israel and Israel Prime Minister, President Park Visit and President of Turkey State Visit.
4.2.5 Sector monitoring and quality assurance The HSDP 2015/16 – 2019/20 emphasizes the provision of equitable, safe and sustainable health services. This is coordinated by Quality Assurance Department (QAD) and is addressed through development, dissemination and effective use of standards and guidelines; regular supervision, inspection and mentoring; capacity building for quality improvement interventions; and establishment of dynamic interactions between health care providers and consumers of health services. Key outputs The bi-annual sector performance reviews were held in 2016 and report was developed and shared with the key stakeholders. Regional Performance Monitoring Teams (RPMTs) coordinated regional performance review meetings with support from GFTAM. The review of the Health Sector Quality Improvement Framework and Strategic Plan (HS QIF & SP) was finalized and was scheduled for launch in the first quarter of 2016/17 FY. Reviewed the Support Supervision guidelines and draft available for finalization next FY. The review of the Client Charters for the MoH headquarters, Mbale, Gulu and Masaka Regional Referral was undertaken with support from the MoPS. Development of the new Charters for these institutions is scheduled to take place during 2016/17 FY. Service delivery standards were developed and finalized. 500 copies of the Uganda Clinical Guidelines (UCG 2012) were disseminated to 40 selected districts in different parts of Uganda. Key messages on Patient Rights and responsibilities were developed and disseminated to the 42 districts supported by Mild-May. Other guidelines disseminated included the Patient and the MoH Client Charters, and the Quality Improvement Manual for Health Workers 2015. Three out of the four planned support supervision visits (Area Team field visits) to Local Governments, Regional Referral Hospitals, General Hospitals and HC IVs were Page | 78
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conducted. Some field visits were partly facilitated by GFTAM for quarter 1 and 2. The major findings were shared with SMC and HPAC and included the following: General staffing has improved for a number of districts although lack of critical staff is still a major challenge for majority of the districts in the country. There is also a big shortage of staff accommodation, lack of uniforms and motivation for health workers. NMS has been able to deliver EMHS to districts on a regular schedule. There is a challenge to on how to handle the accumulation of expired medicines and health supplies as the contract signed with Green label service providers and SDS in some districts is expected to end soon. Maintenance of the new health infrastructure in districts such as Mityana, Mubende and Hoima hospitals among others, has attracted increase in utility bills in these units. Additional PHC funding is needed to address the challenge. HDPs continue to support service delivery especially for HIV/AIDs care and support in districts. Coordination is also improving with regular quarterly stakeholder coordination meetings which are normally chaired by the CAO. Some districts lack transport;(52 districts received GAVI vehicles and every sub county received a motor cycle) waste management infrastructure; basic medical equipment and adequate facilitation for PHC activities. Four technical support supervision visits were carried out in Baylor and STAR-E supported districts focusing on M&E and QI. The main focus was through couching mentorship on functionality of the Quality Improvement Teams, documentation and reporting. QAD participated in the National Service Delivery Survey which was coordinated by the MoPS. The report was shared and it depicted the proportion of those that did not fall sick 30 days prior to the survey increased from 64% in 2008 to 74% in 2015. Availability of medicines perceived to be good among the respondents declined from 26% to 22% in the same period. A number of Implementing Partners have supported the MoH financially and technically, to enable 42 districts and 14 RRHs; 23 general hospitals under the UHSSP be assessed using the Health Facility Quality of Care Assessment Programme (HFQAP). Average district quality of care score adopted as one of the District League Indicators however, application will be after national scale up of the program in 2016/17 FY. 7 out of 12 (58%) Supervision, Monitoring, Evaluation and Research TWG meeting weld held and resolutions submitted to Senior Management Committee. 2 out of the 4 planned quarterly National QI Coordination Committee meetings were held. • Coordinated 10 out of 12 Senior Management Committee meetings and resolutions submitted to HPAC for consideration and endorsement.
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4.2.6 Regulation 4.2.6.1 Uganda Medical and Dental Practitioners’ Council (UNMDPC) The UMDPC is a government agency that has a mandate to regulate the training, practice and discipline of the medical and dental practitioners in the Country. Its functions include monitoring, supervising, maintaining and enforcing professional standards and medical ethics, exercising disciplinary control and protecting society from abuse of medical and dental care and research on human beings and to advise and make recommendations.
During the FY 2015/16 the council was able to complete the national internship guidelines which are expected to streamline internship training in the sector. Review of the curricula for medical and dental training. The 8 medical and dental schools were inspected by UMDPC as well as the East African community, inadequate staff and inadequate infrastructure were found to be major challenges and the medical and dental schools were given time bound recommendations to fulfill.
A total of 418 doctors and dentists were admitted to the register, while 3014 out of 5119 were given Annual Practicing Lincences (APL), the majority of those who did not receive APL did not apply. The specialist register now has 1472 specialists of whom 854 were licenced to practise in the country. 220 practitioners received temporary registration while over 100 practitioners were awarded certificates of good standing. A total of 2135 health facilities were lincenced to operate in FY 2015/2016.
The council on average receives 50 complaints per and in FY 15/16 11 cases were investigated and concluded while others are still being investigated. The council was also able to print and distribute the registered practitioners copies of the following documents UMDPC Act, code of professional ethics, minimum standards of operating health facilities as well as guidelines for CPD and for filing complaints against practitioners. A fitness to practice guideline was also finalized this FY. 37 CPD providers have been accredited.
New regional inspectors have been contracted to improve the inspection of health facilities in the Country. In FY 2015/16, Council licensed 1641 health facilities with 44% in Kampala. There are 87 hospitals and 1554 clinics supervised by Council.
Medical Licensing and Examination Board was established to ensure that persons who register with the Medical and Dental Practitioners’ Council to practice Medicine and Dentistry in Uganda meet minimum standards of training and acceptable level of competence. 87 candidates were handled FY 2015/16. In addition council conducted peer review interviews for 18 specialists that sought to work in Uganda. This aims to ensure Council registers qualified specialists. District Health Supervisory Authorities that were established by the joint Health Professional Councils continue to operate and council inspected 58 out of the 110 DSAs in the country.
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4.2.6.2 Uganda Allied Health Professionals Council 2015/2016 The Allied Health Professionals Council was established by Allied Health Professionals Act Cap 268 of 1996 to regulate, supervise and control the training and practice of Allied Health professionals in Uganda. Its functions are to regulate standards and conduct of allied health professionals and register and monitor performance of allied health professionals. Its objectives are include registration, lincencing, inspection of allied health professionals and practice units across the country as well as inquiring and determining disciplinary matters relating to the conduct of allied health professionals.
During FY 2015/16 a total 2,653 new allied health professionals were registered and 10,818 had their licences renewed. 1,531 health units and 652 laboratories were licenced. This enabled the council to raise a total revenue of 2,062,719,115/= out of the annual budget amounting to 2,864,740,000/= representing 72% budget performance.
The allied health professional’s regulations were approved by the Minister of Health to simplify implementation of the AHPC Act. The council was also able to inspect and supervise all health training institutions. 6 cases of mal-practice were investigated concluded and disposed of. The main challenges the council faces include lack of a clear definition of the scope of authorized practice and failure of units to comply with set standards as well as lack of public awareness of mandate of the council.
Over the medium term the council plans to build capacity of regional supervisory authoritiesand develop and implement information, education and communication strategies that will address community awareness of council’s mandate
4.2.6.3 Pharmacy Council The Pharmacy Council is mandated enforce pharmaceutical standards and ethical codes of conduct countrywide and is the professional body responsible for registration of pharmacists.
During the FY the council was able to finalize internship guidelines and continued to build consensus on the proposed pharmacy bill. It continued to inspect pharmacy schools, internship training centres and pharmacy practice centres. One case of Pharmacy malpractice was reported and is being investigated.
4.2.6.4 National Drug Authority The key achievements this FY were;
• Recruited quality medical officer • Began training staff • Developed and revised implementation manuals • Customer satisfaction survey on going in the Process of changing from ISO 100:2015- 9001:2015 • Sensitized stakeholders about advertising and promotion of products by MDAs Page | 81
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• Approved 24 clinical trial applications • Developed new guidelines and SOP for lincesing • Lincesed 69 pharmacies • Approved 109 medicine samples, 11 samples of LLINs, and 376 samples of condoms
4.2.7 Pharmaceutical Supplies and Health Products 2015/16 4.2.7.1 Pharmacy Division The following key outputs were achieved by the pharmacy Division;
• Developed and disseminated the following strategic documents and reports: o National Medicines Policy (NMP) 2015 and National Pharmaceutical Sector Strategic Plan (NPSSP) 2015/16-2019/20 o Reproductive Health Commodity Security Strategy (2016/17 -2020/21) o Addendum to the Uganda Clinical Guidelines and EMHSLU 2012, focusing on the 13 United Nations Lifesaving Commodities for mothers and children o Alternative Distribution Strategy for contraceptives and selected reproductive health Commodities developed • Six bi-monthly Central Level Stock Status reports were made through routine reviews of stock status at warehouses and recommended inter- warehouse transfers. • Quarterly National SPARS performance reports showing performance of district and health facility performance in medicines management were produced. • A Service Delivery Point Service (SDP) survey for availability of RH commodities and services was conducted. • Estimated the ARV funding requirements to implement the proposed test and treat guidelines for the 2016-2030 period and collaborated with USAID and US Centres for Disease Control and Prevention to calculate the ARV funding gap (US$8.6 million) for October 2016 to December 2016. • Conducted and updated national quantification and supply plans for; o ARVs and Key Laboratory commodities for the Global Fund costed extension Grant worth $36m o Hepatitis B testing kits, vaccine and medicines o Malaria commodities to be included in the concept note for the Global Fund grant application for 2016 to 2017 • Prepared a distribution list for 200 donated Selexon machines for Hepatitis B virus testing, hepatitis B rapid tests, HBeAg, AFP and Crag LFA tests. • 3001 facilitiesstarted Supervision, Performance Assessment and Recognition Strategy (SPARS) Supervisions in 110 districts. 15,663 visits were performed leading to an improvement in medicines management at health facility levels in the areas of stock and storage management, ordering and reporting, prescribing quality and dispensing quality.
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The SPARS supervision tool has also been revised to flexibly include random medicines for which Pharmacy Division can quickly obtain stock status when needed. • Started the implementation of the peer strategyaimed at strengthening the management support for medicines management from MoH PD to the health facilities. The 14 regional pharmacist and 12 RPMT pharmacy persons have this year started providing quarterly targeted support to district based Medicines Management Supervisors (MMS) and health facilities. This activity will continue in the coming year with an expanded scope to include support to ART and ordering and reporting, Vaccine management and rational medicines use. • As part of capacity building the following trainings were conducted; o Four 5 day logistics training courses on ordering and reporting for TB and HIV/AIDS commodities for 107 facility staff members. o 140 staff from 14 UNFPA supported districts trained in medicines supply chain Management o Trained 150 medicines management supervisors in SPARS, 110 practically oriented, 107 in basic computer literacy, electronic data collection and submission. This was done in collaboration with the USAID funded Uganda Health Supply Chain o Five day training of 15 QPPU, warehouse and Program logistics officers in quantification and application of Quantimed and Pipeline tools for forecasting and supply planning respectively. o Training of 10 QPPU and program logistics staff in Quantification of TB medicines and the use of QuanTB tool as an early warning system for monitoring stocks of TB medicines. o 441 health facility staff trained at both government and PNFP facilities as part of the continued roll out of the Rx Solution in health facilities. • Distributed 450 shelving units to 818 health facilities. • Installed Rx solution in a total of 103 health facilities. • 10,000 copies of Practical guidelines for dispensing for higher level facilities were distributed. • The Appropriate Medicines Use Unit was established at the Division that has been coordinating the revision of the UCG and EMHSLU 2016. Experts’ review of the 2012 UCG were solicited and discussed in a one stakeholders’ workshop in June 2016. The input and recommendations are being consolidated in a draft that will be again submitted to the MoH programs for final revision before final approval from top management.
4.2.7.2 National Medical Stores During the FY 2015/16 the NMS was able to;
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o RH supplies worth Shs 8 billion to health centers o Immunization supplies amounting to Shs 9 billion to health facilities o Laboratory commodities worth Shs 5billion to health facilities o Specialized items amounting to Shs 18.104 billion for UHI,UCI,UBTS and treatment of jiggers. o Essential Medicines and Health Services basic kit to; . HC IIs worth Shs 11.163 billions . HC IIIs worth shs 18.36 billions . HC IVs worth shs 7.992 billions . General hospitals worth Shs 13.106 billions . RRHs worth Shs 13.024 billions . National referral hospitals worth SHS 12.366 billions o Supplied ACTs, ARVs and Anti TB drugs to accredited facilities worth Shs 100 billions • Cleared the donated emergency supplies worth SHS 2.5 billion to health facilities
4.2.8 Information for Decision Making in Health Sector The Health sector requires reliable and accurate information to enable evidence based decision-making, sector learning and improvement. Over the HSDP period the sector aims at increasing ownership, leadership, harmonization and coordination of the Health information system including cascading Ehealth to lower level units.
Progress on implementation of health information activities is documented below.
• Conducted two regional e-HMIS training for 29 districts from eastern Uganda and 30 districts from Western Uganda with support from WHO. The trainings aimed at strengthening technical skills of district teams to support health facilities to improve data collection, reporting (through mTRAC) or in DHIS2), utilization and feedback. A total of 118 Participants including biostatisticians and surveillance focal officers participated in a 4 day training. • From mid-2016, the reporting and analysis for Surveillance Indicators from health facilities has drastically improved from 40% to the current over 70%.
FIGURE 18: WEEKLY SURVEILLANCE REPORTING BY REGION
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100 80 60 40 20
0
ReportingRate
2015W1 2015W3 2015W5 2015W7 2015W9 2016W1 2016W3 2016W5 2016W7 2016W9
2015W11 2015W13 2015W15 2015W17 2015W19 2015W21 2015W23 2015W25 2015W27 2015W29 2015W31 2015W33 2015W35 2015W37 2015W39 2015W41 2015W43 2015W45 2015W47 2015W49 2015W51
Central Region Northern Region Eastern Region Western Region MOH - Uganda
• Conducted a TOT for100 participants in OpenMRS across the country. OpenMRS is an Electronic Patient Management Records System which was adopted in 2011 and it is currently running in about 400 health facilities across the country. • Conducted a national stakeholder’s workshop of 60 participants whose objective was to strengthen dissemination of information and receiving feedback for decision-making purposes. Also, to promote accountability, ownership and involvement of all stakeholders in strengthening health service delivery. • Finalize the eHealth Policy and Strategy Processes with support from WHO and UNICEF. • Conducted the data validation exercise on selected data elements generated by Mtrac for the purpose of verifying data in the 2015/16 FY (process on going) • Supported the identification of requirements specification for the deployment of an integrated health facility electronic management system (process on going) • Supported the designing, development and rolling out a situation room that will enable political leaders, program managers, and technical departments at all levels to access all the relevant diseases related data in an easy and interactive manner. This means using automated, frequently updated data, and data visualization tools that are mobile and accessible any time. • Supported a cascaded support supervision mechanism with a phased- out approach by the DHT to the lower health facilities covered all the 112 districts of Uganda. The main objective was to equip lower health facilities with mechanisms of generating health information and intelligence to monitor the health status and health services. Hence improving public health care leadership and evidence based decision-making capacities at all levels. • Activity: Support additional training of Health workers in integrated disease surveillance/HMIS to improve quality of data reported. • Conducted an eHMIS National TOT workshop which was aimed at building a robust team to effectively carry out the regional trainings for the identified weak or poorly performing districts. • The team was tasked with finding out; the causes of low reporting rates, why the quality of data is poor and the challenges of data dissemination, utilization and access. • Conducted eHMIS training for the armed forces (Uganda police, Uganda Peoples Defense Forces and Uganda Prisons); a total of 50 participants attended this training.
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• Support Supervision of the 30 poorest reporting Districts • Refresher training on mTRAC an SMS based application was conducted which is used by the health sector to facilitate timely submission of weekly surveillance data to all stakeholders to monitor disease trends, epidemic outbreaks and track medicines availability as well as Malaria case management. • Over the past seven months, the weekly reporting from regions stagnated at 59 - 77% in western region with an average reporting rates of 75% during this period.
FIGURE 19:REPORTING RATES BY REGION OCTOBER 2015 TO APRIL 2016
100 95 95 90 85 83 80 81 81 82 78 79 77 74 70 72 71 69 68 67 68 6264 60 59 54 55 57 57 50 50 45 40 38 30 20 10 0 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16
Central Eastern Northern Western
• Over 600 health workers have been trained on the HMIS revised tools; additional mentoring and couching was done to improve reporting and data use at a facility level.
4.2.9 Health Infrastructure Development and Maintenance (HIDM) In the financial year 2015/16, the following were the accomplishments;
• Analysis of the inventory data shows that on the average, 72% of the available medical equipment is in good working condition although about 6% of this equipment is not being put to use because of lack of qualified staff to use it, lack of reagents and other consumables and power. • Medical Equipment Maintenance carried out in all RRHs, GHs and HCIVs through the Regional Medical equipment maintenance workshops, • Maintenance of Solar energy systems installed under the ERT II Project in 665 HCs in 40 Districts and 96% of the solar systems are in good functional condition. • Developed a new Medical equipment inventory database system (NOMAD) for equipment inventory management and maintenance planning,
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• Collected Laboratory equipment inventory for all RRHs, GHs, HCIVs and 95% of the HCIIIs as well as completing equipment inventory for all RRHs and 50% of the GHs and HCIVs. An assessment of equipment utilization and performance for 17 Health facilities under the UHSSP Project done. • Spare parts were secured for Solar systems 143HCs in Buliisa, Moyo, Gulu, Soroti, Serere, Pader and Bududa Districts with support from the Nordic Development Fund (NDF). • Three Framework Contracts for supply of Medical Equipment Spare parts were signed and procured spare parts worth UGX 185 million for the Central workshop, Wabigalo. • A Framework Contract for Maintenance of solar systems in 155HCs in 20 Districts was signed and will enable rehabilitation of over 365 solar systems that were procured and installed under the phase I of the ERT Project. • A Framework contract for maintenance of Philips Imaging equipment was signed which will enable rehabilitation of 49 X-ray machines and 45 Ultrasound scanners. • Distributed 7,000 Hospital beds and mattresses to Hospitals, HCIVs and HCIIIs countrywide. • Commenced the procurement of a contract to supply and deliver 3,250 beds, beddings and 325 bedside lockers. Contract signing delayed by PPDA Investigation and Administrative review. • Assorted Medical equipment procured and installed for casualty, Operating Theatre, ENT, CSSD, Dental and Maternity ward in Hoima, Fort Portal and Kabale RRHs under JICA funding. • 23 Engineering and Biomedical Engineering Technicians were trained in basic maintenance of the CD4 PIMA machines with support from the SUSTAIN/USAID Project and IDI/CDC, 26 of them trained in the use and management of the NOMAD Medical equipment inventory management software system aimed at enabling Regional maintenance workshops to collect and maintain equipment inventory for health facilities in their regions. • A draft training curriculum and training manual for maintenance of non-automated laboratory equipment was prepared with support from the American International Health Alliance (AIHA)/CDC/USAID support to aid standardize the training of technicians on maintenance of laboratory equipment, Four Regional Medical Equipment Maintenance workshops’ performance review meetings were organized and held in Mbale, Gulu, Arua and Kabale RRHs and Technical support supervision and monitoring of health infrastructure development in all RRHs and at least 50 LGs were carried out. • Completed implementation of the phase II of the ERT project with overall outputs and achievements as summarized below:
OutputIndicator Funding Planned Actual Remark target Achieved
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OutputIndicator Funding Planned Actual Remark target Achieved
Number of HCs provided IDA/GEF 464 5251 61HCs above planned with modern lighting (i.e. target solar or hydroelectricity 2 power) NDF 112 143 43HCs above planned target Amount of CO2 avoided per IDA/GEF 298 281.9 Achieved 94.6% of the annum by using solar power planned target (Tons) NDF 70.1 93.3 33.1% above the planned target
336.2kWp of solar power generation capacity was installed in 522 HCs under IDA/GEF funding in 39 Districts.
121.16kWp of solar power generation capacity was installed in 143 HCs under NDF funding in 9 Districts.
279 solar vaccine fridges were procured and installed under the ERTII Project.
1,124 solar systems were installed for lighting and operation of low energy consumption equipment for Staff houses.
819 solar systems were installed for lighting and operation of low energy consumption equipment for the OPD, Maternity, general ward and operation theatres in HCII, HCIII & HCIVs.
For the ERTII beneficiary HCs, the overall access to modern lighting increased from 13% to 79% which will support provision of maternal and child health services, EmoC and microscopy, a total of 104 HCIIs had solar vaccine fridges installation of solar vaccine to improve immunisation services. With solar installations under ERTII, solar lighting, general security and work environment was improved contributing to staff motivation.
1 This total includes 3 HCs connected to hydroelectricity for the first time as the only source of modern power (i.e. Bwikara HCIII, Mabaale HC III and Isunga HC III. 2 Scope was increased by 12 additional HCs after an addendum was signed to include Bududa District. Page | 88
Annual Health Sector Performance Report for Financial Year 2015/16
HCIII Centralized solar system Battery Bank inside solar house
Microscope powered by solar power in Vaccine Fridge in one of the beneficiary Obalanga HCIII laboratory HCs
Photo 5: Verification of a staff house solar Photo 6: Maternity with solar power for system by MoH Engineer lighting in Rwebishengo HCIV
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• A number of hospitals that were in dire condition were provided with funds from GoU for renovation as summarized below;
Name of the facility Amount Status of work Comments Pallisa General 500,000,000 Renovation of maternity Less funds Hospital General ward and surgical released ward complete. 100,000,000 Main gate at 50% complete Bugiri General 700,000,000 Renovation of wards Received less Hospital Complete than the contract Water pump installations sums
Kaberamaido HC IV 1,410,000,000 Built staff houses, Funds for OPD and maternity ward upgrading HCIV about 60% to hospital Procurement of equipment
A total of 19 ambulances procured through the United Nations Office for Project Services were distributed to health facilities and are now in use. The beneficiary hospitals were: Itojo, Lyantonde, Nakaseke, Entebbe, Iganga, Bugiri, Bukwo, Buwenge, Moroto, Moyo, Nebbi, Anaka, Apac, Kiryandongo, Masindi, Mityana, and Mubende. The ambulances were supplied with adequate spare parts including a set of tyres. The Project also supported the preparation of ambulance guidelines which were circulated countrywide. Two (2) Mobile workshop vehicles procured earlier from Cooper Motors Cooperation are in use at Mubende and Moroto RRHs. Joh Achillies GmBH was awarded a contract to supply two mobile workshop vehicles for Masaka and Jinja RRHs to facilitate medical equipment maintenance. Advance payment was made and delivery is awaited. Installation of Local Area Networks (LAN) in health facilities; a study to design a unified network solution for the sector; Implementation of Voice over Internet Protocol (VOIP) between the MoH and the Health facilities; and procurement of computers and computer accessories. Installation of LAN has been undertaken as part of the ongoing civil works with the 9 Hospitals of which 8 hospitals have been completed and other works are ongoing. Eight of the nine Hospitals under renovation were completed namely: Entebbe, Nakaseke, Mityana, Kiryandongo, Nebbi, Anaka, Iganga and Nebbi. Moyo hospital still awaits completion as summarized below,
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TABLE 45: PROGRESS OF RENOVATION OF 9 HOSPITALS
No Hospital name, Status Original Extension Comments Contractor & Contract Deadline Contact amount date 1 Mityana GH Completed 24 7 January The scheduled works were completed (100%) August 2016. and hospital was handed over to the Sino Hydro Co 2015 Hospital administration for use. Under Defects Liability Period US$ 6,090,929.55 2 Nakaseke GH Completed 30th July 14 The scheduled works were completed (100%) 2015 September and hospital was handed over to the Yanjian Uganda Ltd 2015 Hospital administration for use. Under Defects Liability Period US$ 5,090,612.23 3 Kiryandongo GH Completed 2nd 10 The scheduled works were completed (100%) August December and hospital was handed over to the 2015 2015 Hospital administration for use. Under China National Defects Liability Period Complete Plant (COMPLANT)
US$ 5,654,229.90 4 Nebbi GH Overall 30 09 May All scheduled works are complete. The progress is August 2016 following facilities were handed over and China Railway No.5 at 97% 2015 are in use: OPD, Casualty, Attendants kitchen and laundry, expansion of T- US$ 3,876,045.19 block, refurbishment of existing OPD, Maternity and Children’s wards, staff house, and water supply and sewage line. 5 Anaka GH Completed 6 July 18 The scheduled works were completed (100%) 2015 September and hospital was handed over to the Excel Construction 2015 Hospital administration for use. Under Ltd Defects Liability Period
US$ 6,545,233.13 6 Moyo GH Overall 6 July 30 The Contractor then had been instructed progress is 2015 October to vacate site, however a meeting was Prism Construction at 85% and 2015 held on the 24th /03/ 2016 by the Co. Ltd. is behind Permanent Secretary in which the schedule. contractor was asked to meet some US$ 4,541,931.32 conditions including commitment to complete works through a revised work program, extension of securities and a revised ESMP plan for submission to the Bank to seek a No objection to facilitate a Contract Extension. These conditions have now been met and this demonstrates commitment on the side of the contractor to complete the works. Page | 91
Annual Health Sector Performance Report for Financial Year 2015/16
No Hospital name, Status Original Extension Comments Contractor & Contract Deadline Contact amount date 7 Moroto RRH Completed 29 July 6 October The scheduled works were completed (100%) 2015 2015 and hospital was handed over to the Excel Construction Hospital administration for use. Under Ltd Defects Liability Period
US$ 8,842,878.01 8 Entebbe GH Completed 14 10 The scheduled works were completed (100%) August December and hospital was handed over to the M/s China National 2015 2015 Hospital administration for use. Under Aero Technology Defects Liability Period International
US$ 7,034,065.42 9 Iganga GH Overall 31 July 6 March The scheduled works were completed Progress is 2015 2016 and hospital was handed over to the M/s China National at (100%) Hospital administration for use. Aero Technology International
US$ 4,933,884.78
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TABLE 46: INFRASTRUCTURE DEVELOPMENT PROJECTS STATUS
Code Project Name Specific objective Achievement Challenges Way Forward 1123 Uganda Health To improve sector Completed renovation of 8/9 hospitals and Underperforming of the Conclude renovation Moyo GH, 26 Systems management, Health 75% of 26 HC IVs contractor at Moyo HC IVs, Complete installation of X- Strengthening infrastructure, Access to Procured and distributed general hospital, delays in ray, dental and laundry equipment quality maternal and equipment to 65 hospitals and 230 HC IVs, procurement for Replace the rejected equipment new born health, Family 19 ambulances to 19 hospitals Installation replacement of rejected Additional funds of UG 250m are planning services of X-ray, Dental and laundry equipment, medical equipment, required. Scholarship awards to 797 health workers, Limited staffing and HRIS rolled out to 31 districts funding for renovated hospitals 1393 Construction and Construction & Public Works Investment Agreement Insufficient GoU Additional funds of UG 51.7 are still Equipping of the Equipping of a 240 bed signed allocations on the project needed International hospital Land secured that requires counterpart Construction expected to Specialised Procurement of Designs in final stages Funding to the tune of commence in Nov 2016 Hospital of Specialised medical UGX 54.4 billion Completion of designs Uganda equipment Financing by the M/S Finasi/Roko SPV in final stages 1243 Rehabilitation and To contribute to the The detailed design and tender documents Insufficient funds that Additional 17.64 billion still needed Construction of delivery of the UNM HC were finalised project would require an to be allocated over project life General hospitals Package through Studies for Busolwe GH awaiting approval additional UGX 17.64billion cycle. improvement of Invitation for Bids was published. Accident, Emergency Evaluation process for Kawolo civil works and Reproductive health ongoing services 1187 Support to Mulago Improve delivery of Capacity Development & System Delay in procurement, Revise disbursement targets during Hospital quality services, Strengthening, Revitalizing Referral & encroachers on hospital projects Rehabilitation Decongest, Strengthen Counter-Referral systems in KCCA. land, lack of space for staff Preparation of designs and Bid Medical Education and Expanding & Improving Specialised accommodation documents Research capacity Services in KCCA. Rehabilitation when patients are still in Hospital 1344 Rehabilitation and To deliver the Uganda Design and Construction supervision A gap in understanding of Need for training for technical staff, Expansion of National Minimum consultant procured, Technical staff operating procedures An additional UG 17.9 billion be Page | 93
Annual Health Sector Performance Report for Financial Year 2015/16
Code Project Name Specific objective Achievement Challenges Way Forward Kayunga and Health Care Package recruited, Procurement of a contractor has Limited funds. allocated, Yumbe hospitals (UNMHCP) commenced. Limited knowledge to Need to complete the designs and technical staff tender documents. 1141 GAVI Vaccines TO strengthen health 4 insulated trucks to NMS, 12 cold rooms Delayed procurements for No Cost Extension should be and HSSP systems& ensure at NMS, 65 vehicles to 65 districts, 600 civil works for constructing extended to allow time for universal access to the motorcycles to HC IIIs, 1000 vaccine DMS and health workers completion of remaining UNMHCP in order to carriers and 500 gas cylinders, houses. constructions. reduce morbidity and Introduction of HPV vaccine, Inactivated mortality. polio vaccine,
1185 Italian support to Construction of 34 staff Site handed over & started, Contract for Inadequate allocation for Close monitoring and supervision the HSSP and housing units in supervision awarded to Ms. Zhonghao GOU co- financing, of works. PRDP: Karamoja Karamoja, assorted Overseas Construction Engineer Co at a Delayed implementation An additional of 1.8 billion be staff housing medical equipment to be price of US $ 5,592,885.18, Contract of initiation due procurement allocated to the project. provided by in-kind by supervision to Ms. Joadah Consult at a delays. donor price US $ 210,000. Counterpart funding of UG 2.751 billion required.
1218 Uganda Sanitation To increase Village triggered 37%, Village declared Low absorption capacity in The project to be renewed for Fund development and ODF 58%, New latrines constructed 59%, LGs another 4 yrs. (up to 2020). utilisation of sanitation Additional population served, New HWF Commission of UG Shs 7 billion for and hygiene facilities installed 37%, improve latrine coverage the renewal phase aiming at reduction of 84%people living in ODP 58%, adapting of Counterpart funding of UGX Shs 7 morbidity and mortality HWWS 61%s billion to be required. rate Signing of GSA for the extension and expansion of the program. 0220 The Global Fund Scaling up prevention, TB GRANT, Successfully conducted TB Procurement delays Instituting monthly and quarterly Grants to fight Care, Treatment and prevalence survey, a number of shipments Understatement of grant review HIV/AID, Malaria Health System arrived at NMS and cleared, GOU budgets Regular briefs to MoH top and and Tuberculosis Strengthening. procured 3.8 MoS of streptomycin Limited community Senior management Support for the injection. involvement Distribution of printed HMIS in introduction of highly MALARIA GRANT, Funds advance to Weak referral network progress. Effective Artemisinin- implementers, conducted clinical audits, Digital migration to DHIS2 Scaling up DQA in progress. Page | 94
Annual Health Sector Performance Report for Financial Year 2015/16
Code Project Name Specific objective Achievement Challenges Way Forward Based Combination 50 IMM trainings conducted, evaluation of Invest in modification of Therapy Treatment. the SRs has been concluded, M& E Plan infrastructure to support TB printing and distribution done. infection control. 1345 ADB support to To address the crucial The project received its first disbursement Delayed implementation of Expedite the process of hiring UCI labour market shortages of USD 71,383. the project, Failure to consultants and development of highly professionals in The procurement of consultancy for design secure counterpart for the the training. oncology sciences and supervision of the multipurpose building to project FY 2015/16. The work plan and procurement cancer management in house the project, Office equipment and Lack of a Biomedical plans have been revised to cover Uganda and EAC furniture, evaluation report for the Engineer to help in medical up June 2017. region. procurement of 3 project vehicles finalised, equipment specification Additional funds of 4.18 billion developing specification for medical development. need to be allocated. equipment for Mayuge and Arua satellite Limited funds out of 12.18 clinics was finalised, the training plan has billion 8 billion are already been developed by Atraining available. Advisory Committee ( TAC) --- Development of a To contribute to A design consulted Ms Arch Design Ltd Accumulated VAT on civil The project is still on track and Specialised reduction of maternal was hired at a cost of USD 542, 646, 50. works and consultants construction work as envisaged. Maternal and and neonatal morbidity, A supervising consultant,M/S Joadah services. Neonatal Health To improve maternal consult Ltd Construction works GoU counterpart funding of Care Unit in and child health care A procurement of a National Consultant to US $ 3.42 Million. Mulago services develop up to date effective hospital and clinical protocols.
1145 Rehabilitation of Proposal submitted to JICA for Grant Confirmation of funding Follow up of approval of financing Lira, Gulu & Arua financing from JICA by JICA referral Hospitals The name should be changed to “Rehabilitation and Equipping of Hospitals in Uganda with JICA support”
Improve training, Participated in the independent audit for Long procurement Process East Africa Public Regional diagnostics & East African Public Laboratories. for equipment Health Laboratory Surveillance. Support supervision and mentorship Page | 95
Annual Health Sector Performance Report for Financial Year 2015/16
Code Project Name Specific objective Achievement Challenges Way Forward Networking Build capacity for provided to five satellite laboratories. Project operational research,and Operational research on three protocols (EAPHLNP) Knowledge Sharing for entrices, Tuberculosis and malaria. 28 laboratory staff trained on quality Management system. Institutional Improve effective Guidelines & implementation manual for Short project life span Accelerated implementation Capacity Building delivery of an integrated RBF developed. Training for RBF UNMHCP implementation started. Grants to approved facilities to improve service delivery began.
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PHYSICAL PROGRESS OF RENOVATION OF HEALTH FACILITIES
Main Block at Entebbe GH-Commissioned by HE the President of the Republic of Uganda on May 3, 2016
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Annual Health Sector Performance Report for Financial Year 2015/16
Staff houses, T-block, duty room for female ward and Isolation ward at Nebbi GH
New Casualty already in use with its operating theatre in use, Nakaseke Hospital
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Contracts were signed for renovation of 26 HCIVs and the sites were handed over to the contractors in June 2015. The HCIVs include: Kasanda, Kiganda, Ngoma, Mwera, Kyantungo, Kikamulo, Kabuyanda, Mwizi, Kitwe, Rubare, Aboke, Aduku, Bwijanga, Bullisa, Padibe, Atyak, Obongi, Pakwach, Buvuma, Budondo, Ntenjeru-Kojja, Buyinja, Nankoma, Bugono, Kiyunga, Kibuku and
Theatre block at Budondo HCIV top left, Maternity ward at Ntejeru Kojja, top right, Maternity ward at Buyinja HCIV bottom left; and maternity ward at Mwizi HCIV bottom right.
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4.3 Annex Three: Progress in Implementation of the 21st RJM Aide Memoire Milestone Priority Actions Responsibility Timeframe Progress
1. HUMAN RESOURCES FOR HEALTH 1.1 Improved Recruitment of the critical MoH - Human Resource By June 2016 Overall decentralised staffing staffing levels to cadres specifically Department, MoLG, level at 70%. However the most deliver UHC anesthetists, midwives, MoFPED, understaffed cadres in the sector ophthalmic and dental are Anaesthetic officers 27%, personnel. Ophthalmic Clinical officers 36%, Dispensers 40%, Pharmacists 40%, Physiotherapists and Occupational therapists 45%, imaging staff 49% and medical doctors 49% . Some Districts still have staffing levels below 50% Fast track the restructuring MoH - Top Management By June 2016 New structures approved by process to meet the current cabinet. Implementation has service delivery needs. started. Include cadres like Biomedical Engineers, Counsellors 1.2 Improved Ensure quality HRH training MoES, MoH - Clinical June 2016 Guidelines and tools for quality of HRH through proper planning, Services Department, supervision and inspection of training adequate practicum sites, Hospital Directors and health training institutions supervisors, equipment etc. Professional Councils. developed and launched by the inter-ministerial committee in October 2015. Page | 100
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Milestone Priority Actions Responsibility Timeframe Progress
Pursue the policy of MoH Health Committee of Inter ministerial discussions on taking back management of Parliament this action have started the health training institutions for HRH. 1.3 Improved Coordination and MoES, MoH - Interns June 2016 New guidelines on internship budgetary information sharing Committee, MoFPED training developed to provisions and between Interns Committee, comprehensively address supervision of Universities, MoE, MoH and Internship training in the sector interns MoFPED. 1.4 Training of Review process of training MoES, MoH - Human June 2017 New curriculum developed and anaesthetists anaesthetists to provide for Resource Development approved streamlined with direct entry into the training other courses to institution for anesthesia. increase on their numbers Inservice training of Medical MoH - Clinical Services June 2017 Pending due to limited Officers to give spinal and Department resources. ketamine anesthesia. 1.5 Provision of Recruitment should always MoH, LGs, HSC, DSCs, June 2016 Accounting officers directed to adequate wage be aligned to available wage MoFPEP recruit only when wage budget bill allows Continue lobbying for Parliamentary Committee June 2016 Increase in Wage bill planned for raising the wage bill of Health, LGs FY2017/18 Complete the absorption and MoH, MoFPED, June 2016 Absorption planned for FY regularization of Bonded Public Service 2017/18 when additional wage and Project staff in Govt. Commission bill will be provided payroll
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Milestone Priority Actions Responsibility Timeframe Progress
1.6 Timely Expedite process of MoH, LGs, Service June 2916 Accounting Officers directed to recruitment to fill replacement for posts falling Commissions promptly declares vacancies to posts that fall vacant as soon as vacancies the relevant service vacant arise. commissions. 1.7 All staff in Review and redefine concept MoPS June 2017 On going discussions with Mops hard to reach of hard to reach areas to to review the areas areas motivated build the case for all hard to reach areas. 1.8 Staff uniforms Provide budget for staff MoH - Nursing June 2016 UGX 3 billion provided in FY provided uniforms Department, MoFPED 2016/17 2. HEALTH FINANCING 2.1 Increased Lobby to increase Senior Top Management, June 2017 Increased Funding planned in FY financing for government funding (MTEF) Parliamentary Committee 2018/19 health service for implementation of the for Health, CSOs delivery Health Sector Development Plan Develop evidence-based MoH Planning June 2016 On going. To be included in the rationale for increased Department sector’s BFP Government funding (MTEF) for health to be shared with MoFPED Harnessing health related Inter-Ministerial June 2017 Commitees in place and meetings resources from other sectors Committee, Intersectoral held Committees In consultation with HDPs MoH, Partners, CSOs June 2016 RBF strategy and develop innovative financial Implementation manual finalised modalities (PBF, Pool Funds,
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Milestone Priority Actions Responsibility Timeframe Progress
etc.) to attract additional resources for the sector 2.2 Improved Joint planning and budgeting MoH - Planning June 2016 Not held due to lack of funds resource at regional and district level Department, LGs, HDPs, allocation to Global initiatives, PNFP, ensure equity PHP, CSOs Revise and disseminate the MoH - Planning June 2016 New resource allocation formula resource allocation formula Department, MoFPED disseminated during Regional LG to LGs and Health Facilities Budget workshops Conduct the assessment of MoH - Planning, HDPs December Costing done for HC IIs, IIIs, IVs standard costs by level of 2016 and General Hospitals under ICB facility to produce a reliable project estimate of the input requirements for each district. 2.3 Framework Define a national framework MoH - Planning and Policy March 2016 Frame work developed for Results Based for RBF in the Health Sector Directorate, MoFPED, Financing (RBF) based on the experiences PNFP in the health from pilots and bench sector defined marking from Uganda and other countries. 2.4 Reduced out Finalize the operationalize MoH, Partners December Health financing strategy of pocket the Health Financing 2015 launched payments Strategy (HFS) Finalize and implement the MoH, MoFPED, Partners March 2016 Costing of the scheme reviewed National Health Insurance and Request for Certificate of scheme (NHIS). Financial Implications submitted Page | 103
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Milestone Priority Actions Responsibility Timeframe Progress
in March 2016. MoFPED requested for further review of the costing to fit within the MTEF and review down. To forward new request for CFI to MoFPED in October 2016. 3. HEALTH INFRASTRUCTURE 3.1 Increased Budget provision for LG MoH - Senior Top June 2017 LGs requested to submit Costed funds for Development projects which Management and plans/Arrears for inclusion in infrastructure were initiated before Planning Department budget for FY2017/18 development and reduction in PHC maintainance Development Grant sent to LGs. Increase budget provision MoH, MoFPED June 2017 Rehabilitated Hospitals allocated for running costs and more funds during FY 2016/17 maintenance of equipment Shs 9.5 Bn and infrastructure of rehabilitated hospitals Procurement and fair MoH, HDPs June 2016 Procured and Distributed 65 allocation of vehicles to LGs double cabin pick up trucks to LGs 3.2 Improved Regular update of health LGs - DHOs - Private June 2016 Health Facility Inventory in place inventory facility inventories. Facilities and currently being printed management at facilities 4. SERVICE DELIVERY 4.1 Improved Plan and budget for Health Facility Managers June 2016 Health Facilities guided to plan &
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Milestone Priority Actions Responsibility Timeframe Progress health care waste management of health care & Partners budget for healthcare waste management waste management Budget provision for medical MoH , MoFPED June 2016 Provided for under NMS waste disposal including FY2016/17 expired medicines 4.2 Improve staffing, equipment MoH, MoFPED, MoPS June 2017 An additional UGX 4.7 billion Operationalizatio and funding of HC IV provided from FY 2016/17 n of the HC IV towards the Constituency / HSD Task Force meetings, health camps, mentorship and supervision activities 4.3 Upgrading of Upgrading of Maternal health MoH, MoLG, MoFPED, June 2017 Proposed for 40 HC IIs under HC II and delivery capacity of the Partners URMNCAH project HC II to HC IIIs to ensure 100% coverage of Subcounties with HC IIIIs. 5. MEDICINES AND HEALTH SUPPLIES 5.1 Proper Dissemination of guidelines MoH - Pharmacy Division June 2016 Guidelines disseminated management of on management of donations donated Donations should be medicines and supplied in coordination supplies with pharmacy division and DHOs 5.2 Improve Improve complementarities MoH, NMS, JMS, MAUL June 2016 Facilities allocated to specific coordination and reduce overlapping in warehouses, buffering and inter- between NMS, JMS the distribution of EMHS and house transfers done at central and MAUL ART to the facilities level.
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Milestone Priority Actions Responsibility Timeframe Progress
6. HEALTH INFORMATION 6.1 Improved data Budget allocation for MoH - Resource Centre, June 2016 UGX 1 billion allocated in FY quality printing of new HMIS tools MoFPED 2016/17 Train health workers in the MoH - Resource Centre, June 2016 Over 20,000 Health Workers use of the new data tools HDPs trained and mTrac. 6.2 Increased Extend DHIS2 access rights MoH - Resource Centre, June 2016 Still limited to district level due HMIS data use to lower facilities so that HDPs to poor connectivity at health they can use their data. facility level 7. GOVERNANCE AND LEADERSHIP 7.1 Inter sectoral Develop a clear center of OPM, MoH, MoLG, MOES, Sept 2016 Mechanisms in Place. Inter- collaboration for authority to coordinate and MOGLSD, MOWE, MoFPED ministerial committees and the ensure effective inter- Technical Planning committees implementation sectoral collaboration at the at LG level of HDSP center and LGs
7.2 Improved Institutionalize the roles of MoH, MoPS, MoFPED June 2016 Being reviewed supervision and Regional Performance monitoring Monitoring Teams. Revise Support Supervision MoH - Quality Assurance March 2016 Final draft available Guidelines and tools Department 7.3 Resume Guidelines and tools for the MoH, Planning March 2016 Revised planning guidelines in Regional Planning Regional Planning Department place and is being printed. Soft extended to all copies provided in this JRM stakeholders 7.4 Improved Strengthen Partnership MoH - Health Policy April 2016 PPP Act 2015 enacted. MoU Partnership coordination in the MoH Advisory Committee, being revised and PPPH
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Milestone Priority Actions Responsibility Timeframe Progress coordination PNFP, PHP, CSO Implementation guidelines for mechanisms in PPPH in the PNFP sector the health sector developed 7.5 Improved Enforcement of the existing National Drug Authority June 2016 On going regulation of policies and regulations and Professional traditional and Councils complementary practitioners 7.6 Improved Development, Adoption and PS / US MoH June 2016 Ongoing accountability of Implementation of Action public Plan to address OAG annual expenditures audit recommendations
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4.4 Annex Four:Disaggregation of Key Performance Indicators
Indicator Performance 2015/16 Achievement Disaggregation Numerator Denominator ART Coverage 88% 898,197 1,196,547
HIV+ pregnant women not on 68.3% 34,357 50,323 HAART receiving ARVs for eMTCT during pregnancy, labour, delivery and postpartum TB case detection Rate (all 121/100,000 forms) IPT2 doses coverage for 55% 982,276 1,787,840 pregnant women IPT3 doses coverage for NA pregnant women In Patient malaria deaths per 21 M 3,473 1,787,840 100,000 persons per year F 4,252 18,378,995 Total 7,725 35,756,800 Malaria cases per 1,000 408 M 6,338,728 17,377,805 persons per year F 8,837,077 18,378,995 Total 15,175,805 35,756,800 Under five vitamin A second 28% M (27%) 902,606 3,302,175 dose coverage F (28%) 986,447 3,492,424 Total 1,889,053 6,794,599 DPT3HibHeb3 Coverage 103% M (105%) 782,600 747,246 F (99%) 779,580 790,297 Total 1,562,180 1,537,542 Measles coverage under 1 year 96% M 718,100 (96%) 747,246 F 715,692 (93%) 790,297 Total 1,443,015 1,537,542 Bed occupancy rate 83% Regional Referral 4,686 5,665 (Hospitals & HC IVs) Hospital 62% General Hospital 9,395 15,255
52.2% HC IV 3,547 6,788 Average length of Stay 4 Regional Referral 1,710,441 432,064 (Hospitals & HC IVs) Hospital 4 General Hospital 4,716,538 1,191,578
3 HC IV 1,279,980 521,991 Contraceptive prevalence Rate 30% (UDHS 2011) Couple year of protection 2,242,225 ANC 4+ Coverage 14% 248,076 1,787,840 ANC 4 Coverage 38% 667,119 1,787,840 Health Facility deliveries 55% 958,077 1,787,840 HC IVs offering CEmOC 36.4% 72 198 services Page | 108
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Indicator Performance 2015/16 Achievement Disaggregation Numerator Denominator HC IVs conducting C/S 62% 122 198 HC IVs conducting blood 40.4% 80 198 transfusion New OPD Utilization rate 1.0 M 17,983,547 17,377,805 1.5 F 26,313,103 17,915,056 1.2 Total 44,296,650 35,889,418 Hospital (Inpatient)Admissions 7.2 2,515,434 35,889,418 per 100 population Population living within 5km of 100% a Health Facility Availability of a basket of 87% commodities in the previous quarter (% of facilities that had over 95%) Facility based fresh still births 12.7 12,154 958,077 (per 1000 deliveries) Maternal deaths among National Referral 100,000 health facility Hospital deliveries Regional Referral Hospitals General Hospitals HC IVs 119 Total 1,136 958,077 Maternal death reviews 37% 419 1,136 Under Five deaths among 15.1 M 9,695 642,001 1,000 under 5 admissions 22.3 F 13,125 587,620 18.6 Total 22,820 1,229,621 ART Retention rate 79% 42,641 54,209
TB treatment success rate 79% Client satisfaction index 46% (NSDS 2015) Timeliness of reporting (HMIS 79.4% 105) Latrine coverage 75%
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