SI A Y I N Q A B KINGDOM OF SWAZILAND MINISTRY OF HEALTH REGIONAL HEALTH PERFORMANCE REPORT
LUBOMBO REGION
2015
Strategic Information Department This publication was produced with the support of the United States Agency for International Development (USAID) under the terms of MEASURE Evaluation cooperative agreement AID-0AA-L-14-00004. Views expressed are not necessarily those of USAID or the United States government TABLE OF CONTENTS
List of acronyms...... v Acknowledgements...... vi Executive summary...... vii Annual Regional Objectives...... viii
CHAPTER 1: Introduction...... 1 1.1 Regional background...... 2 1.1.1 Geographic Location...... 2 1.1.2 Population profile...... 2 1.1.4 Determinants of Health...... 3 1.2 National Guidance...... 4 1.2.1 Vision...... 4 1.2.2 Mission...... 4 1.3 Leadership and Governance...... 4 1.3.1 Health system structure...... 4 1.3.2 Regional Health Management Team...... 4 1.3.3 Report Overview...... 6 1.3.4 Data sources...... 6 1.3.5 Report writing process...... 6
CHAPTER 2: Management of In-Patients...... 7 2.1 In-patient mortality...... 8 2.2 Disease-burden...... 9 2.3 Length of stay...... 12
CHAPTER 3: Management of Out-Patients...... 13 3.1 Disease Burden...... 14 3.2 Notifiable conditions...... 17 3.3 Sexually Transmitted Illnesses (STIs)...... 18
CHAPTER 4: Health Services Outcomes...... 19 4.1 Promoting Health through the life course...... 20 4.1.1. ANTENATAL CARE (ANC)...... 20 4.1.2. Deliveries...... 21 4.1.3 PREGNANCIES PROTECTED AGAINST TETANUS TOXOID (TT)...... 22 4.1.4 SYPHILIS AMONG PREGNANT WOMEN...... 23 4.1.5 POST NATAL CARE (PNC)...... 23 4.2 CHILD HEALTH...... 25 4.2.1 Child Growth Monitoring...... 25 4.2.2 Immunization Coverage...... 25 4.2.3 NEONATAL MORTALITY...... 26 4.2.4 Diarrhoeal diseases...... 26 4.2.5 Respiratory tract infections...... 27 4.3 ADOLESCENTS...... 27 4.3.1 Deliveries for under 18 years...... 27 4.4 Reproductive health...... 28 4.4.1 Family Planning...... 28 4.5 Cervical cancer screening...... 29 4.6 Preventing Communicable and non-communicable diseases...... 30 Communicable Diseases...... 30 4.6.1 Human Immunodeficiency Virus (HIV)...... 30 4.6.2 PRE- ART...... 32 4.6.3 VOLUNTARY MALE CIRCUMCISION ...... 32 4.6.4 Antiretroviral Therapy (ART)...... 32 4.6.5 Tuberculosis (TB) ...... 36 4.6.6 Malaria...... 40
CHAPTER 5: Regional Achievements and Best Practices...... 41 5.1 Data...... 42 5.2 Supervision...... 42 5.3 Training/Capacity Building...... 42 5.4 Community Mobilization...... 42 5.5 Advocacy...... 42
CHAPTER 6: Conclusions & Recommendations...... 43 6.1 Conclusions...... 44 6.2 Recommendations...... 44
References:...... 43 LIST OF ACRONYMS
ANC Ante-natal care ART Antiretroviral Therapy CTX Cotrimoxazole CPT Cotrimaxazole Preventive Therapy CW Child welfare DBS Dry Blood Spot DNA Deoxyribonucleic Acid FP Family Planning H1N1 Hemmagglutinin 1 Neuraminidase 2 HCW Healthcare workers HIV Human Immune Virus HTC HIV Testing and counselling HMIS Health Management Information System IHM Institute for Health Measurement IPT Isoniazid Preventive Therapy M&E Monitoring & Evaluation M2M Mothers to Mothers MICS Multiple Indicator Cluster Survey MOH Ministry of health NHSSP National Health Sector Strategic Plan OPD Out Patient Department PMTCT Prevention of Mother to child Transmission PNC Post Natal Care RDQA Routine data Quality assessment ReHSAR Regional Health Semi-annual Review RHMT Regional Health Management Team SAM Service Availability Mapping SID Strategic Information Department SNAP Swaziland National AIDS Program STI Sexually Transmitted Infections TB Tuberculosis
WHO World Health Organization URC University Research Co.,LLC
ACKNOWLEDGEMENT
The Lubombo Annual report has been made possible through the tireless hard work of the Health workers in the region. Without their commitment to service delivery, this report would not be possible. The team would also like to thank the support and leadership provided by Regional Health Management Team (RHMT). The report would not be possible without financial and technical support from IHM and URC for which the Ministry of Health is deeply grateful. The success of the planning process was possible through the commitment of SI officers from IHM, URC and MOH.
The following team put together the Lubombo Health performance report for 2015:
1. Phetsile Ndabandaba - MoH- SID 2. Thulane Dlamini - MoH-SID 3. Mxolisi Khumalo - MoH-SID 4. Tengetile Tsabedze - IHM-SID 5. Ireen Hakasenke - IHM- SID 6. Makhosazana Matsebula - URC 7. Bandzile Mthethwa - URC 8. Janet Ongole - URC 9. Sandile Ginindza URC 10. Khanyisile Nkabindze – MoH 11. Dr Arnold Mafukidze – URC 12. Sibongile Simelane - MoH
Lastly, many more other people not mentioned here contributed in different ways and capacities to the report, your contributions as individuals and teams were invaluable. EXECUTIVE SUMMARY
The Regional Health performance report is an essential document designed to provide regional and national policy and decision makers, Health care providers, partners and the general public, information on the availability of health services and health resources. The report is comprised of different indicators within the programs: HTC, Malaria, TB and ART, within the entry points; Inpatient, OPD, ANC, CW, PNC, Maternity and FP.
HMIS Data was used to compile the report. The report planning process involved; regional SID which comprises of Ministry of Health (MOH) officers and analyst as well as the Regional partner (URC) and MOH national SID and IHM SID officers. A verification of the availability of data for the indicators was done during the planning process. All the data that was used was validated 1st by HMIS and then M&E. The report writing process involved M&E officers from MOH and URC.
The data that was analyzed showed that most of the conditions that were a threat and classified under the top 10 leading conditions in 2013 and 2014 were still a threat in 2015. Complicated malaria was the leading notifiable condition in 2015. For the STIs category, there was no clear guidance on the type of STI that was a threat since most conditions were classified under “Other STIs”. More women came for their 1st before 16 weeks in 2015 when compared to 2013 and 2014. There were less deliveries that were reported by the system in 2015 than the subse- quent years. Sithobela Health Centre had no data clerk in 2015 and thus data for the center was not captured. Most women delivered through Natural virginal births in 2015. Deliveries for the under 18s were a few when compared to the subsequent years. There were more immunizations for DPT3 when compared to the other immunizations in 2015.
More women are given TT1 immunizations and most drop out, until a few a given TT5 immunizations. More women use injectable than the other forms of contraceptives. HTC at ANC was 98% and CTX at ANC was 99%. New ART initiations at 2015 was 3829 and currently on ART for 2015 was 27891 and cumulative clients on ART was 36 429. More TB clients were bacteriologically confirmed than clinically diagnosed. There are more admissions for females than for males in the period 2015. ANNUAL REGIONAL OBJECTIVES
• To increase ART Uptake amongst all positive pregnant women from 60% to 80% by the end of December 2015
• To increase immunization coverage of infants from 81% to 95% by December 2015
• To increase the number of Outreach Services in the Region
• To improve CD4 testing documentation from 53% to 80% by the end of December 2015.
• To Improve the Quality of Health Care Services in the Region by December 2015
• To scale up VIA screening.
• To reduce the proportion of exposed infants testing HIV positive at 12 to 18 months from 27% to 5% by December 2015.
• Scale up IPT from 10% to 50% by December 2015. CHAPTER 1: INTRODUCTION 1.1 REGIONAL BACKGROUND
1.1.1 Geographic location
The Lubombo Region is the largest region in the country situated in the Eastern part of Swaziland with the least population. Its boundaries are Manzini Region on the North, Shiselweni Region on the South, and Mozambique on the East and South Africa on West.
1.1.2 Population profile
According to the 2007 Population and housing census, it has population of 207,731 (de jure population), constitut- ing of 99,973 males and 107,758 females. Furthermore it is the least densely populated region with 35.58 persons/km2 with most of the population residing in rural areas. The population of Lubombo accounts for 20, 4% of the total population, of which, 48, 1% are males and 51, and 9% are females. According to the Swaziland Popula- tion Projections, in 2014, the population structure for the region was estimated to be 224 300, of which 108 334 was estimated to be males and 115 996 was to be females.
LUBOMBO 2015 POPULATION PROJECTIONS
over 80 years 758 644 75-79 years 722 598 70-74 years 1,095 956
65-69 years 1,559 1,383 60-64 years 1,997 1,807 55-59 years 2,506 2,222 female Male 50-54 years 3,272 2,743 45-49 years 4,358 3,309
40-44 years 5,621 4,132 AGE 35-39 years 7,171 5,572 30-34 years 8,483 7,157
25-29 years 9,274 9,93 8 20-24 years 11,950 11,690 15-19 years 13,328 13,115
10-14 years 13,973 14,090
5-9 years 14,070 14,314
0-4 years 16,411 16,582
25000 20000 15000 10000 5000 0 5000 10000 15000 20000 25000 NUMBERS
Figure 1: Population projections
In 2022, the population is projected to reach 240 107, with 117 556 males and 122 551 females. The population is projected to continue growing at the base, indicating an increase in the dependency rate.
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 2 1.1.4 Determinants of Health
The regional literacy rate is 84% according to the 2010 Labour Force Survey, with 58% of the population in the region participating in the labour market. The unemployment rate for the region is estimated to be at 40.9%. Of those employed, the majority are males, accounting for 66, 7% of those employed. The region has the lowest infor- mal sector employment, with 6, 6% of the population employed in the informal sector. Only 62,4 of the population is using improved sources of drinking water, 53,7% of households do not have access to drinking water within their premises. 27, 1% of the population defecates in the open (MICS, 2010). 28, 9 % of the households in the regions do not have access to soap.
The proportion of OVC in the region is at 37%, the highest nationally (MICS, 2010). The neonatal mortality rate was at 16, with post-neo-natal mortality rate at 57, Infant mortality rate was 73, child mortality rate was 23, and overall under 5 mortality was 94 in 2010 according to MICS. Children aged 0-59 months who received ORS during diarrhoea was 58.1%, with 17% having had diarrhoea in the last two weeks of the survey, 67,7% received ORS or increased fluids. 13.1% had a suspected case of pneumonia in the last two weeks of the survey.
Individual Lifestyle Factors (Age, sex, and constitutional factors) • Population of 207,731 constituting of 99,973 males and 107,758 females. • Adolescent birth rate Unemployment (15-19years) • Unemployment rate: 40% • Share of women in wage employment: 31,7%
Education Water & Sanitation • Net enrolment • Improved drinking Primary water: 55.1% education: 74,9% • Improved • Net enrolment Healthy Lubombo sanitation: 63.2% Population
Agriculture and Healthcare Services food production • Percentage of women 15-49 • least densely populated who delivered in a health region with 35.58 facility in the two years persons/km2 with most of preceding the survey; 66.5% the population residing in Housing and • Under 5 mortality rate: rural areas Living conditions 94/1000
• Access to electricity: 25% • Percentage of households with at least one mosquito net : 36% • Have a mobile phone: 54.1% • Open defaecation: 27.1%
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 3 1.2 NATIONAL GUIDANCE Regional Health Sector Goals and Vision;
1.2.1 Vision To provide quality health care services to all by 2022.
1.2.2 Mission The Lubombo region seeks to improve the health of the Lubombo population by providing preventive, curative, promotive health and rehabilitative services that are of high quality, relevant, accessible, equitable and socially acceptable to all communities.
1.3 LEADERSHIP AND GOVERNANCE 1.3.1 Health system structure
According to WHO standards on health systems (2010), there should be 2 facilities per 10,000 populations. Based on the total population projection of 224 297 for 2014, the facility population ratio is 2.1 per 10,000 population. The region is doing relatively well in this regard as there are 2.1 facilities per 10 000 population density.
The major challenge in the region is that there are very few clinics offering maternity services, yet a majority of them have the maternity wing but maternity services are not offered. A majority of facilities in the region are clinics without maternity (75%) followed by clinics with maternity.
It has a total number of [45] forty five health facilities i.e. 23 government, 8 mission, 4 private, 7 Industry facilities, 2 army health facilities, and 1 correctional health facility. The region has 1 regional referral hospital, 2 regional hospitals, 1 health centre, 1 public health unit and 40 clinics.
1.3.2 Regional Health Management Team
The Lubombo Regional Health Management Team (RHMT) consist of members employed by Government, Mission, Private and regional supporting partners. They are responsible for the general development and decentralization of health services within the region. This team mainly provides strategic direction for the regional health sector and mobilize for resources.
SAM 2013 categorized health facilities in nine different types as shown in the table below. The major challenge in the region is that there are very few clinics offering maternity services, yet a majority of them have the maternity wing but maternity services are not offered. A majority of facilities in the region are clinics without maternity (75%) followed by clinics with maternity.
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 4 The map below depicts Health Facilities in the region.
Figure 2: Lubombo Region Health Facilities Map
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 5 Table 1: Health Facilities by type
0 1 0 National Referral Regional Referral Specialized Hospital Hospital Total number of Clinics 48 1 1 6 No. of facilities per Health Care Public Health Unit Clinics with Maternity 10,000 population, 2013 2.2 36 2 1 Clinics without Specialized Clinics Private Hospital Maternity Private Hospital
1.3.3 Report Overview
The purpose of the report is to present the performance of regions against the regional health strategic plan, and the National Health Sector Strategic Plan II (NHSSPII).
While this report is not designed to provide complex analysis due to various constraints, it indicates areas where more detailed, complex analysis would be fruitful. The data are presented in terms of national level statistics and for population subgroups such as those defined by age, and sex of the country. When necessary and appropriate to a topic, further data analysis and disaggregation will be shown. It is intended that this report will continue to be produced annually in order to identify trends and changes over time.
1.3.4 Data Sources
The Health Management Information System (HMIS) database was used as the main source of the service delivery results. The results are based on data collected routinely from 2010 to 2015.
1.3.5 Report Writing Process
The report writing process began in the regions whereby Regional SID Officers led the process in collaboration with regional supporting PEPFAR partner. The teams reviewed the required data sources, including key performance indicators. Relevant data was extracted from the HMIS and cleaned by the Data Management Committee.
A data analysis and report finalisation workshop was conducted in collaboration with different supporting partners, National health programs and Strategic Information Department team (both regional and national).
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 6 CHAPTER 2: MANAGEMENT OF IN-PATIENTS 2.1 IN-PATIENT MORTALITY A) Deaths by Diseases
Understanding the burden of disease in Lubombo is critical in the management of patients and improving primary health care.
Swaziland is classified as facing a double-burden of communicable diseases, namely TB and HIV. In 2015, the high- est leading cause of death in the Lubombo region was Tuberculosis, accounting for 19% of all deaths recorded at facilities. Non infective Gastroenteritis and colitis contributed to 7% of all deaths, followed by unspecified anaemia’s at 6% and Acquired Immune Deficiency Syndrome (AIDS) at 5%.
The region has also recorded a burden of cardio-vascular related deaths, with 4% of deaths in 2015 resulting from Hypertension and inflammatory diseases of the central nervous system. Among the deaths in 2015 there are discrepancies in age and sex. Therefore the following section will report on the relationship between age and sex in connection to the diseases that have the highest recorded death rates.
PROPORTIONAL DISTRIBUTION OF DEATHS BY DISEASE 2015
Meningitis due to other Organisms 4% Essential B) Leading causes of death 4% Hypertension Acquired Immune The leading cause of death in the region in 2015 was 5% Deficiency Syndrome Pulmonary Tuberculosis is the leading cause of Other Unspecified mortality, followed by other Non- infective gastroen- 6% Aneamias teritis and colitiss. Cardiomyopathy had the least number of deaths. Non-ifective 7% Gastroenteritis 59% and Colitis Other 19% Pulmonary Tuberculosis Figure 3: Proportional Distribution of Deaths by diseases in 2015
TOP 10 LEADING CONDITIONS RESULTING TO MORTALITY AT INPATIENT, 2015
2 Cardiomyopathy 5 4 Intracerebal Harmorrhage 4 4 Pneumonia due to Other specified Organisms 6 5 Pneumonia, Organisms Unspecified 8 Male female 11 Meningitis due to Other Organisms 3 7 Essential Hypertension 7 6 Acquired Immune Deficiency Syndrome 11 6 Other and Unspecified Aneamis 14 11 Nonifective Gastroenteritis and Colitis 11 38 Pulmonary Tuberculosis 26
0 5 10 15 20 25 30 35 40
Figure 4: Top leading causes of death by sex, 2015
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 8 The table below shows the leading cause of death by age for 2015. There were more deaths due to pulmonary tuberculosis, for most of the ages 10 to 39 and ages 45 to 59. Hypertension has more deaths from the ages 60 and above.
Table 2: Leading causes of death by age, 2015 The figure below shows the top 10 leading causes for admissions in health facilities in Lubombo in 2015. Maternity services were the leading cause of admission in health facilities with the highest number of cases recorded in Age Conditions resulting to Mortality Number of deaths patients coming in for normal delivery at 2673 followed by cases reporting other indications for care or intervention Under 1 Other Non-infective Gastroenteritis and Colitis 6 related to labour at 615. Notably, Tuberculosis is the 7th leading cause for admission with 235 reported cases and age 1-4 Other and Unspecified Protein - Calorie Malnutrition 5 the 1st leading cause of death in the region. Age 5-9 Acquired Immune Deficiency Syndrome 1 Age 10-14 Pulmonary Tuberculosis 2 Age 15-19 Pulmonary Tuberculosis 3 Age 20-24 Pulmonary Tuberculosis and Pneumonia due to 4 specified organism Age 25-29 Pulmonary Tuberculosis 11 Age30-34 Pulmonary Tuberculosis 16 Age 35-39 Pulmonary Tuberculosis 4 Age 40-44 Meningitis Due To Other Organisms 4 Age 45-49 Pulmonary Tuberculosis 9 Age 50-54 Pulmonary Tuberculosis 6 Age 55-59 Pulmonary Tuberculosis 5 Age 60-64 Essential Hypertension and Chronic Liver Disease 4 and Cirrhosis 65+ Essential Hypertension 8
2.2 DISEASE-BURDEN A) Leading causes of admission
NUMBER OF INPATIENTS SEEN IN LUBOMBO, 2010-2015
The number of admission in Lubombo has been some- 10,451 9,515 9,564 9,674 9,568 what stable since 2010 with the exception of 2013. In
2010, there were 9 515 admission reported via HMIS in 6,623 the region, and in 2015 the data shows 9 568 admis- sions. The admission rates are constrained by the number of admitting facilities in the region.
2010 2011 2012 2013 2014 2015
PROPORTION OF INPATIENT ADMISSION BY REGION, 2015
19% HHOHHO 35% LUBOMBO Of the 55 835 admissions in health facilities in 2015, about 17% came from Lubombo, which was 9 568 MANZINI 29% admissions in total. SHISELWENI
17%
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 9 The figure below shows the top 10 leading causes for admissions in health facilities in Lubombo in 2015. Maternity services were the leading cause of admission in health facilities with the highest number of cases recorded in patients coming in for normal delivery at 2673 followed by cases reporting other indications for care or intervention related to labour at 615. Notably, Tuberculosis is the 7th leading cause for admission with 235 reported cases and the 1st leading cause of death in the region.
TOP 10 LEADING CAUSES OF ADMISSION, 2015
Injury, Other and Unspecifie 145 Other and Unspecified Aneamias 157 Diabetes Melitus 210
Pulmonary Tuberculosis 235 Early or Threatened Labour 350
Cause of admission Pneumonia, Organism Unspecified 360 Cataract 380 Other Non-ifective Gastroenteritis and Colitis 545 Other Indications for care or intervention related to labour 614 Normal delivery 2,673
0 500 1000 1500 2000 2500 3000 Number of cases 2.2 DISEASE-BURDEN Figure 5: Leading causes of admission, 2015 A) Leading causes of admission
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 11 The table below presents the leading cause of admission by age and sex. However, further analysis for age groups and sexes with the highest reporting of admissions is critical to ensure that health promotion programmes are effective in reducing the incidence. Moreover, the data shows that in-patient admissions are largely seen among females accounting for over 73% of all the admissions with the age 20-24, and 25-29. These are women of reproduc- tive age who are largely coming for those services. Among the males seen in 2014, the largest proportions were those under 5 years old. The next group is men aged 30-34.
The in-patient admission indicates that it is children and people of the reproductive age that place the biggest burden on services in the health facilities.
ADMISSIONS BY AGE AND SEX, 2015
65+ 285 421 112 60-65 178 209 50-59 208 143 45-49 151 Male female
40-44 145 227 172 35-39 509 196 30-34 995
AGE 167 25-29 1304 131 20-24 1441 83 15-19 796 91 10-14 72 141 5-9 106 407 1-4 338 288 Under 1 223
200 400 600 800 1000 1400 1600
NUMBERS
Figure 6: Number of admissions by age and sex, 2015
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 12 2.3 LENGTH OF STAY
The following section looks at efficiency and burden. Average lengthen of stay is a component of quality of care. If the average length of stay is in line with the national target it indicates that decisions about patients are being made quickly and facilities are able to diagnosis, given treatment, and discharged in a timely manner.
The formula for length of stay is;
Total Number of inpatient days = Number of inpatient days + 1/2 day patients = 34 100 + 1/2 (400) = 34 100 + 200 = 34 300
Total Number of separations = Discharges + transfers + deaths + day patients = 6 810 + 80 + 200 + 400 = 7 490
Total Number of inpatient days 34 300 = = Total Number of separations 7 490
= 4.6 days
AVERAGE LENTH OF STAY (ALOS) FOR INPATIENTS FROM 2012 - 2015
4 Days 4 Days 4 Days 5 Days 2012 2013 2014 2015
Figure 7: Average length of stay for inpatients, 2015
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 13 CHAPTER 3: MANAGEMENT OF OUT-PATIENTS The outpatient morbidity embraces all diseases diagnosed during general outpatient visits. In the HMIS, the extent to which the population is affected by disease is measured through the rate at which people are presenting them- selves to the facilities due to some conditions in a given period, and the occurrence of death resulting from a given diagnosis. This chapter will also discuss Notifiable conditions as well as sexual transmitted infections (STI).
Outpatient care describes medical care or treatment that does not require an overnight stay in a hospital or medical facility. Outpatient health care services are offered in all health facilities in Swaziland. Clinics can be privately oper- ated or publicly managed and funded, and typically cover the primary health care needs of populations in local communities, in contrast to larger hospitals which offer specialized treatments and admit inpatients for overnight stays.
3.1 DISEASE BURDEN
In the HMIS there are 63 listed diagnoses, the table below present the top ten causes of OPD attendances to health facilities during the period under review.
A) Leading conditions at OPD
NUMBER OF OPD EPISODES IN LUBOMBO, 2010-2015
926,312 Lubombo region has seen a steady increase in the 871,505 number of OPD cases from 2010 at 762 500 762,500 757,292 764,068 698,635 admissions to 926 312 in 2015. This increase is
almost an additional 200 000 OPDs in the region over the last 5 years. Worth noting is that in 2015 the region had admissions rates that were higher than that of Hhohho region. This can be also be attributed to the opening of the Lubombo referral hospital in late 2014.
2010 2011 2012 2013 2014 2015
Proportion of OPDs by Region, 2015
12% 24% HHOHHO Of the 3 815 849 OPD episodes in the HMIS in 2015, LUBOMBO a total of 926 312 were from Lubombo which is 24% MANZINI of all OPDs in the country. The number of OPDs in the region were higher in number than those of SHISELWENI 40% Hhohho region in 2015. 24%
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 16 TOP 10 LEADING CONDITIONS FOR THE <5 YEARS AGE GROUP AT OPD, 2015
Intestinal worms 1,855
Eye Diseases 2,540
Pneumonia (Mild) 2,864
Condition Diarrhoea with blood/Dysentery 3,797
Ear Problems 4,322
Digestive Disorders 4,867 Lower Respiratory Infection (Mild) 9,468
Skin Disorder 14,783
Acute Watery Diarrhoea 16,955
Upper Respiratory Infection 33,388
0 10000 20000 30000 40000 Number of cases
Figure 8: Top 10 leading conditions for the under 5 years age group at OPD
The table above presents the top 10 leading conditions in the region. The conditions in descending order are as follows: upper respiratory infection, acute watery diarrhoea, skin disorder, Lower respiratory infection (mild), diges- tive disorders, ear problems, diarrhoea with blood/dysentery, mild pneumonia, eye diseases and intestinal worms.
TOP 10 LEADING OPD CONDITION FOR THE UNDER 5 YEARS DISAGREGATED BY SEX, 2015
Intestinal worms Eye diseases Pneumonia Diarrhoea With Blood/Dysentery Ear problems Digestive Disorders Male female Lower Respiratory Infection (Mild) Skin disorder Acute Watery Diarrhoea Upper Respiratory Infection 0 2000 4000 6000 8000 10000 12000 14000 16000 18000
Lower Diarrhoea Upper Acute Skin Respiratory Digestive Ear With Eye Intestinal Respiratory Watery Pneumonia disorder Infection Disorders problems Blood/Dyse diseases worms Infection Diarrhoea (Mild) ntery Male 16888 8717 7608 4923 2315 2254 2038 1493 1275 878 Female 16500 8238 7175 4545 2552 2068 1759 1371 1265 977
Figure 9: Top 10 leading conditions for the children <5 years at OPD disaggregated by sex, 2015
The table above depicts the top 10 leading OPD conditions for the population aged 5 and below, disaggregated by sex. There are more male conditions (48 389) than female conditions (46 450) in the period as opposed to the top 10 leading conditions for the population above 5, where there were more females conditions than male conditions.
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 17 TOP 10 LEADING CONDITIONS FOR THE >5 YEARS AGE GROUP AT OPD, 2015
Other STIs 14,123
Diabetes Mellitus 14,853
Digestive disorders 16,521
Lower respiratory infection (Mild) 17,122
Acute water diarrhoea 20,076 Condition Ear problems 22,683
Skin Disorder 24,977
Muskulo skeletal conditions 27,143
Hypertension 47,467
Upper Respiratory Infection 74,201
0 10000 20000 30000 40000 50000 60000 70000 80000 Number of cases
Figure 10: Top 10 Leading conditions for adults >5 years at OPD
The table above depicts the top 10 leading conditions for the population under 6. Some of the conditions were also among the top 10 conditions for the under 5. The conditions that were among the top 10 leading conditions for both the under 5 and over 5, were as follows: upper respiratory infection, skin disorders, ear problems, acute watery diarrhoea, lower respiratory infection and digestive disorders. Upper respiratory infection, was the highest leading cause of morbidity among the population aged 6 and above in 2015. It was also the leading cause of morbid- ity for the under 5 population in 2015. Hypertension, was the 9th leading cause of morbidity for the over 5 popula- tion in 2015.
Muskulo skeletal conditions were the 8th leading cause of morbidity, followed by skin disorders, ear problems and acute watery diarrhoea. Lower respiratory infection (mild) was the 6th leading cause of morbidity, and digestive disorders were the 8th leading cause. Diabetes mellitus and other STIs were the 9th and the 10th leading cause of morbidity consecutively.
TOP 10 LEADING OPD CONDITIONS FOR THE ABOVE 5 YEARS AT OPD DISAGREGATED BY SEX, 2015
Other STIs Diabetes mellitus Digestive disorders Lower Respiratory Infection (Mild) Acute watery diarrhoea Male female n Ear problems i ti o
d Skin Disorder n
o Muskulo Skeletal Conditions C Hypertension Upper Respiratory Infection 0 5000 10000 15000 20000 25000 30000 35000 40000
Lower Upper Muskulo Acute Skin Ear Respiratory Digestive Diabetes Respiratory Hypertension Skeletal watery Other STIs Disorder problems Infection disorders mellitus Infection Conditions diarrhoea (Mild) Male 34918 15445 11935 12200 10263 8445 7522 7100 6065 6195 Female 39283 32022 15208 12777 12420 11631 9600 9421 8788 7928
Figure 11: Top 10 leading conditions for adults above 5 years disaggregated by sex at OPD, 2015
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 18 The table above depicts the top 10 leading OPD conditions for the population aged 6 and above, disaggregated by sex. There are more female conditions than male conditions. In total there were 159 078 female cases under the top 10 leading OPD conditions, and there were 120 088 male conditions.
3.2 NOTIFIABLE CONDITIONS
In striving to adequately monitor thus be able swiftly intervene in cases of notifiable conditions the Kingdom of Swaziland has established the Emergency Preparedness Response (EPR) unit within the Ministry of Health. This unit has set up systems that allow for immediate notification of certain conditions through a toll free number used by facilities and the public to notify the unit. The responsible officers in turn send messages via SMS to the relevant departments within the ministry who will upon receiving the messages rush to the particular facility to assist or investigate. This unit was also set up to respond to emergencies especially accidents.
All facilities in the country are expected to alert the unit in case they come across notifiable conditions in the course of service delivery. The following conditions are classified as notifiable conditions in the context of Swaziland: Malaria (confirmed), Maternal Death, Perinatal Death, Suspected Neonatal Tetanus, Suspected Measles, Suspected Human Rabies, Suspected H1N1, Acute Flaccid Paralysis, Viral Haemorrhagic Fever, Suspected Rift Valley Fever, Suspected Yellow Fever, Suspected Typhoid Fever, Suspected Cholera, Suspected Severe Food Poisoning and Suspected Meningococcal Meningitis.
Table 3: Number of notifiable conditions by quarter in 2015
Condition Q1 Q2 Q3 Q4 Total Malaria (Uncomplicated) 58 67 67 37 287
Malaria (Severe Anaemia) 10 12 19 30 71
Suspected Measles 0 2 1 6 9 Meningitis 5 4 4 5 18 Suspected Cholera 0 1 0 0 1 Rabies 3 0 0 1 4 Acute Flaccid Paralysis 0 0 2 1 2 Neonatal Tetanus 0 0 0 0 0 Typhoid Fever 0 7 0 0 7 Yellow Fever 0 0 0 0 0
Complicated malaria, was the leading notifiable condition in 2015, followed by malaria (Severe anaemia).meningitis was the third leading notifiable condition, followed by suspected measles rabies and acute placid paralysis respec- tively. Neonatal tetanus and yellow fever had no cases for the whole year.
Uncomplicated malaria had more cases in quarter two and quarter three in 2015. Suspected measles had more cases in quarter four. Meningitis had more cases in quarter one and four. Suspected cholera had one case in quar- ter two. Rabies had more cases in quarter one, acute placid paralysis had the most cases in quarter three and typhoid fever had the most cases in quarter two.
3.3 SEXUALLY TRANSMITTED ILLNESSES (STIs)
The Ministry of Health Protocol for the Management of Sexually Transmitted Infections (STI) 2009, stipulates that sexually transmitted infections remain a priority for the Ministry of Health because of their correlation with HIV. It is therefore essential that STIs are properly managed at first point of contact with health services using the syndrome management approach which was adopted by the country in 1996 because it had been found to be the most efficient and effective approach. This approach to diagnosis and treatment reduces costs and increases access to treatment, thereby providing a more practical and cost-effective intervention for reaching the majority of STI patients, especially in resource limited settings.
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 19 CHAPTER 4: HEALTH SERVICES OUTCOMES Health service outcomes help the Ministry measure its performance as it renders services to the public and as it works with partners to achieve the ultimate goal of a health nation. Following the NHSSP II approach, 5 thematic areas have been selected to give strategic direction on implementation of the NHSSP II. These are: promoting health through the life course; prevention of communicable and non-communicable diseases; influencing health in key sectors, managing medical and related conditions and rehabilitation following health events. The following sections gives outcome results of the 5 thematic areas.
4.1. PROMOTING HEALTH THROUGH THE LIFE COURSE
The National Health Sector Strategic Plan II promotes health through the life course: These services are aimed at maintaining the health of the population at all ages. By promoting health, the health sector is aiming at maximising the available health resource for the Swazi population.
The strategic approach of the health sector intends to introduce and scale up a range of interventions that aim at promoting the health of the people across the life course. The sector intends to achieve this by focusing on:
• Enhancing integrated approach to delivery of Child and Maternal Survival services • Providing a male-tailored Essential Preventive Health service Package • Promoting understanding and practice of healthy ageing for men and women • Making physical Exercise for All (E4A) a popular national sustained campaign • Promoting, protecting and supporting appropriate infant and young child feeding practices and behaviours with focus on the first 1000 critical days
4.1.1. ANTENATAL CARE (ANC)
The Ministry of Health recommended that the first ANC visit should take place as soon as the women realizes she is pregnant preferably within the first trimester (before 14 weeks of gestation.
ANC coverage in the region is high, with MICS 2010 reporting that 95% of women attend ANC services. Although the coverage is high, the majority of women come to the health facility late. The Ministry of Health has set as a priority a need to increase the number of women coming to ANC early.
The number of women attending 1st ANC visit before 16 weeks has been increasing through the years, in 2013, 19% attended 1st An before 16 weeks, in 2014 21% attended 1st ANC before 16 and then in 2015, 28% of women came for their ANC visit before 16 weeks. The region has not yet met the national target of 60% of women attending their 1st ANC visit before 16 weeks gestational age by 2018. Early antenatal care is critical in ensuring the health and wellbeing of both mother and child.
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 21 PROPORTION OF WOMEN ATTENDING 1ST ANC BEFORE 16 WEEKS GESTATIONAL AGE, 2013-2015
Target 60%
50%
40%
30% 28% 20% 19% 21% Proportion of women 10%
0 2013 2014 2015 Years
Figure 12: Number of women attending 1st ANC trend, 2013-2015
4.1.2 DELIVERIES
To reduce maternal mortality, the Ministry of health promotes deliveries by skilled birth attendants and facility based deliveries. According to MICS 2010, the Lubombo region had the lowest health facility deliveries with only 66.5% of women delivering in health facilities.
The HMIS data shows that there is a reduction in the NUMBER OF DELIVERIES number of deliveries in the region between 2013 and DISAGGREGATED BY THE PLACE OF 2014. The total number of deliveries happening in the region have been decreasing over the years. In 2013 DELIVERY FROM 2013 TO 2015 the were 4620 births, in 2014 they were 4446 births and in 2015 they were 3166. Facility deliveries reduced from 3883 in 2013, to, 3695 in 2014 and further decreased to 3070 in 2015.Home deliveries have decreased drastically, to 96 deliveries in 2015. In 2013 hey were 737 home deliveries and decreased to 751 in Home Deliveris Facility Deliveris 2014. 2013 2013 16% 84% There were 737 There were 3883 A) Deliveries by type Home Deliveries Facility Deliveries The figure belows looks at the number of women who delivered at health facilities in the region. In line with national surveys, the region is still lagging behind in terms of women delivering at health facilities. 2014 17% 2014 83% There were 751 There were 3695 Home Deliveries Facility Deliveries PROPORTION OF DELIVERIES BY TYPE FOR 2015
2015 3% 2015 97% There were 96 There were 3070 18% Caesarian Home Deliveries Facility Deliveries
82% Figure 13: Number of deliveries by place of Normal delivery, 2013-2015 Virginal Delivery
Figure 14: Proportion of deliveries by type, 2015
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 22 The table above describes deliveries that happened in the region. WHO target is between 10 % and 15 % for Caesar- ian deliveries. 18% of all the deliveries that happened in the region were Caesarian and 82% were Normal Virginal Deliveries. The region needs to formulate strategies that will ensure that the WHO target is met.
B) Deliveries by age groups
An analysis of the age of the females who deliver in the region indicates that the largest group utilizing the services is the population less than 20 years. Under 15s and over 45 years account for less than 1% of deliveries, whilst those aged 15-19 account for 17% of deliveries. The largest group delivering at the facility is women aged 20- 24 years. , Women aged 20-24 represent 32% of all deliveries at health facilities in Lubombo. The second highest group is those 25-29 years. Women aged 30-34 and 15-19 represent 16 and 17 percent of deliveries respectively. The data indicates that FP interventions should be targeted at those 20-24.
PROPORTION OF DELIVERIES BY AGE GROUP, 2015
40-44 yrs 2% 35-39 yrs 15-19 yrs 8% 17% Under 15 years 30-34 yrs 1 delivery 16% Over 45 years 7 delivery 32% 20-24 yrs
26%
25-29 yrs
Figure 15: Number of deliveries disaggregated by age group, 2015
4.1.3 PREGNANCIES PROTECTED AGAINST TETANUS TOXOID (TT)
The table below shows women of child bearing ages that are receiving TT1-TT5 in all the reproductive age groups. A majority of women received TT1 and TT2. Worth noting is that mostly are those who are between 15-29 years. Fewer women are reported to have received TT4 and TT5. In age group 30-49, fewer women reported to have received TT1 and TT2 dose as compared to the other age groups which can be attributed to the fact that fewer women fall pregnant for the first time during that age group. Due to data limitations, it is difficult to ascertain if women complete their recommended doses.
Table 4: Number of women of reproductive age given TT, 2015
Women by age TT 1 TT 2 TT 3 TT 4 TT 5 15-19Years 1178 614 111 9 1 20-24Years 1391 821 376 74 16
25-29Years 1029 565 332 106 41
30-49Years 935 406 206 124 58
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 23 4.1.4 SYPHILIS AMONG PREGNANT WOMEN
According to the revise PMTCT guidelines, all pregnant presenting to ANC should be tested for syphilis to prevent complications to a child born to syphilis and those testing positive should be given treatment. This could be attrib- uted to that during the year there was a major stock out of re agents for the testes and made many women to walk out without the test. The region experienced reagent stock out for testing syphilis therefore could reach 100 testing rate. All women attending ANC should be tested for Syphilis at least once during their time in ANC.
SYPHILIS TESTING CASCADE FOR WOMEN ATTENDING 1ST ANC, 2015
6000 5225 5000
4000 73%
3000
2000 Number of Clients Number 1000 1% 100% 0 Number of 1st ANC Number of 1st ANC Number testing positive Number initiated on tested for Syphilis for Syphilis treatment
Figure 16: Pregnant women tested for syphilis at ANC, 2015
The table above shows screening for syphilis the region. The region faced some stock out of syphilis test kits in 2015. The stock outs contributed to the region not being able to test all women attending 1st ANC. 5225 women came for their 1st ANC visit in 2015, 3813, which is 73% of the total 1st ANCs were tested for syphilis. 57 women, which is 1% of those tested for syphilis were tested positive and all of those tested positive were initiated on treat- ment.
4.1.5 POST NATAL CARE (PNC)
According to SDHS, a large proportion of maternal and neonatal deaths that occur during the first 48 hours post- delivery, are mostly due to preventable causes. Women after delivery are provided with post-natal care services as to monitor their conditions and the milestones of the baby.
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 24 COMPARISON OF WOMEN ATTENDING PNC AT 7-14 DAYS AMONGST WOMEN WHO DELIVERED IN 2014 AND 2015
99.8% 4500 100% 94% 90% 4000 80% 3897 3500 3695 70% 60% 3000 50% 40% 2500 30% Number of women Number 2000 20% 10% 0 2014 2015 years
Number of deliveries Number attended PNC at 7-14 days
Figure 17: Number and proportion of women attending PNC within 7-14 days, 2014-2015
C) PNC visits
The graph below depicts Post Natal Care (PNC) visits by attendence. The are more 1st Attandences (3659) than Re-Attendences (2464). 60% of all the visits are 1st attendences and 40% of all visits are Re- attendances.
PROPORTION OF WOMEN ATTENDING PNC DISAGGREGATED BY ATTENDANCE, 2015
40% 1st Attendants
Re-Attendants 60%
Figure 18: Proportion of women attending PNC within 7-14 days, 2014-2015
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 25 4.2 CHILD HEALTH
Children less than five years have a lowered immunity system and their mortality rate is 85 per 1000 live births (DHS 2007), gastro enteritis and pneumonia are one of the leading causes of deaths. The children nutritious status has to be monitored frequently as to avoid cases of severe acute and chronic malnutrition. When a child is malnour- ished the immunity system is compromised making prone to several infections such as TB. Mother-baby pair should be promoted when seeking health services as to provide adequate care. Most of the children are from mothers who work in the factories or others go to South Africa to work and the children are left with their grandmothers at home or under the care of unregistered day care centres.
4.2.1 CHILD GROWTH MONITORING
Children less than 5 years should come every month to monitor their growth and for immunizations injections as to prevent childhood illnesses.
Table 5: Nutritional status for children under 5 years, 2015
Weight 0-6 Months 7-23 Months 24-59 Months Grand Total Normal Weight 22317 24053 20968 67338 Over Weight 142 152 113 407 Severe Under Weight 11 11 7 29 Under Weight 177 319 105 601 Wasting 4 8 7 19 Total 22651 24543 21200 68394
The table above shows the nutritional status of children under 5 years who came for growth monitoring. Out of all the children who came 67338 (98%) of them were of normal weight, whilst 1% of them were underweight, 0.04% of them were severe underweight and 0.03% of them were wasting.
4.2.2 IMMUNIZATION COVERAGE
The under 1 year (12 months) catchment population for 2013 was 6479, was 6537 in 2014 and rose to an estimated 6596 in 2015. The table below shows less than 1 year (12 months) immunizations for the region. Overall immuniza- tion coverage has been fluctuating over the years. In 2013, DPT coverage was at 85%, rose and maintained 95% coverage in 2014 and 2015. DPT 3 coverage was highest in 214 with 99% and was lowest in 2013 with 81%. Measles coverage on the other hand had the lowest coverage in 2014 and the highest in 2015. BCG coverage was highest in 2014 with 82% and lowest in 2013 with 26%.
Table 6: Immunization coverage, 2013-2015
Vaccine Doses of Vaccine Immunization Coverage %
Year 2013 2014 2015 2013 2014 2015 DPT 1 5491 6217 6280 85% 95% 95% DPT 3 5246 6462 6276 81% 99% 96% DPT dropout 245 - 245 4 4% -4% 1% rate Measles 5351 3554 6062 83% 54% 92% BCG 1693 5331 5152 26% 82% 78%
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 26 4.2.3 NEONATAL MORTALITY
The neonatal death rate is children who die before they reach 28 days of their age in days.
The bar chart denotes that the leading cause of neonatal mortality is children with other non-infective gastroenteri- tis and colitis, followed by those with other and unspecified complications of the puerperium.
NUMBER OF NEONATAL MORTALITY CASES REPORTED FOR INPATIENT, 2015
Other and Unspecified Aneamias 1
Injury, Other and Unspecified 1 Condition Other Perinatal Jaundice 2
Other and Unspecified Protein - Calorie Malnutrition 2
Other and unspecified complcations of the puerperium 2
Other Non-ifective Gastroenteritis and Colitis 6
0 2 4 6 8 Number of cases
Figure 19: Neonatal mortality cases reported at inpatient, 2015
4.2.4 DIARRHOEAL DISEASES
The table below shows the incidence of diarrheal diseases for children under 5 years. Diarrhea is more prominent among males than females and they were more cases for acute.
DIARRHOEAL DISEASES AMONG CHILDREN UNDER THE AGE OF 5 YEARS DISAGGREGATED BY SEX AT OPD, 2015
126 Persistent Diarrhoea 106
12 Male female Diarrhoea with some Dehydration 14
Diarrhoea with Severe Dehydration 0 1 136 Diarrhoea with Blood/Dysentery 119 684 Acute Watery Diarrhoea 704
0 100 200 300 400 500 600 700 800
Figure 20: Diarrhoeal diseases among children 5 years and below at OPD, 2015
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 27 4.2.5 RESPIRATORY TRACT INFECTIONS
The table below denotes children under 5 who came with respiratory conditions, the leading respiratory condition is upper respiratory infection, with 33 477 which is the total for both males and females, followed by lower respira- tory infection and then mild pneumonia. Severe pneumonia had the least number of cases.
COMPARISON OF RESPIRATORY TRACT INFECTIONS BETWEEN MALES & FEMALES AT OPD FOR CHILDREN <5 YEARS, 2015
4,563 Lower Respiratory Infection (Mild) 4,933
610 Lower Respiratory Infection (Severe) 590
1,371 Male female Pneumonia (Mild) 1,493
Pneumonia (Severe) 142 Condition 128
197 Suspected Pulmonary TB 236 16,541 Upper Respiratory Infection 16,963
0 2k 4k 6k 8k 10k 12k 14k 16k 18k Number of cases
Figure 21: Respiratory tract infections for children 5 years and below at OPD, 2015
4.3 ADOLESCENTS
According to the World health Organization adolescent are individuals in the age group 10-19 years, youth are individuals in the 15-24 years age group .The adolescent has physical, psychological emotional and sociocultural dimensions. Experimentation and risk-taking are normal during adolescence and are part of the process of devel- oping decision-making skills; adolescents are both positively and negatively influenced by their peers, whom they respect and admire. Adults play an important role in this regard and can help adolescents weigh the consequences of their behaviors (particularly risky behaviors) and help them to identify options. The influence of at least one positive adult and a nurturing family are protective factors during this period of development and can help adoles- cents cope with stress and develop resilience.
At one end of the continuum are very young adolescents (10 to 14 years of age), who may be physically, cognitively, emotionally and behaviorally closer to children than adults. Very young adolescents are just beginning to form their identities, which are shaped by internal and external influences. Signs of physical maturation begin to appear during this period: pubic and axillary hair appear; girls develop breast buds and may begin to menstruate; in boys, the penis and testicles grow, facial hair develops and the voice deepens.
4.3.1 Deliveries for under 18 years
Understanding the demographics of the population that utilizes services is critical in planning interventions for these populations. In Lubombo the delivery rate for under 18 years is currently at 9.5%. The proportion has been decreasing over the last 3 years. In 2012 and 2013, 11.5% of deliveries in the facility were by females under the age of 18.
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 28 PROPORTION OF ADOLESCENTS (18 YEARS & BELOW) DELIVERIES FROM 2013 - 2015 2013 2014 2015 There were There were There were 3846 3805 3897 deliveries deliveries deliveries
and 442 and 438 and 300 deliveries 11.5% deliveries 11.5% deliveries 9.5% under 18yrs under 18yrs under 18yrs
Source: HMIS 2015
Figure 22: Number of adolescent deliveries, 2012-2015
4.4 REPRODUCTIVE HEALTH 4.4.1 Family Planning
The table below shows the contraceptive uptake by method to both new and re- attendees in the Lubombo region. The contraceptive methods are grouped into three; orals and injectable which are short term methods and Implants which are long term methods. It is worth noting that, Implants (long term methods) are the least preferred form of contraceptives among all the three forms of contraceptives. Injectable are the most preferred form of contraceptives. When analysing throughout the three forms of contraceptives; DMPA is the most preferred form by new acceptors, whilst NST is most preferred by Re-attendees. Implanon is the least preferred form by new accep- tors, whilst the Intrauterine Device (IUCD) is the least preferred by Re-attendees.
Among orals the Lofeminal is the most preferred form of contraceptive whilst Jadelle is the most preferred form among implants.
INJECTABLE CONTRACEPTIVE UPTAKE DISAGGREGATED BY ATTENDANCES, 2015
16000 14735 14000 13720 12000 10000 8000 Re-attenders 6000 New acceptors 4000
Number of attendences Number 2000 848 1919 1428 0 158 DMPA Norigynon NST
Figure 23: Number of injectable contraceptive uptake, 2015
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 29 ORAL CONTRACEPTIVE UPTAKE DISAGGREGATED BY ATTENDANCES, 2015
6000
5000
4000
3000
Number of attendences Number 2000
1000
0 Lof Micro Ovral Post 2
Re-attenders 4710 642 3485 76 New acceptors 552 513 428 415
Figure 24: Number of oral contraceptive uptake, 2015
LONG TERM (IMPLANT) CONTRACEPTIVE UPTAKE DISAGGREGATED BY ATTENDANCES, 2015
150
125
100
75
50
25 Number of womenttendences Number
0 Implanon Jadelle IUCD
Re-attenders 2 23 1 New acceptors 0 115 1
Figure 25: Number of oral contraceptive uptake, 2015
4.5 CERVICAL CANCER SCREENING
Cervical cancer is one of the opportunistic infections associated with HIV as a result of HPV infection. This disease can be averted at three levels of prevention: primary, secondary and tertiary. As a secondary prevention method, the country routinely screens for cervical cancer through conducting Pap smears and VIA screening. A third of the women who have pre-cancerous lesions (VIA positive) would not reach the next level of care. To minimize lost to follow up for cervical cancer patients, the screen and treat approach has been adopted whereby patients receive such care at the same facility.
The graph below illustrates the number and the different types of cancer screenings done in the region. 879 clients did VIA screening, and 13% (113) of the 879 screened positive. 108 clients did Pap smear.
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 30 NUMBER OF WOMEN SCREENED FOR CERVICAL CANCER, 2015
900 879
800
700
600
500
400
300 Number of women Number 200
108 13% 100
0 PAP Smear Visual Inspection Acetic VIA Screening Acid (VIA) Screening Positive Services
Figure 26: Cervical Cancer Screening uptake, 2015
4.6 PREVENTING COMMUNICABLE AND NON-COMMUNICABLE DISEASES
COMMUNICABLE DISEASES
The following section looks at the three communicable diseases that are a priority in Swaziland; HIV, TB and Malaria.
4.6.1. Human Immunodeficiency Virus (HIV)
Swaziland has the highest HIV prevalence rate in the world: 25 percent on the population of workforce age 15-19 years is HIV positive and 39.2 percent of pregnant women attending antenatal care centres are infected. HIV testing and counselling (HTC) services have helped millions of people learn their HIV status and for those positive, learn about options for long term care and treatment. Late diagnosis of HIV infection, result in delay initiation of antiret- roviral therapy (ART). The 2015 Swaziland Integrated HIV Management guideline clearly states that HTC must be offered at all possible points of contact with client in the health system and community structure.
Figure below shows HIV testing trends in the Lubombo region between 2011 and 2015. Data indicates that there was significant increase (33%) in the number of tests conducted in the region in 2014. The rapid increase in HIV testing may be a direct result of the corresponding increase in number of HIV testing and counselling sites as a result of the introduction of provider initiated HIV testing and counselling (PIHTC) and client initiated HIV testing and counselling (CIHTC). On another note data from the region indicates a downward trend in percent testing positive from 17% in 2011 to 7% in 2014
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 31 Table 7: Number of patients tested for HIV by Entry Point, 2015
Female Male
Grand Negative Positive Total Negative Positive Total Total OPD 54,337 5,101 59,438 36,120 3,726 39,846 99,284
Inpatient 1,639 159 1,798 1,667 144 1,811 3,609
STI 108 21 129 140 23 163 292
MC 64 1 65 854 23 877 942
FP 28,220 788 29,008 336 10 346 29,354
TB 1,148 97 1,245 1,267 120 1,387 2,632
ANC 27,397 2,057 29,454 572 23 595 30,049
Maternity 821 37 858 17 0 17 875
PNC 8,199 154 8,353 218 4 222 8,575
CWC 17,061 194 17,255 12,904 182 13,086 30,341
PEP 205 8 213 102 2 104 317
Total 139,199 8,617 147,816 54,197 4,257 58,454 206,270
The table above shows Provider Initiated HIV Testing and Counselling (PIHTC) by entry points for the region in 2015. Most of the tests were done at OPD, for both males and females. The entry point with the second highest number of entry points for males if Child Welfare (CW) followed by inpatient and then TB. Maternity has the least number of tests amongst all the other entry points.
FP has the second highest number of tests for females, followed by ANC and then CW. MC has the least number of tests done from females.
Table 8: Number of patients tested for HIV (CIHTC), 2015
Female Male Grand Negative Positive Total Negative Positive Total Total CIHTC/VCT 26101 2294 28395 27508 1919 29427 57822 HBHTC 64 5 69 37 4 41 110 Outreach 21831 862 22693 21868 617 22485 45178 Campaigns 435 20 455 386 9 395 850 Totals 48431 3181 51612 49799 2549 52348 103960
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 32 The table above shows the number of Client Initiated HIV Testing and Counselling (CIHTC) in 2015. Most of the tests were done through VCT for both males and females, followed by outreaches and then HBHTC. Campaigns had the least number of tests.
4.6.2 PRE- ART
The Ministry of Health (MoH) continues to provide a basic care package for PLHIV (commonly referred to as Pre- ART). The package of Pre-ART aims to delay progression to AIDS stage, prevent and manage common opportunistic infections (OIs), and provides an opportunity for early initiation of ART. As provided by the national integrated HIV management guidelines, PLHIV are enrolled in chronic care and actively followed up, with a standard package of care provided. This involves at least, biannual CD4 cell count testing, regular screening for TB, provision of cotri- moxazole, isoniazid preventative therapy and secondary prophylaxis for Cryptococcus’s with fluconazole.
4.6.3 VOLUNTARY MALE CIRCUMCISION
Circumcision reduces chance of contracting HIV by 30%. Furthermore, VMMC reduces the risk of acquiring several STI including HPV among female partners (HSRP 2014-18). The country adopted the ambitious Accelerated Satu- rated Initiative (ASI) in 2010, which seeks to increase VMMC uptake to 80% among males within the age group of 15-49 years 7. The country continues to provide VMMC to all eligible males, and the results are presented in this section.
NUMBER OF MALES CIRCUMCISED DISAGGREGATED BY AGES, 2015
2500
2000 1923
1500
1000
618 Number of clients Number 500 152 70 213 32 27 7 10 8 1 0 1-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50+ Missing ages Age groups
Figure 28: Number of males circumcised disaggregated by ages, 2015
The table above denotes that most of the circumcision happens between the ages 10 to 14, followed by the ages 15 to 19, and then the ages 1 to 9.
4.6.4 PREVENTION OF MOTHER TO CHILD TRANSMISSION (PMTCT)
A) HTC Uptake for pregnant women at ANC
Below is a table that presents HTC at ANC. The number of women attending 1st ANC visits increased from 2013 to 2014 but decreased in 2015. The proportion of clients that came with a known HIV positive status was high in 2015 when compared to the other years. On the contrary, the proportion of clients who know their HIV status and the proportion of clients testing HIV positive at 1st ANC has been decreasing over the years.
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 33 HTC CASCADE AT ANC, 2015
Total HIV+ women on ART 97%
Total HIV+ women 36%
# of women testing HIV positive 13%
# of women with known HIV status 94%
Known HIV+ on ART 66%
# of women tested for HIV 3615
Known HIV positive 25%
# of women attending 1st ANC visit 5227
0 1000 2000 3000 4000 5000 6000 Number of women
Figure 29: HTC Uptake cascade at ANC, 2013-2015
NUMBER OF EXPOSED INFANTS TESTED USING DBS AT 6-8 WEEKS CASCADE AND GIVEN CTX PROPHYLAXIS
# of exposed infants given CTX 99%
# of exposed infants testing positive at 6-8 weeks 3%
# of exposed infants tested using DBS at 6-8 weeks 98%
# of exposed infants seen at 6-8 weeks 1754
0 400 800 1200 1600 2000
Number of infants
Figure 30: Prevention therapy for exposed infants, 2015
4.6.4 ANTIRETROVIRAL THERAPY (ART)
Swaziland continues its commitment towards reaching the goal and targets outlined in the 2011 United Nations political declaration of HIV and AIDS. Intensifying our efforts to eliminate HIV and AIDS, has also served to guide Swaziland’s HIV response towards reaching Millennium Development Goal 6 to “halt by 2015 and begin to reverse the spread of HIV and AIDS “focused and concrete progress towards these global targets.
The country has the highest HIV prevalence in the world, with 26 percent of the population aged 15-49 living with HIV (Swaziland Demographic and Health Survey, 2014). As the HIV pandemic matures, increasing numbers of people are reaching advanced stages of HIV infection. Antiretroviral combination therapy has been demonstrated to reduce morbidity and mortality among those infected with HIV. Efforts have been made to make ART more affordable especially in less developed nations. This section assesses progress in providing antiretroviral combina- tion therapy to everyone.
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 34 The Ministry of Health working with partners has scaled up and decentralized HIV care services over the past 5 years. The Lubombo region has been getting support from ICAP; However, ICAP is leaving the region in June/July 2014 and will be replaced by URC. There are 32 ART initiation sites in the region; with 9749 new ART initiations since 2011.
NEW ART INITIATIONS TREND FROM 2011 TO 2015
4000 3829
3500 3570
3000 2753 2731 2603 2500 2455 2336 2468 2000 1662 1500 1514 Number of patients Number 1000
500 298 267 263 148 259 0 2011 2012 2013 2014 2015 Years
Children (0-14 yrs) Adults (15+ yrs) Total
Figure 31: New ART initiations trend, 2011-2015
The table above shows the number of new ART initiations for Children 0 to 14 years and adults aged 15 and above. The number of new ART initiations for both the population 0-14 years and the population aged 15 years and above has increased significantly from 2014 to 2015. The number of new ART initiations for the population 0-14 years has been decreasing from 2011 to2014 and then significantly increased in 2015. On the contrary new initiation for the population 15 and above has been fluctuating over the years, reaching its highest in 2015. The total number of new initiations also fluctuated from 2011to 2015.
CURRENTLY ON ART TREND FROM 2011 TO 2015 30000 27891
25000 25913 22768
20000 21020 17405 15639 15000 13446 15734 14049 11956 10000 Number of patients Number 5000 1490 1590 1671 1748 1978 0 2011 2012 2013 2014 2015 Years Children (0-14 yrs) Adults (15+ yrs) Total
Figure 32: Number of HIV+ clients currently on ART, 2011-2015
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 35 The graph above depicts the number of clients that are currently on ART. The number of clients that are currently on ART has been increasing over the 5 year trend. The number of clients on ART increased the most from 2013 to 2014 for the population 15 and above and increased the most from 2014 to 2015 for the population 0 to 14.
CUMULATIVE NUMBER OF PEOPLE ON ART INITIATED FROM 2011 TO 2015
40000 36,429 35000 34,368 33,739 30000 31,802
25000 23,543 21,463 20000 18,401 19,263 21,227 15000 16,408 Number of patients Number 10000
5000 1,993 2,200 2,316 2,566 2,690
0 2011 2012 2013 2014 2015 Years
Children (0-14 yrs) Adults (15+ yrs) Total
Figure 33: Cumulative number of people on ART, 2011-2015
The table above illustrates the number of clients cumulative on ART. In 2011, they were 18 401 clients cumulative on ART, in 2015, cumulative clients on ART were 36429. The total number of clients cumulative on ART increased the most from 2013 to 2014.
Table 9: ART Retention, 2009-2015
Cohort 6 months 12 months 24 months 36 months 48 months 60 months
<15 15+ <15 15+ <15 15+ <15 15+ <15 15+ <15 15+ Age Yrs Yrs Yrs Yrs Yrs Yrs Yrs Yrs Yrs Yrs Yrs Yrs
2009 92% 88% 88% 84% 84% 81% 83% 76% 80% 75% 78% 73%
2010 90% 90% 86% 87% 84% 82% 82% 79% 80% 77% 78% 76%
2011 93% 93% 89% 90% 84% 84% 81% 82% 80% 81%
2012 93% 93% 90% 91% 88% 88% 86% 86%
2013 96% 95% 94% 94% 90% 91%
2014 97% 98% 96% 96%
2015 99% 98%
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 36 4.6.5 TUBERCULOSIS (TB)
The chart below shows TB case notification for the year 2015 whereby the region registered 782 patients, 355 (45%) of them were bacteriologically confirmed new TB cases, 140 (18%) of them were retreatment cases and the new cases make a total of 642. The high rate of retreatment cases brings the possibility of the region having an increased number of DR-TB cases. The rate of clinically diagnosed without sputum examination is at 11% which is above the target of less than 5%, hence some interventions have to be put in place to decrease this rate.
TB CASE NOTIFICATION IN THE LUBOMBO REGION FOR 2015
Other previously treated 10%
Extra Pulmonary TB 14%
Treatment after failure 0%
Treatment after default 0%
Relapses 7%
Clinically diagnosed (Sputum not done) 11%
Clinically diagnosed (MTB-) 12%
Bacteriologically confirmed (MTB+) 45%
Case Notification - All cases
0 100 200 300 400 500 600 700 800 900
Number of TB cases
Figure 34: TB case notification, 2015
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 37 IMPLEMENTATION OF TB/HIV ACTIVITIES TREND FROM 2013 TO 2015
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0 2013 2014 2015
Total # of Registered TB cases 1,236 961 842 # Tested for HIV 1,180 940 825 HTC Uptake % 95% 98% 98% # Tested HIV positive 860 645 576 Positivity rate % 73% 69% 70% # Initiated on CPT 837 631 567
CPT Uptake % 97% 98% 98% # Initiated on ART 646 514 523 ART Uptake % 75% 80% 98%
Figure 35: TB/HIV Cascade, 2013-2015
The above graph shows the implementation of TB/HIV activities in the region. The entry point starts at testing patients who are diagnosed with TB. The number of registered cases here is not the same as those registered as indicated in the case notification chart because of the new reporting system that was introduced in the first quarter of 2015 by the TB Program whereby TB/HIV activities were reported for previous quarters. The HTC uptake accord- ing to the graph above has risen from 95% in 2013 to 98% in 2015, although the target is 100%. The positivity rate has dropped from 73% in 2013 to 70% in 2015. CPT uptake has improved by a percentage, 97% to 98% between 2013 and 2015. The target for CPT uptake is 100% since all patients who are co-infected are expected to receive this prophylaxis or at least dapsone if they are allergic to the latter one. Also all co-infected patients are to be initiated on ART but the region has not met the target in 2015 as 91% were initiated although there was an improvement from the previous years as it was at 75% and 80% in 2013 to 2014 respectively.
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 38 IMPLEMENTATION OF TB/HIV ACTIVITIES AMONGST PEADIATRICS FROM 2013 TO 2015
100% 90% 80% 70% 60% 50% 40% 30%
Proportion of patients 20% 10% 0 2013 2014 2015
Total # of Registered TB cases 173 92 59 # Tested for HIV 154 89 56 HTC Uptake % 89% 97% 95% # Tested HIV positive 70 39 27 Positivity rate % 45% 44% 48% # Initiated on CPT 67 38 27
CPT Uptake % 96% 97% 100% # Initiated on ART 50 33 24 ART Uptake % 71% 85% 89%
Figure 36: TB/HIV Cascade amongst peadiatrics, 2013-2015
The above graph shows the implementation of TB/HIV activities amongst paediatrics in the region. The HTC uptake according to the graph above has risen from 89% in 2013 to 95% in 2015, although the target is 100%. The positivity rate has increased from 45% in 2013 to 48% in 2015. CPT uptake has improved from 96% to 100% between 2013 and 2015 reaching its target. All TB/HIV co-infected patients are to be initiated on ART but the region has not met the target in 2015 as 89% were initiated although there was an improvement from the previous years as it was at 71% and 85% in 2013 to 2014 respectively.
COMPARISON OF SPUTUM SMEAR CONVERSION RATES BETWEEN NEW & RETREATMENT TB CASES AT 2/3 MONTHS 500 100% 471 400 426 78% 80% 65% 66% 77% l e 384 p
o 300 54% 60% e 313 295 p
279 f
o 52%
r 200 40% e b
m 100 u 20% 52 N 54 28 67 35 19 0 0% 2013 2014 2015
Bacteriologically confirmed TB cases (New) Bacteriologically confirmed TB cases (New) Bacteriologically confirmed TB cases (Retreatment) Bacteriologically confirmed TB cases (New) Not converted rate % (New) Not converted rate % (Retreatment)
Figure 37: Sputum smear conversion between new & retreatment cases at 2/3 months, 2015
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 39 The chart above shows the conversion rates between new and retreatment TB cases that were bacteriologically confirmed at diagnosis in 2015. The results show that the conversion rate is slightly higher amongst retreatment cases as compared to the new cases. It is very important to have all patients done the follow up smear at 2/3 months so as to see if the medication is helping them and to be able to find DR-TB suspects to take the necessary actions. Other factors that may have affected the conversion rate are those who were not done the follow up smears, died patients, those who did not convert as well as those who transferred out of facilities and their smears not followed up by the time the reports were compiled.
COMPARISON OF FAILURES TO CONVERT BETWEEN NEW & RETREATMENT TB CASES FROM 2013 TO 2015
500 471 11% 12% 426 10% 400 9% 384 l e
p 8% o 300 7% e p
6%
f 5% 6% o
r 200 4% e 4% b
m 100 u 54 67 2% N 43 35 3 22 4 17 5 0 0% 2013 2014 2015
Bacteriologically confirmed TB cases (New) Bacteriologically confirmed TB cases (New) Bacteriologically confirmed TB cases (Retreatment) Bacteriologically confirmed TB cases (New) Not converted rate % (New) Not converted rate % (Retreatment)
Figure 38: Failures to convert comparison between new & retreatment cases at 2/3 months, 2015
Figure above shows that there has been a decline in the failures to convert at 2/3 months between 2013 and 2015 for both new and retreatment TB cases. Even though for retreatment cases the trend is up and down showing 6% in 2013 then rising to 11% in 2014 and going down to 7% in 2015. On the other hand the conversion rate for new cases, the data shows that there has been a constant decline form 9% in 2013 to 4% in 2015. These cases who did not convert at 2/3 months are therefore DR-TB suspects.
Table 10: TB treatment outcomes, 2013-2015
Treatment Outcomes Treatment Outcomes HIV + 2013 2014 2015 2013 2014 2015 All registered TB cases 1340 1243 939 984 885 639 Cured 216 273 299 (32%) 147 193 201 (31%) Completed 676 600 438 (47%) 497 408 298 (47%) Treatment success rate 67% 70% 78% 65% 68% 78% Died 241 177 113 (12%) 202 151 82 (13%) Treatment Failure 41 27 31 (3%) 32 15 20 (3%) Lost-to-follow-up 166 166 58 (6%) 106 118 38 (6%)
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 40 Below is a table showing treatment outcomes for TB patients. The data shows that there is no significant difference between treatment outcomes for all cases and those who are TB/HIV co-infected. The cure rate is low compared to the treatment completed rate. The death rate is high as it is 12% for all cases and 13% for co-infected patients yet the target is less than 5%. The region is affected by cross border patients who come from South Africa and Mozam- bique hence why the lost-to-follow-up rate is at 6%. A total of 31 patients failed treatment in 2015 and 20 of them were TB/HIV co-infected.
4.6.6 MALARIA
Malaria remains a threat to about 286,000 people living in Swaziland’s Lowveld and Lubombo Plateau regions. The goal of Swaziland‘s malaria elimination strategy is to end malaria by 2015 in the country. Only confirmed cases are reported not suspected. In 2014, 499 confirmed cases were reported while 46% of them were locally cases while a larger portion of cases are imported cases in the country. Of the total Malaria cases reported in the country, 45% reported cases are from Lubombo region as shown in the table below.
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 41 CHAPTER 5: REGIONAL ACHIEVEMENTS AND BEST PRACTICES 5.1 DATA
To improve the quality of data, the region conducted Routine Data Quality Assessment (RDQA) and Regional Semi- Annual Health Reviews. According to the regional plan, this activity need to be conducted twice a year. In 2015, the region was able to conduct all the planned activities.
RDQA- This exercise is used to assess the quality of data on selected indicator(s) based on dimensions of data qual- ity: Accuracy, Reliability, Completeness, Timeliness, Availability and Integrity.
ReHSAR is a regional event which usually take two and a half days to review and discuss facility level data. It provide a platform to share program information and new developments. It also harmonize partner support and equip facilities to develop quality improvement projects (QIPs) related to shortfalls observed from their data. Worth noting is that this activity for now it only focus on HIV related data (PMTCT, EID, HTC, ART and TB) but in future data for all services provided at facilities will be shared.
5.2 SUPERVISION
Supportive supervision and mentoring is routinely done in the region. It is done between Monday and Thursday. At most three facilities are visited per day. The supervision team consist of SID team, clinic supervisors, regional men- tors, PMTCT coordinator and EPI focal person. For transportation, the team was supported by EGPAF then URC took over when coming in as the regional clinical PEPFAR partner.
5.3 TRAINING/CAPACITY BUILDING
Table 11: Regional Trainings by type 5.4 COMMUNITY MOBILIZATION Type of trainings Supportive supervision review • Conducted Community Health services in Lonkhuntfu and Leadership and Management Hlane. • In all regional and national events , the region was able to ART and Pre ART provide quality health services (Buganu and Non Communicable Diseases Bemanti) MDR • Community health days were also conducted in different IMAI Chiefdoms in the region. NARTIS • African Vaccination week was also conducted IMCI • Conducted Malaria day in Siphofaneni GBV • Conduct AIDS day in Lomahasha Semi -annual review on maternal and • The region successfully National TB day neonatal mortality • ART school debate in Gucuka was a great success. • Managed to increase outreach sites in the region, 2 Siteki PHU, 3 for Sithobela. • The Tinkhundla integrated health care services is on-going and now more comprehensive. 5.5 ADVOCACY
• Region scored second position two during the culture day and was awarded with a trophy • 89% of health facilities are now initiating ART. • 64% of health facilities are now initiating TB treatment. • The region received 2 vehicles for sample transportation. • Great improvement in TB management… TB success rate was at 76%, conversion rate was at 89%, HTC uptake was at 100%, CPT was at 99%, ART was at 89% and lost to follow up was reduced to 2%. • Implementing NCD pilot project in 10 facilities • Installation of soap and paper towel dispensers in all governmental health facilities to strengthen IPC mea- sures • Two facilities in the region were awarded baby friendly health initiative certificate of accreditation • Received 1 park home for Siteki Public Health Unit. • Managed to increase outreach sites in the region, 2 Siteki PHU, 3 for Sithobela
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 43 CHAPTER 6: CONCLUSIONS & RECOMMENDATIONS 6.1 CONCLUSIONS
The region has been performing fairly well in meeting most the regional objectives. The region had an objective to increase ART uptake amongst all HIV positive pregnant women from 60% to 80% by end of December 2015. The region managed to reach this target and initiated 97% of all pregnant HIV positive women on ART. The region however, did not manage to reach the immunization coverage that it had opted to meet. Immunization coverage for 2015 was 91% as opposed to the 95% that the region had set out to meet.
The third objective was to increase the number of outreach services in the region. This objective was also met, as the region added five (5) more outreaches, two (2) outreaches were added to Siteki PHU, and three (3) outreaches were added to Sithobela. The region also managed to reduce the proportion of HIV exposed infants from 27% to 3% by December 2015.
The report however, was not able to track the outcome of two objective in the region, since they are not measur- able: To improve CD4 documentation from 53% to 80% by the end of December 2015 and to scale up VIA screening in the region.
6.2 RECOMMENDATIONS
• The data source for the report (HMIS) had data issues and needs to be attended to. For data to improve, HMIS must be routinely supported to monitor the core indicators; completeness, timeliness and accuracy. This would reduce the challenges in the data experienced. • SID (HMIS unit) needs to see to it that, a data clerk for inpatient in Sithobela is hired. • Synchronizing two different datasets is time consuming and impossible to analyze for some indicators. Data collection tools need not be changed mid-year, and only changed at the beginning of the year. • The report was not able to capture the number of participants trained and the targets for the trainings. The training register should be used to document all training done. Proper documentation should also be done on the register and a quarterly training report should be written and consist of the following: Type of train- ing, purpose, target and attendance. SID should take a lead in registering trainings. • The is also a need to have cleaned data sets at the beginning of each calendar year to make the report writing activity faster and more efficient.
LUBOMBO HEALTH PERFORMANCE REPORT, 2015 Page 45