ANNUAL ANALYTICAL REPORT for the FY 1St July 2014-30Th June 2015

Home , Kisoro, Mutolere, Mutolere Hospital

ST. FRANCIS HOSPITAL MUTOLERE

ANNUAL ANALYTICAL REPORT FOR THE FY 1st July 2014-30th June 2015.

KEEP THE CANDLE BURNING AND PASS ON THE LIGHT

Written by: Dr. Mugisha Jerome

Medical Director/CEO.

ENDORSEMENT OF REPORT

This annual analytical report for St. Francis Hospital - Mutolere covering the FY 1st July 2014-30th June 2015 has been prepared by the management of the Hospital. I endorse that it represents management’s views on the position of the hospital in the period under report.

………………………………………………….

Dr. Mugisha Jerome

Chief Executive Officer

St. Francis Hospital - Mutolere

Date…………………………………..

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

Mutolere covering the FY 2014/2015. I have read it and endorse its authenticity and the representativeness of the position of the hospital in the year under report

……………………………………………………..

Rev. Fr. Zeno Mbishinzimana

Chairperson of the Board of Governors

St. Francis Hospital –Mutolere

Date…………………………………………

LIST OF ACRONYMS

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

iii

ACKNOWLEDGEMENT I would like to acknowledge and recognize the contributions of the following individuals for the support rendered in the compilation of this 2014/2015 Annual Analytic Report. Mr. Pontius Mayunga (the Hospital Administrator), Mrs. Immaculate Asiimwe (The Human Resource Officer), Sr. Inviolate Baganizi (The Principal, Nurses’ &Midwifery Training School), Sr. Beatrice Kefuruka (The Senior Nursing Officer), Ms. Katto Justine (Co-ordinator Public Health Program), Mr. Tuyikunde Peter (Hospital accountant), Mr. Paschal Nsekuye (head OPD) and Ms. Winnie Nyiramugisha (responsible for palliative care services) and all ward/departmental in-charges for the various technical and moral support provided during and in the process of compiling this report.

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

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

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

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

…………………………………..

Dr. Jerome Mugisha

TABLE OF CONTENTS

1. Endorsement of report…………………………………………………………………………...... ii 2. List of acronyms……………………………………………………………………………………...... iii 3. Acknowledgement…………………………………………………………………………………………………. iv 4. List of tables………………………………………………………………………………………………………….. vi 5. List of figures……………………………………………………………………………………………………………viii 6. Important indicators and definitions…………………………………………………………………….. ix 7. Executive summary………………………………………………………………………………………………….xi 8. Chapter 1: Introduction…………………………………………………………………………………………..1 9. Chapter 2: The health policy and district health services………………………………………..5 10. Chapter 3: Governance and management……………………………………………………………….18 11. Chapter 4: Human resources for health…………………………………………………………………..23 12. Chapter 5: Finances…………………………………………………………………………………………………27 13. Chapter 6: Hospital activities……………………………………………………………………………………41 14. Chapter 7: Hospital support services……………………………………………………………………….65 15. Chapter 8: Quality and patient safety improvement……………………………………………...70 16. Chapter 9: Mutolere vegetable gardens project………………………………………………………73 17. Chapter 10: The nurse training school……………………………………………………………………..78

18. Chapter 11: Hospital projects…………………………………………………………………………………..82

List of Tables

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

Table 2: MCHC activity indicators at Mutolere hospital compared to HSD, district and country FY 2014/15.

Table 3: Data of HCT coverage for the year 2014-2015

Table 4: Detailed MC H activities for the FY 2014/15:

Table 5: Table indicating Number of OVC supported.

Table 6: Table indicating performance in CCMB activities for the year 2014- 2015.

Table 7: Hospital compliance with statutory requirements

Table 8: Disaggregated staff data FY 2014/15

Table 9: Hospital Budget against actual income for FY 2014-2015

Table 10: Trend of hospital Income over the last 5 years

Table 11: Hospital expenditure for FY 2014/15 compared with the previous year.

Table 12: Hospital expenditure categories over 5 years

Table 13: Average User Fee per SUO Op Comparisons from 20109/10 FY through to 2014/15 FY

Table 14: Average Expenditure per SUO Op Comparison from 2010/11 through to 2014/15

Table 15: Hospital liquidity

Table 16: Utilization of the OPD for the last 5 years.

Table 17: Mutolere hospital OPD diagnoses FY 2014/15

Table 18: Current palliative care staffing Mutolere hospital

Table 19: Palliative care cases attended to in FY 2014/15

Table 20: Ophthalmology cases for the year

Table 21: HIV/AIDS counseling and testing activities FY 2014/15.

Table 22: IPD utilization for the year 2014/15

Table 23: Morbidity patterns 2014/15

Table 24: Mortality patterns for FY 2014/15.

Table 25: Admissions and deaths per cause FY 2014/15 Table 26: Fast moving items at Mutolere hospital FY 2014/15

Table 27: Expiries for FY 2014/15

Table 28: X-ray report 1st July 2014 – 30th June 2015

Table 29: Laboratory activity report in table form (FY 2014/15).

Table 30: Quality indicators for the period for 2014/15 with comparisons for two previous years and projections for 2015/16.

Table 31: Hospital gardens project results by objectives for FY 2014/15

Table 32: Enrollment and Performance of Mutolere school of Nursing and Midwifery

vii

List of Figures

Fig 1: Graph showing the trend of attrition of Clinical Staff for the last five years.

Fig 2: Reasons for attrition of clinical staff

Fig 3: Graph showing an analysis of the employment cost of the total recurrent costs for the past five years.

Fig 4: Proportionate contribution of income sources to the hospital in FY 2014-2015

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

Fig 6: Proportionate contribution of PHC conditional grant to total hospital income in 5 years

Fig 7: User fees plus PHC CG per SUOop and total recurrent costs per SUOop compared over a 5 yr period

Fig 8: Contribution of different expenditure lines to total hospital expenditure

Fig 9: Employment costs and costs of medical goods and services as % of total hospital costs

Fig 10: OPD trends in the last 5 years

viii

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

2. Average Length of stay (ALOS)

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

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

3. Bed Occupancy Rate expressed as %

= used bed days/available bed days

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

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

4. Throughput

=Average number of patients utilizing one bed in a year

=Number of patients/no. of beds

5. Turn over interval

=Number of days between patients

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

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

7. Post C/S Infection Rate:

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

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

8. Recovery Rate:

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

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

9. Maternal Mortality Rate (for the hospital):

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

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

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

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

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

EXECUTIVE SUMMARY

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

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

In the year under report, we saw an increase in SUOop from 153546 to 161890 and a further increase in SUOop to 169618 is expected in FY 2015/16. The bed occupancy rate also increased from 64% in 2013/14 to 66% in 2014/15 and is projected to remain on a positive trend, rising to 76% in 2015/16.

Economic (total cost per SUOop) and technical (SUOop per staff) efficiency showed a downward trend for the third year running but a reversal is expected in FY 2015/16. The hospital continues to rely heavily on user fees to finance its activities. The other source of income, the PHC CG, is on gradual decline in real terms for the 10th year running and currently contributes about 15% of the total income.

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

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

In the year to come 2015/16, the hospital will consolidate its gains, while continuing advocacy and lobby of major stakeholders to improve its ability to attract support necessary for offering quality services efficiently. Further, the hospital will emphasize high efficiency and frugality to reduce/contain the high costs of offering services that are threatening its long term survival.

CHAPTER ONE INTRODUCTION

The Hospital and its environment

History of the hospital St. Francis hospital Mutolere, a 210 bed capacity hospital, was established in 1957 by the Franciscan Sisters of Breda (The Netherlands) as a church based voluntary health agency under the Catholic Diocese of Kabale. The hospital was run by the founding congregation of the sisters until 1994 when its ownership was handed over to the Board of Trustees of Kabale Diocese.

At the time it was founded, Kisoro was a county of the then Kigezi district. It is thus commendable that Dr. Bruno Rochus, a German, dedicated his life to the service of Bafumbira for nine years after a stint in the Second World War. By then, there was no telephone access. The roads were hardly passable. Thus his decision to come and serve the people of Kisoro, a place that is an exact opposite of his own birthplace, should forever be appreciated. He was later to be followed by Drs. Ruppen, Moll, Boot, Ndagijimana, Neijzen, Houghton, Eishhorn, Rodermond and Kamuzinzi in a period of two decades.

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

The Hospital is currently governed by a Board of Governors (BOG) appointed by the Chairperson of the Registered Trustees of Kabale Diocese, the Bishop of the Diocese, currently, the Right Reverend Bishop Callist Rubaramira. The Hospital is run on a day-to-day basis by a management team appointed as outlined in the Hospital Charter. The Hospital is comprised of five (5) primary departments: Medical, Nursing, Administration, Training and Community Health. The latter has for long served as the headquarters of Bufumbira East health sub-district until this mandate was withdrawn by the district under circumstances that are poorly understood. The medical section in turn consists of the medical wards (male and female), male surgical ward, female surgical ward, pediatric ward, maternity ward, gynecological ward with their support departments: X-ray, laboratory and Pharmacy.

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

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

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

The proximity of the hospital to two countries with recent history of political instability means the hospital occasionally receives casualties of civil wars and sometimes refugees seeking medical care. The latter are not able to pay medical bills and this has led to self- discharges and defaults on payments.

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

THE COMMUNITY AND HEALTH STATUS: The population of Kisoro district is mainly Bafumbira and their local language is Rufumbira. Although this is spoken by majority of the people, those from the northern part of the district tend to speak Rukiga just like those in the neighboring Kabale, Rukungiri and Kanungu districts. English, the Uganda official language, is spoken by those with formal education. The main food crops are beans, Irish potatoes, cabbage, maize, sorghum, tomatoes and sweet potatoes. Some few animals like cattle, goats, sheep, poultry, and pigs are kept. The entry of the NAADS program in the district is a step towards modernizing agriculture, a government ambitious long term program to ensure transformation from peasantry to commercial farming as an impetus for poverty eradication. Cash crops like coffee and tobacco are grown on a very small scale. There are two FM radio stations in our catchment area and the district as a whole. This is useful for relaying messages for example during the child days and other health campaigns.

Malaria has been the leading cause of admission among children and adults, though there is an increasing burden of trauma, respiratory tract infections and non communicable diseases. Although we are trying our best to improve maternal and child health services in the sub district and district as a whole, the difficult terrain and cultural factors remain a major hindrance. Pregnant mothers have to move long distances for pre-natal care. They have difficulties reaching the hospital to get skilled attendance at the time of delivery. More recently it has been observed that even those who are admitted waiting for labor don’t report the onset of labor for fear of possible interventions. This is premised on the belief that birth is a natural process that must be braved by a true African woman. Culturally, children are highly revered to the extent that the average woman here will produce more children than the national average of 6.9 children per woman. They detest caesarean delivery for it is believed to reduce the chances of producing more children. A number of women attempt herbal remedies before they can go to hospital for delivery.

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

POPULATION GROUP FORMULAE Catchment HSD District Area

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

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

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

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

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

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

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

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

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

PMTCT mothers tested 4781 14316

Mothers tested HIV 48 279

positive

CHAPTER TWO: HEALTH POLICY AND DISTRICT HEALTH SERVICES

Health Policy Mutolere Hospital has been offering care in line with the National Health Policy I (NHP I) (2000-2010) in its work implementation, and for the FY 2014/2015, it re-aligned its health care delivery to the NHP II to fit in the National health goals. The hospital also follows Health Sector Strategic and Investment Plan 2010/11 – 2014/15 as the guiding framework for delivery of health services.

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

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

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

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

The hospital has aligned its services to the Health Sector Strategic and Investment Plan (HSSIP) 2010/11—2014/15 which builds upon the previous two HSSPs. This HSSIP provides the medium term strategic framework, and focus that the Government intends to pursue in regard to attaining the health

goals for the country. It is anchored on the NHP II, the National Development Plan and the Public Investment Plan, aimed at achieving the overall goals and deliverables of the country.

District Health Services

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

The public private partnership at district level is however still weak, but in Kisoro, being that there is one PNFP general hospital, and two lower level PNFP health units (Rutaka and Kinanira HCIIIs), this partnership should pick up to leverage on the resources of the sector for better service delivery.

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

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

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

The hospital hopes to continue to strengthen the relationship with District health services based on existing national and local policy. The second National Health Policy II (2010/11-2019/20) which is intended to guide the health sector for the next 10 years with a theme; “Promoting people’s health to enhance socio-economic development” will be a critical guide to strategic development of the hospital and its constituent departments. 6

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

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

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

PREVENTION AND HEALTH PROMOTION SERVICES

THE PUBLIC HEALTH PROGRAM

Public health department

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

• Planning activities e.g. meetings

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

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

The activities performed by the Public health program in the year under report include the following: • Social mobilization and Health Education both at the static unit and outreaches • Maternal Child Health (MCH) services and Prevention of Mother to Child Transmission of HIV (PMTCT),

• Early Infant Diagnosis (EID) and follow up of Exposed infants • HIV Prevention services including HIV counseling and testing • Antiretroviral therapy, • Treatment for Opportunistic infections • Care and Support to people living with HIV/AIDS (PLWHAs) • Combating Child mortality among Batwa in Kisoro District (CCMB) and • Support to Orphans and Vulnerable Children (OVC).

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

1. MCH AND PMTCT SERVICES AT MUTOLERE HOSPITAL

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

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

Below is a table indicating the hospital performance in MCH services for the year 2014/2015

Table 2: MCHC activity indicators at Mutolere hospital compared to HSD, district and country, FY 2014/15.

Hosp. Hospital Attenda In the In the In the attendance nce

hospital HSD district output as % of output HSD as % of district

Total immunization doses

BCG 2112 3450 10290 61.2% 20.5%

DPT+Hep+Hib3 872 3348 9714 26% 9%

Measles vaccine 760 3814 11443 20% 6.6%

Total family planning attendances

New acceptors for f/p 527 1790 5075 29.4% 10.4%

Re-attend for family planning 1069 4021 14855 27% 7.2%

Total new ANC attendances 1929 8174 16347 24% 12%

Child days (mass Deworming +Vit. A supplementation)

Deworming October 2014 7644 42712 81208 17.9% 9.4%

October 2014 Vitamin A 2491 16088 49767 15.5% 5%

April 2015 Deworming 6679 47882 155251 14% 4.3%

April 2015 Vitamin A 1294 17745 56553 7.3% 2.3%

PMTCT no. Mothers tested 1885 4781 14316 39.4% 13.2%

No. of Mothers tested HIV positive 21 48 279 44% 7.5%

Challenges in providing MCHC services -Few staffs are trained in PMTCT while those who were trained left the hospital.

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

2. HCT services

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

Table 3: Data of HCT coverage for the year 2014-2015

No of individuals No of individual No of Individual No of individual No of Individuals Total 0- <2 yrs 2 - <5 yrs 5- <15 yrs 15 – 49 yrs >49 yrs Category M F M F M F M F M F

Number of Individuals counseled 50 39 1416 1416 172 207 3345

Number of Individuals tested 15 17 29 27 50 39 1461 1416 172 207 3433

Number of Individuals who received HIV test results 15 17 29 27 50 39 1461 1416 172 207 3433

Number of Individuals who tested HIV positive 15 17 29 27 50 39 1175 1287 166 199 3006

H IV positive individuals with suspected TB 00 00 01 00 01 00 39 27 03 03 72

HIV positive cases started on Cotrimoxazole 00 00 00 00 00 00 05 00 00 00 05 preventive therapy (CPT)

Number of Individuals tested twice or more in the 00 00 01 00 01 00 33 21 02 02 60 last 12 months (re- testers)

Counseled and tested together as couple 137

Counseled and received results together as couple 137

Concordant positive couple 01

Discordant couples 00

Individuals counseled and tested for PEP 00

Safe male Circumcision 02 02 19 436 02 461

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

Table 4: Detailed MC H activities for the FY 2014/15:

6.2.1 ANTENATAL Number 6.2.5 FAMILY PLANNING METHODS NEW USERS REVISITS A1-ANC 1st Visit 1901 F1-0ral : Lo-Femenal A2-ANC 4fu Visit 847 F2-0ral: Microgynon 11 09 A3- Total ANC visits new clients + Re-attendances 5402 F3-0ral: Ovrette or another POP 01 M-ANC Referrals to unit 231 F4-0ral: Others 08

A5-ANC Referrals from unit 00 F5-Female'condoms 145 piece A6-First dose IPT IPT1 1633 F6-Male condoms 03 A7-Second dose IPT (lPT2) 1022 F7-IUDs 413 894 A8-Pregnant Women receiving Iron/Folic Acid on ANC 1st Visit 1750 F8-lnjectable A9-Pregnant women receiving free ITNs 742 F9-Natural A10-Pregnant women tested for syphilis 1889 F10-Other methods 20 A11-pregnant women tested positive for syphilis 25 Total family planning users A12-pregnant women counseled, test and received HIV test results 1885 A 13-HIV positive pregnant women given cotrimoxazole for F11-Number of HIV positive family planning 21 12 prophylaxis users 25 A15 HIV Positive Pregnant women assessed for ART eligibility 22 A16-pregnant women who knew their HIV status before the 1st ANC F12-Number of first-visit clients (of the year) 316 visit for this month

A 17-pregnant women given SD NVP ARVs for prophylaxis AZT - SD NVP 6.2.6 CONTRACEPTIVES DISPENSED PMTCT) 3TC-AZT-SD NVP No. Dispensed at No. Dispensed by CONTRACEPTIVE A 18-0thers Specify for Unit CORPs regimens covered D1-0ral: Lo-Femenal (Cycles) A 19-Prenant women on ART for their own health 00 02-0ral: Microgynon (Cycles) A20-Male partners tested and received HIV results in PMTCT 467 D3-0ral: Ovrette or another POP (Cycles) 06 cycle 6.2.2 MATERNITY D4-0ral: Others (Cycles) M1-Admissions 2486 D5-Female condoms (Pieces) M2-Referrals to unit 163 D6-Male condoms (Pieces) 145 pieces M3-Referrals from unit 00 D7-IUDs (Pieces) M4-Delivenes in unit 2137 D8-lnjectable (Doses) 1307 doses M5-Delivenes HIV positive in unit 33 D9-Emergency Contraceptives 06 M6-Delivenes HIV positive who swallowed ARVs 33 M7-Live birth in units 2079 M8-live births to HIV positive mothers 33 M9-Birth asphyxia 50 6.2.7 MINOR OPERATIONS IN FAMILY PLANNING NUMBER M10-Babies born with low birth weight «2,5Kgs) OPERATION M11-Babies (born to HIV positive mothers) given ARVs 33 01-Female Sterilisation (Tubal ligation) 69 M12- HIV positive mothers initiating breastfeeding within 1 hour 33 02-Male Sterilisation (Vasectomy) 03 M13-No, mothers tested for HIV 116 03-lmplant new users M14-No, mothers tested HIV positive in maternity 01 04-lmplant revisits 02 M15-Mother given Vitamin A supplementation 1624 05-lmplant removals 06 M16-Fresh Still births in unit 32 M 17 -Macerated still births in unit 18 M18-Newborn deaths (0-7days) 29

M19-Matemal deaths 02 M20-Deliveries with Traditional Birth Attendants TBA 00 6.2.8 CHILD HEALTH 6.2.3 POSTNATAL 6-11 12-59 1-4 5-14 P1-Post Natal Attendances 66 CHILD HEALTH SERVICES Months Months Years Years P2-Number of HIV + mothers followed in PNC 00 M F M F M F M F P3-Vitamin A supplementation 00 C1-VitA supplem 1st Dose in the year 417 370 83 76 P4-Clients with premalignant conditions for breast 00 C2-Vit A supplem 2nd Dose in the year 38 35 41 37 P5-Clients with premalignant conditions for cervix 00 C3-Dewormed 1st dose in the year 165 159 04 10 C4-Dewormed 2nd dose in the year 25 31 10 07 C5-Total Children weighed at measles E1-Exposed infants tested for HIV below 18 months (by 1st PCR) 12 315 319 vaccination E2-Exposed infants testing HIV positive below 18 months 00 C6-Under weight (below -28D line) 14 10 E3-Exposed infants given Septrin for prophylaxis within 2 months after 17 C7-0verweight (above +38D line) birth

TETANUS IMMUNISATION (1T VACCINE) 6.2.11 CHILD IMMUNISATION under 1 Non-pregnant Immunisation 1-4 Years Doses Pregnant women women in School Doses Mal Female Male Female T1-Dose 1 1188 353 01 11-BCG 1076 1042 T2-Dose 2 806 07 03 12-Protection At Birth for TT 03 T3-Dose 3 239 02 01 (PAB) 973 959 T4-Dose 4 148 01 00 13-Polio 0 501 497 T 5-Dose 5 172 01 00 14-Polio 1 436 422 I5-Polio 2 458 427 I6-Polio 3 509 489 17-DPT-HepB+Hib 1 434 431

6.2.10 HPV VACCINATION I8-DPT-HepB+Hib 2 460 429 Vaccination of girls Number 19-DPT-HepB+Hib 3 521 513 HPV1-Dose 1 00 110-PCV1 445 424 HPV2-Dose 2 00 111-PCV2 479 490 HPV3-Dose 3 00 112-PCV 3 113-Rotavirus 1 114-Rotavirus 2 115-Rotavirus 3 11G-Measles 378 359 117-Fuliy immunized by 1 year 378 359 (Protection at birth) 118-DPT -HepB+Hib doses wasted 397

OTHER ACTIVITIES OF PUBLIC HEALTH PROGRAMME INCLUDE;

Health Education. Health education talks were carried out daily at the static unit, during outreaches and to some organized groups such as the Ngobyi groups

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

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

Nutrition education and Cooking Demonstrations

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

Support to people living with HIV/ADS.

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

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

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

Training OVCs in sustainable Agriculture.

The training was sponsored by Together for Uganda.

The purpose of training the OVCs was to provide them with skills which would enable them earn some income through using low cost technology. We also aimed at improving the health of children through good nutrition. Thirty three (33) OVCs from upper Primary and Secondary schools were trained for a period of one month / 4 weeks.

During the training OVCs got exposed to the following;

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

Challenge

Most of the OVCs do not have startup capital; some do not even have where to practice the acquired skill from.

Future plans;

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

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

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

Table 5: Table indicating Number of OVC supported.

Activity Number supported

Number Support in Primary schools 124

Number supported in Secondary schools 53

Number supported in tertiary institutions 11

Number trained in sustainable agriculture 60

Challenges

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

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

The services provided during outreaches included: Community Mobilization for health services, Health education talks for positive behavior change among the Batwa. Other services included immunization and growth monitoring, Antenatal care, family planning and postnatal care. HIV counseling and testing services plus treatment for common diseases was also offered. Mothers are encouraged to deliver at the health facility. The above services have been offered to 24 Batwa communities who converged in 12 places/outreaches every month to access health services.

Table 6: Below is the table indicating performance in CCMB activities for the year 2014- 2015.

Activity Total Remarks

Total Immunizations 2004 These include all vaccines for batwa and non-batwa

Growth monitoring 2058 Both batwa and non-batwa.

Total number of Batwa children 22 One child died due to severe malnutrition. These were who were under weight rehabilitated from home.

ANC 178 Most of them attended from outreaches

Deliveries at health facilities. 35 were delivered by C/S

Family Planning 26 Were all batwa 27 were new acceptors, 21 were re- attendencies.

Total number of Batwa treated at the 248 . hospital as out patients (OPD)

Total number of Batwa admitted 108

Total number of patients treated at 3436 These included batwa and non-batwa. outreaches.

HIV Counseling and Testing 305 254 – Females

50 males

1 male tested HIV positive.

Challenges in providing CCMB activities • Most of the Batwa are landless and very poor, this hinders positive behaviour change. • We got many Batwa coming in the hospital with injuries due to fighting or as a result of falling down after excessive alcohol consumption 16

• The funding for the CCMB project is soon ending and we are worried we may not get more funding to continue the activities. Achievements:

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

All activities were integrated.

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

Appreciation.

We appreciate the support from:

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

-PHC funds through Kisoro District LG.

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

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

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

-SUSTAIN FOR LIFE that supported outreaches to Batwa communities

CHAPTER THREE:

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

THE BOARD OF GOVERNORS:

This is the overall policy making body for the hospital. Policies are made in accordance with guidelines/standards from UCMB as well as the MOH. The Bishop, in consultation with the hospital management team appoints them. They meet twice in a year (in May to, among other things analyze budget performance and forecast the revenue and expenditure for the coming year; and then in December to, among other issues receive report on performance towards indicators of faithfulness to the Mission). The BOG is assisted by committees to carry out its functions. The committees include:

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

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

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

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

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

In terms of compliance with the UCMB requirements, the hospital has endeavored to meet the requirements for accreditation for the year 2014/15. The statutory requirements for UCMB affiliated hospitals are tabulated below:

Table 7: Hospital compliance with statutory requirements

No REQUIREMENT Did you Comment achieve it?

Yes, Partly, No

Government / MOH Requirements

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

2 NSSF YES Always paid on time

3 Local service tax YES

4 Annual operational licence YES Processed through UCMB

5 Practicing licence for staff

7 Monthly HMIS YES Given on time

UCMB statutory requirement

1 Analytical Report end of FY year YES

2 External Audit end of FY year YES

3 Charter (still valid)* YES

5 Contribution to UCMB for the year YES

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

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

8 Manual of Employment (still valid) YES

9 Manual of Financial Management (still YES valid)

10 Report on Undertakings and Actions of YES the year

*GOU statutory requirements are a must not for accreditation but ensuring the hospital operates in a regulated legal framework. There is another GOU statutory requirement that is yet to be complied with: attaining a license to operate radiation equipment.

For the year under report, the schedule of meetings and main agenda items is tabulated below:

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

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

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

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

BoG policy decisions and recommendations are communicated to HMT in HMT meetings that immediately follow the Board meeting by either the M/S or the Hospital Administrator, where as well, implementation strategies are laid out. The decisions and/or recommendations from BoG are communicated to the staff through written notices to departmental notice boards and the staff conference. For day-to-day information dissemination from HMT to staff is through departmental written notices, and intra-departmental communication is through unit in-charges in liaison with respective heads of departments. External (outside the hospital) communication for information or communication is through the Medical Superintendent or a specific approved designate. The storage and access to important hospital information is rather lax, and would easily land in wrong hands.

Recommendations, Action Plans for FY 2015/2016 for Management The HMT will endeavor to sustain the good practices (such as regular HMT meetings, and timely submission of reports for accreditation) for the year ended, and improve on the shortfalls for the past year, the hospital now employs a person responsible for information, communication and marketing who, though attached to the public health program, assists the main hospital; we intend to develop some guidelines such as the Information, Communication and Data Management guidelines which are not in existent and other related documents as well as development of other Policy documents such as the Volunteers’ policy, donations policy and trainees’ policy etc. for review and consideration by the BoG.

Advocacy, Lobby and Negotiation

For the year under review, FY 2014/2015 the hospital continued, albeit with challenges, to implement activities under the strategic plan, 2012 - 2016.

Advocacy activities are conducted at every opportunity as it arises with church leaders, politicians— particularly the District council members, and members of parliament and technical staff from the relevant ministries. A good opportunity for advocacy was the first diocesean health assembly where the Chief Executive officer represented the hospital and informed the delegates, who included the state minister for health as the guest of honor, the enormous challenges the hospital faces to carry out its activities that complement the government’s efforts to fight disease. It is also because of the continued advocacy that the road from Kisoro town to the hospital and the hospital walkways have been paved to bitumen standards.

Above: Paved roads within the hospital. Support by KDLG.

CHAPTER 4: HUMAN RESOURCES FOR HEALTH

Status of Human Resources

The total workforce as at 30th June 2015 was 176 as compared to 175 as at 30th June 2014. There were staff arrivals during the year under report but these were mainly to replace those who had left hospital service, which shows a resultant of one extra staff as compared to the previous year.

Table 8: The disaggregated staff data:

June 2014 June 2015

Clinical Staff 95 88

Non Clinical staff 60 67

Training school staff 20 21

Total 175 176

As shown from the table above, of the 176 staff for the year under report, 50%were employed to offer clinical services, then 38% to provide non clinical support services like administrative work, cleaning and security services, and 11.9% for the training school. It is however still a big challenge to the hospital given the fact that our staff most especially the clinical staff keep leaving for government jobs and better job opportunities as it is shown in the analysis below.

The analysis considers clinical staff, and these include: Doctors, Clinical officers, Allied health professional staff, Registered Nurses and Midwives, Enrolled Nurses, Enrolled comprehensive nurses and Enrolled midwives and Nursing Assistants.

Fig 1: Graph showing the trend of attrition of Clinical Staff for the last five years.

60% Trend of attrition for Clinical staff from 2011-2015 56% 50% 51% 50% 44% 40% 41%

30%

20%

10%

0% 2010/11 2011/12 2012/13 2013/14 2014/15

The graph above shows the clinical staff attrition for the past five years. Over these years, enrolled comprehensive nurses have had the highest attrition rate followed by enrolled Nurses. A big number of them go for government jobs and others go for further studies, as it is shown in the graph below.

Fig 2: Reasons for attrition of clinical staff

Out of the 20 clinical staff who left 50% of them were recruited by the local government, followed by 20% who went for further training and then 10% left for better pay in other organizations.

Efforts have been made to motivate our employees but this still remains a big challenge to the hospital because of limited resources to be able to offer equal remuneration to the government staff, and also provide desirable accommodation to the staff. For those posts that imply a entitlement to accommodation in the hospital premises, the staffs have free water and electricity. The hospital Management Team is very grateful to our donors; the Friends of Uganda (The family of Dr Vierhout), who have helped in the construction of 6 units, now accommodating 6 of our senior staff.

All the employees of the hospital receive a monthly pay for the services offered. The hospital adopts a salary structure almost similar to that used in civil service, to facilitate the ratings of each post and its assignment to a specific schedule, scale and given a point in scale. The hospital also makes 10% contribution to NSSF while the employer contributes 5% and this money is meant to assist the employees at the time of retirement.

Analysis of the Employment Cost

Over the years considered, that is from July 2010- June 2015, the employment cost has continuously been the highest source of expenditure in the hospital.

Fig 3: Graph showing an analysis of the employment cost of the total recurrent costs for the past five years.

Analysis of entire employment cost as a %age of total recurrent cost from 2015-2010 70.0 60.9% 60.0 53.0% 50.8% 51.2% 48.8% 50.0

40.0

30.0

20.0

10.0

- 2014/15 2013/14 2012/13 2011/12 2010/11

Employment costs Board costs Administration costs Property costs Transport & plant costs Supplies & services Medical goods & services Other expenditures

The above graph clearly shows efforts made to motivate the employees inorder to maintain staff retention over years. The employment costs is much bigger than other costs of the hospital.

Studies are underway to see the financial impact of other motivation strategies like free water and electricity for accomodated staff.

CHAPTER FIVE:

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

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

Table 9: A table showing Hospital Budget against actual income for FY 2014-2015

% ge Annual Actual Income Budgeted Income Actual Income FY Income of the Income Line FY 2013-2014 FY 2014-2015 2014-2015 budgeted

User Fees 952,498,810 1,183,001,000 1,158,337,700 98

PHC CG(Hospital) 282,644,108 287,756,400 287,746,352 100

Donations 93,003,696 137,001,000 130,871,476 96

Other Incomes 335,863,951 225,410,369 189,987,813 84

TOTAL INCOME 1,664,010,565 1,833,168,769 1,766,943,341 96

The overall financial performance in terms of income was 96%. The hospital received 98% of the budgeted user fees and 100% of the budgeted PHC CG. User fees continues to form the bulk of the hospital income, a sign of inevitable fall in equity as a result of stagnating government support in form of PHC CG over the last couple of years. This is in spite of increasing cost of rendering health care.

Figure 4: PROPORTIONATE CONTRIBUTION OF INCOME SOURCES TO THE HOSPITAL IN FY 2014-2015

User fees accounted for 66% of the total income of the hospital. There has been an increase compared to last year, when user fees accounted for 57% of the total income. With the increasing cost of doing business occasioned by rising costs of medicines, employment costs, costs of utilities among others, the hospital has, over the years continuously raised user fees since government subsidies have stagnated in absolute terms (thus declining in real terms). The table below gives the picture over a 5 year period.

Table 10: Trend of Income over the last 5 years

Description 2010-11 2011-12 2012-13 2013-14 2014-15

User Fees 917,158,414 762,887,960 916,804,540 952,498,810 1,158,337,700

PHC CG (Hospital) 262,253,305 269,021,893 284,815,815 282,644,108 287,746,352

External Donation 190,478,000 20,000,000 237,980,850 93,003,696 130,871,476

Credit Line Both

(Drugs & lab 74,215,322 - 37,673,525 Supplies) - -

Other Income 88,418,388 53,550,429 224,908,485 335,863,951 189,987,813

Total Income 1,532,523,429 1,143,133,807 1,664,509,690 1,664,010,565 1,766,943,341

From the table, it is evident that the hospital has continuously attempted to raise more money in form of patient fees and this explains the gradual increase over the years and the higher proportionate contribution as compared to other income sources over a 5 year period. Figure 5: Proportionate contribution of User fees to total income in 5 years

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

Figure 6: Proportionate contribution of PHC conditional grant to total hospital income in 5 years

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

Over the years, the gap between the main sources of income combined in comparison to the SUOop (User fees and PHC CG per SUOop) and total hospital recurrent costs per SUOop has continuously widened leaving funding gaps (see figure 7 below).

Such funding gaps are compensated by:

• Donations in kind

 Used equipment

 Donated sundries

 Personnel (expatriates) on short term placements

 Specific project support

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

 Laboratory reagents

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

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

Hospital expenditure.

The budget expenditure performance was according to plan (i.e. 95%).There are no over-spent votes, which is a sign of financial discipline on the side of the management team.

Table 11: Hospital expenditure for FY 2014/15 compared with the previous year.

Expenditure Line

Budgeted %-ge of Actual Expenses FY Actual Expenses Expenditure Line Expenses FY Budgeted 2013-2014 FY 2014-2015 2014-2015 Expenditure

Employment Costs 885,023,697 965,001,000 945,962,483 98

Hospital Board Cost 6,163,000 7,000,000 6,382,600 91

Administration Costs 62,356,171 84,619,769 64,354,900 76

Property Costs 122,177,159 139,501,000 124,116,838 89

Transport &Plant Costs 43,698,900 41,500,000 24,453,320 59 Supplies & Services 3,447,000 7,800,000 4,283,500 55

Medical Goods & Sundries 99 298,672,855 366,501,000 364,201,712

Capital Development 181,251,814 194,504,000 181,026,106 93

Other Expenditures 52,296,550 26,742,000 20,455,350 76

TOTAL EXPENDITURE 1,655,087,146 1,833,168,769 1,735,236,809 95

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

Fig 8: Contribution of different expenditure lines to total hospital expenditure

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

Fig 9:

Table 12: .Hospital expenditure categories over 5 years

Description 2010-11 2011-12 2012-13 2013-14 2014-15

Employment cost 600,203,775 768,803,577 752,377,168 885,023,697 945,962,483

Medical Goods & 294,316,297 355,953,469 282,199,576 298,672,855 364,201,712 Services

Capital Development 59,949,394 166,355,900 220,903,108 181,251,814 181,026,106

Property costs 100,884,142 110,426,080 125,686,345 122,177,159 124,116,838

Other Expenditure 25,559,464 11,272,100 61,658,900 52,296,550 20,455,350

Administration cost 50,658,438 61,499,440 51,157,873 62,356,171 64,354,900

Transport & Plant Cost 34,509,420 32,860,100 43,944,300 43,698,900 24,453,320

Supplies & Services 4,508,000 3,755,000 6,231,000 3,447,000 4,283,500

Hospital Board Cost 7,310,600 5,676,700 5,282,000 6,163,000 6,382,600

Total 1,177,899,530 1,516,602,366 1,549,440,270 1,655,087,146 1,735,236,809

Table 13: Average User Fee per SUO Op Comparisons from 20109/10 FY through to 2014/15 FY

YEAR 2010/11 2011/12 2012/13 2013/14 2014/15 USER FEES 762,887,960 917,158,414 952,498,810 1,158,337,700 916,804,540

SUOop 217161 170168 162849 153546 161890 Fees per 3513 5389 5629 6203 7155 SUOop

The table shows an increase in average user fee per SUO Op, which implies progressive “unaffordability (inequitable)” of hospital services. The average user fees per SUO Op are progressively going up over the years and this is a proxy indicator of unaffordability of hospital services. The general trend is upward which correspondingly infers progressive un-affordability of hospital services assuming the economic status of the catchment community, and costs for running the hospital remained the same like the years under review. This indicator is a trend indicator but will require a standard comparative indicator. At Ug.Shs. 7155 per SUO Op (compared to a similar setting facility—within an urban area, accessing the same markets for medicines and supplies etc), it is likely that the hospital is either greatly affordable or just un-affordable. The assessment of the hospital shows we are highly affordable. National statistics indicate that over the last 6 years there has been a progressive increase in the per capita Gross National Income, which may indicate the affordability of health care services with changes in hospital operational and other costs. The trends show, there is a progressive annual increase in the average user fees/SUO OP. The fees per SUOop has doubled in the last five years.

This trend however may not necessarily depict increasing un-affordability of services because there has been a corresponding increase in average monthly household income over the years. According to the UNHS 2009/10, average rural household incomes—as those mainly served by the hospital have increased from Ug.Shs. 142,700/= in 2005/06 to Ug.Shs. 222,600/= in 2009/10, an increase in average rural household income by 56% in 5 years.

Table 14: Average Expenditure per SUO Op Comparison from 2010 /11 through to 2014 /15

2011/12 2012/13 2013/14 2014/15 Total recurrent 1350246466 1328522142 1429973898 1670881909 Expenditure SUO OP 170168 162849 153546 161890 Avg. Cost per 7934 8158 9313 10321 SUO OP

2011/12 2012/13 2013/14 2014/15 SUO OP 170168 162849 153546 161890 Number of Staff 155 156 158 170 SUO OP per Staff 1097 1043 971 952

The above shows an interrelated trend of events: a gradual fall in the SUOop meaning reducing accessibility; this however is followed by ba rise in access in the year under report. The average cost per SUOop has continuously increased, an indicator that the hospital is increasingly becoming more expensive to run as it is less efficient.

Assessment of hospital liquidity:

Table 15: Hospital liquidity (Source: Audited financial statements).

FINANCIAL YEAR

2010/11 2011/12 2012/13 2013/14 2014/15*

Current ratio (Assets over liabilities) 7.7:1 8.8:1 11.4:1 3.96:1

Creditor relative to current assets 13% 11% 9% 25%

Debtor relative to current assets 18.7% 15% 13% 17%

Sundry debtors (unpaid charts) 8,880,500 6,844,000 8,556,500 8,067,500 11,824,000

Sundry debtor as % of total user fees 1.17% 0.76% 0.93% 0.90% 1.13%

Cumulative sundry debtors 8,880,500 15,724,500 24,281,000 34,198,500 46,022,500

Although the debtor relative to current assets minus creditor relative to current assets ratio would show a positive balance of payments, thus a healthy financial position, the picture has largely been due to accumulated school income (school fees) which:-

. Is sometimes received towards the close of the financial year and used in another financial year

. Some of the school fees has been in form of bursaries with restrictions on its usage which makes it accumulate on the account

Other factors are:

. Debt from the pre-payment scheme which, as it appears, is poised to become a bad debt

. Other debtors who have failed/refused to honor their obligations

. Cumulative sundry debtors

On the positive note however, it is because of the positive balance of payments that the hospital was able to purchase a lorry (TATA) from internally generated funds though this has limited use at the moment as it was bought to transport medicines and JMS has put its act together, transporting medicines to clients following numerous complaints. Further, the positive balance of payments is the reason we have been able to embark on an ambitious project: construction of a storied girl’s dormitory which is now in advanced stages. Following this attempt, the founders of the hospital felt a need to supplement our efforts and made a donation of UGX 627,144,975.

In order to address the issue of bad debts, hospital hopes to continue collecting advances from inpatients while balancing the delicate issue of remaining humane. We continue to computerize the patient’s registers with support from UCMB EPRM project with the hope that this will improve efficiency and plug some loopholes of manual receipting and recording. Attempts have been made to enlist services of a local debt collector to follow up some clients who disappear yet their addresses are known.

To improve on income both in cash and kind, we continue with lobbying especially the local and central government for support. To this note, the hospital participated in the first ever diocesan health assembly where we highlighted our challenges and need for support especially increasing the PHC CG, reviewing the policy on taxation of hospital consumables like sundries and laboratory reagents, re- instating the EDP support and support in form of human resources among

Above: Recently constructed senior staff houses. Support through Dr. and Mrs. Vierhout.

Above: New Universal anesthetic machine and below are new autoclaves.

CHAPTER SIX:

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

Curative: A. OPD

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

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

Table 3 : Here below we give the utilization of the OPD for the last 5 years.

2010/11 2011/12 2012/13 2013/14 2014/15 New 0-4 yrs 2660 2230 1618 1479 1826 Attendance 5yrs and Over 14012 10807 10071 9698 11721 0-4 yrs 177 66 49 37 34 FEMALE Reattendance 5yrs and Over 1423 860 510 211 192 New 0-4 yrs 2730 2333 1681 1581 1897 Attendance 5yrs and Over 8886 8147 5720 5575 6044 0-4 yrs 208 95 64 48 45 MALE Reattendance 5yrs and Over 1422 816 454 155 142 TOTAL 31518 25354 20167 18710 21901 S

Figure 1: OPD attendance over 5 year period 2010/11-2014/15

Over the last couple of years, there has been a gradual but steady fall in OPD utilization at Mutolere hospital though there was a 17% increase in the year under report. The OPD reduction has occurred despite the gradual increase in immunizations and antenatal care. With this reduction in the numbers of persons accessing (or utilizing hospital services) there are two or three probable possibilities which could be existing either singly or in combination—either people are increasingly seeking health care services elsewhere—such as, especially government facilities or generally morbidity (ill health) has reduced among the population—due to extensive health preventive/promotive initiatives (e.g. increased access to safe drinking water, increased numbers sleeping under an ITN, VHT initiatives etc…) or possibly people are not seeking health services—perhaps due to financial barriers or other reasons. The increase in OPD utilization by 17% could be due to improved quality of care as a result of constant availability of doctors and medicines. The recent upgrade of the hospital walkways, the cleanliness (well manicured gardens, garbage bins and planted vegetation) are likely to be responsible for the positive comments that we get which may also be slowly attracting clients. An analysis of the data from Kisoro government hospital and the district as a whole indicates that with exception of outpatient attendances, there has not been a substantial change in the other indicators. It is likely therefore that Kisoro hospital’s OPD increase is a result of the scale up of the HIV/AIDS activities and not a general increase in disease burden of the population with most of them preferring the unit to LLHUs and the PNFP. On the other hand the loss of EDP meant that Mutolere has to charge essential

drugs that were provided free after payment of the consultation fee. In such cases, chronically sick patients normally do not come for follow up and this may explain the low re-attendance rates. There is also increased competition from traditional and complementary health care providers who have mastered the art of advertising ability to treat “all illnesses” and the unsuspecting public has fallen prey to their machinations. OPD attendances’ fall may be due increasing functionality of lower level government health facilities which have registered marked improvement in availability of the 6 trace medicines nationally, with the percentage of facilities without stock out of any of the 6 indicator medicines increasing from 21% in 2009/10 to 43% in 2010/11 and 69.8% in 2011/12 (AHSPR 11/12).This means progressive increase in availability of medicines at the government units, therefore functionality. The 6 indicator medicines include CoartemR, Measles vaccine, ORS sachets, Cotrimoxazole, Fansidar and Depo-Provera. The Mutolere pre-payment scheme has also had substantial reduction in membership (from 9,213 for the July-Dec 2010 semester to 4,457 for the July-Dec 2011 semester and 3,319 for the Jan-June 2012 semester) which directly results into less OPD utilization since they were known to over utilize OPD services due to adverse selection.

The main OPD diagnoses are shown in the HMIS extract below. (HMIS 107 for year 201/1). From the table, the top causes of morbidity are malaria, respiratory tract infections, skin diseases, intestinal worms, sexually transmitted diseases, eye conditions, ear, nose and throat conditions and diarrheal diseases. Majority of these are amenable to public health interventions and this is a red alert that we should focus on the non-communicable diseases because the above will be severely reduced if the economy continues to grow at the current pace.

Table 17: OUTPATIENT DIAGNOSES 0-4 years 5 and over 0-4 years 5 and over Diagnosis Diagnosis Male Female Male Female Male Female Male Female 1.3.1 Epidemic-Prone Diseases 1.3.4 Maternal and Perinatal Diseases 01 Acute flaccid paralysis 01 00 00 00 45 Neonatal septicemia 00 00 02 Cholera 00 00 00 00 46 Perinatal conditions in newborns (0-7 days) 00 00 03 Dysentery 02 05 20 23 47 Neonatal conditions in newborns (8 - 28 days) 00 00 04 Guinea worm 00 00 00 00 1.3.5 Non Communicable Diseases 05 Bacterial Meningitis 48 Anaemia 14 05 21 27 06 Measles 49 Asthma 02 06 52 185 07 Tetanus (Neonatal) (0 -28 days age) 50 Periodontal diseases 00 00 00 00 08 Plague 51 Diabetes mellitus 00 00 182 268 09 Rabies 52 Bipolar disorders 00 00 10 Yellow Fever 53 Hypertension 503 916 11 Other Viral Haemorrhagic Fevers 54 Depression 00 00 00 08 12 Severe Acute Respiratory Infection (SARI) 55 Schizophrenia 00 00 08 01 13 Adverse Events Following Immunization (AEFI) 56 HIV related psychosis 22 22 589 163 43

14 Other Emerging 57 Anxiety disorders 00 00 04 33 infectious Diseases, 58 Alcohol abuse 00 00 09 01 specify e.g. small pox, ILI, 59 Drug abuse 00 00 00 00 SARS 60 Childhood Mental Disorders 00 00 00 00 1.3.2 Other Infectious/Communicable Diseases 61 Epilepsy 07 07 21 14 15 Diarrhea- Acute 255 231 38 69 62 Dementia 01 08 16 Diarrhea- Persistent 02 02 00 00 63 Other forms of mental illness 00 00 17 22 17 Ear Nose and Throat (ENT) conditions 56 41 140 252 64 Cardiovascular diseases 00 00 54 74 18 Ophthalmia neonatorum 02 01 65 Gastro-Intestinal Disorders (non-Infective) 24 23 357 785 19 Other Eye conditions 109 90 244 402 66 Severe Acute Malnutrition (Marasmus, Kwashiorkor, Marasmic-kwash) 20 Urethral discharges 00 00 22 22 21 Genital ulcers 00 00 00 00 67 Jaw injuries 00 00 00 00 22 Sexually Transmitted Infection due to SGBV 00 00 00 00 68 Iniuries- Road traffic Accidents 05 01 70 33 23 Other Sexually Transmitted Infections 00 01 105 391 69 Injuries due to Gender based violence 00 00 00 00 24 Urinary Tract Infections (UTI) 24 10 281 627 70 Injuries (Trauma due to other causes) 08 16 194 118 25 Intestinal Worms 80 82 128 216 71 Animal bites 00 00 02 00 26 Leprosy 00 00 00 00 72 Snake bites 00 00 00 03 27 Malaria 101 87 29 453 1.3.6 Minor Operations in OPD 28 Other types of meningitis 00 00 00 00 73 Tooth extractions 00 00 126 192 29 No pneumonia - Cough or cold 625 601 502 1064 74 Dental Fillings 00 00 00 00 30 Pneumonia 241 190 76 77 1.3.7 Neglected Tropical Diseases (NTDs) 31 Skin Diseases 171 173 283 409 75 Leishmaniasis 32 Tuberculosis (New smear positive cases) 00 00 26 05 76 Lymphatic Filariasis (hydrocele) 33 Other Tuberculosis 00 00 25 11 77 Lymphatic Filariasis (Lympoedema) 34 Typhoid Fever 00 01 69 22 78 Urinary Schistosomiasis 35 Tetanus (over 28 days age) 00 00 00 00 79 Intestinal Schistosomiasis 36 Sleeping sickness 00 00 00 00 80 Onchocerciasis 37 Pelvic Inflammatory Disease (PID) 399 Ca C4 00 00 00 62 Ca prostate 00 00 00 11 81 Other diagnoses 38 Abortions due to Gender-Based Violence (GBV) 00 Ca Breast 00 00 05 00 (specify priority diseases 39 Abortions due to other causes 124 for District) 40 Malaria in pregnancy 06 41 High blood pressure in pregnancy 00 42 Obstructed labour 04 82 Deaths in OPD 00 00 00 00 43 Puerperial Sepsis 05 83 All others 573 507 2416 3494 44 Haemorrhage in pregnancy (APH and/or PPH) Total Diagnoses 11422

SPECIAL CLINICS.

PALLIATIVE CARE ANNUAL REPORT 2014 – 2015

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

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

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

Table 18: CURRENT PALLIATIVE CARE STAFFING

CADRE QUALIFICATION

2 Registered Nurses 1 Diploma in Palliative care

1 Certificate in Palliative care

1 Pastoral care giver

Table 19: TABLE SHOWING SOME OF THE PATIENTS ATTENDED TO IN THE REPORTING PERIOD

NO PATIENT’S DX NUMBER

1 Ca cervix 7

2 HCC 03

3 Burns 04

4 Ca Stomach 03

5 Ca Breast 02

6 Retinol Blastoma 01

7 Ca vulva 01

8 HIV/AIDS (Opotunistic infections 02

9 Camgrene 01

10 Other form of chronic pain 13

Total 37

ACHIEVEMENTS

- Consistent supply of both weak (5mg/5ml) and strong (50mg/5ml) morphine. - Availability of other drugs used to manage pain (adjuvants). - Assessment and regular reviews of patients in need of services.

CHALLENGES

- Staff shortage – the Clinical Officer who had been recently trained left and is not yet replaced. - Lost to follow up, some clients are seen only once or twice and never seen again. - The services are only limited to in-patients and outpatients – therefore those at home and unable to come due to different reasons do not access the care. - Some trained staff not very active.

RECOMMENDATIONS

- Training other staffs so as to boost the team to provide the services. - Possibly consider some small PHC fund to cater for palliative services. - To motivate the inactive trained staff to be active.

Great thanks to the hospital management for a pastoral care Rev. Sister who helps a lot in palliative care services. ‘Palliative care should be as available as AIR’ reference to Dr.Amandua 2015 PCAU International conference.

We look forward to seeing other staffs being sent for palliative care training.

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

During the year under report, eye camps were conducted in Dec 2014 and May 2015 by Dr. Keith Waddel from Ruharo eye center Mbarara. Other operations were performed by the PCO/Cataract Surgeon. The specific outputs for the year under report are given below: 46

Table 20: Ophthalmology cases for the year

Normal eyes Refractive error 10 Presbyopia Aphakia Allergic Conjuctivities 346 Other Conjuctivities 158 Trachoma Corneal Diseases 25 Cataracts 78 Leprosy Lesions Glaucoma 11 Onchocerciasis 00 Trauma 40 Uveitis 15 F.B 12 Squint 11 Lidsflaluv app Xerophthalmin 02 Others 167 Optic nerve and retina disease 01 Total 876

Major procedures Cataract 57 Glaucoma 01 Others

Minor procedures: Entropion Other 18 The hospital is in the process of developing a proposal to be supported by Sustain for Life to find children with blindness and assist them to access health care and education with close collaboration with Kisoro Demo. This is premised on the observation that there are not many opportunities for the visually impaired children, a group tht is even ostracised by the parents who consider them curses in the families. As such they are not allowed any education opportunities; there are few schools capable of handling children with special needs. Besides, these children are often left at home for nature. The project is also expected to have a component to deal with children with hearing impairment so that they too can have education opportunities.

ORTHOPAEDIC SERVICES

The Hospital has a highly experienced and motivated orthopedic officer who handles all the orthopedic cases with assistance from doctors and visiting surgeons. This ensures that most orthopedic cases are handled here and only a few are referred to Mbarara regional referral hospital and Mulago National referral hospital for an orthopedic surgeon. The orthopedic services offered include; management of all fractures that can be treated conservatively, external fixation of fractures (with the help of the visiting Surgeons from Holland). The hospital is in the process of enhancing capacity to carry out internal fixation of fractures through the SIGN program. The hospital has no qualified physiotherapist, nor does it have a specialist occupational therapist to handle post-fracture patients’ recovery and rehabilitation.

The number of fractures/and trauma cases in general has risen significantly because of the new paved roads. This explains the higher bed occupancy rate for the surgical wards and internal fixation of fractures with intramedullary nails under the SIGN program is meant to address this problem.

There is an increasing number of people reporting to the hospital with old fractures and dislocations. Such people have gone to “traditional bone setters” only for them to come with deformities which defeats the purpose for management of orthopedic conditions which includes, inter alia, prevention of deformity. Such occurrence is a consequence of the unregulated practice of traditional and complementary practitioners who have gained legitimacy in the current and previous national health policies.

Majority of the orthopedic conditions seen in the unit are Degenerative conditions (osteoarthritis, spondylitic conditions e.t.c), Infective conditions (osteomyelitis, infective arthritis), Congenital Talipes Equino-varus (CTEV) and fractures of extremities e.g. metatarsals, metacarpals e.t.c. The hospital will need to consider the recruitment of a physiotherapist and perhaps an occupational therapist initially on a part-time basis, in view of the increasing numbers of orthopedic cases requiring these services.

Above: A patient with fracture treated with external fixation.

HIV/AIDS SERVICES.

The Hospital runs an HIV clinic, which has been running since the late 1990’s initially providing Counseling and testing services with support from CORDAID. ART services were started at the hospital in 2003/04 by the hospital management with support from the Ministry of Health. Currently the clinic is supported by the USAID funded Strengthening TB and AIDS Response in the south-western region (STAR-SW) through a cost reimbursement type of assistance. The objectives are to increase the uptake of comprehensive HIV/AIDS and TB services at the hospital, strengthen linkages and referral systems within and between health facilities and the catchment community, increase demand for comprehensive HIV/AIDS and TB prevention, care and treatment services to the hospital, and finally increase the demand and uptake of PMTCT/EID services at the hospital. The clinic has been run by two clinical officers, a counselor, a nurse, two lab technicians, and a number of volunteers. Due to the pressure exerted on the thin human resource at Mutolere hospital, it was decided that HIV/AIDS patients coming for drug refills (ARVS and/Cotrimoxazole) should have a clinic day on Mondays and Thursdays. These days are convenient because the patients use ready available transport inform of trucks which bring them as they bring people to the market in Kisoro town.

The overall co-ordination of the HIV/AIDS activities is under the Public health program. With support from USAID (SDS), we are going to deploy a medical officer and enrolled midwife to support in running the clinic. The outputs for the HIV/AIDS counseling services in the FY 2013/14 are indicated in the table below (source HMIS). 49

Table21: HIV/AIDS COUNSELING AND TESTING (HCT), FY 2014/15.