KITOVU HEALTH CARE COMPLEX P.O. BOX 524

In Christ We Serve

ANNUAL ANALYTICAL REPORT 2008/2009

COMPILED BY THE MEDICAL SUPERINTENDENT Kitovu Hospital Annual Report 2008/2009

Endorsement of Report

This annual analytical report for Kitovu Hospital covering the period 2008/2009 has been prepared by the management of Kitovu Hospital. I endorse that it represents management’s views on the position of the hospital in the period under report.

Sr. Scholastica Nakakawa

Chief Executive Officer Kitovu Hospital

Date 30th October 2009

This is to acknowledge that I have received this annual analytical report for Kitovu Hospital covering the period 2008/2009 I have read it and endorse its authenticity and representative of the position of the hospital in the year under report

Rev. Fr. Denis Ddamulira Chairperson of the Board of Governors

Date 30th October 2009

Kitovu Hospital Annual Report 2008/2009 2 Kitovu Hospital Annual Report 2008/2009

TABLE OF CONTENTS: Abbreviations: ……………………………………………………….………... 4 - 5

Executive Summary: ……..…………………………………………………..…. 6 - 9 Introduction: ……………………………………………………………….……. 10 The Hospital and its Environment: ………………………………………...…… 11-13 The Community and Health Status: …………………………………………….. 13-14 Health Policy and District Health services: ……………………………………………………...... 15-16 Governance and Management:…………………………………………….……... 17-20 Human Resource: ………………………………………………………..……… 21-26 Finance: ……………………………………………………………...……. 27 Activities: Curative: OPD: ……………………………………………………………..….…. 28-31 Wards:……………………………………………………..………. 32-41 Special Curative Services: Tuberculosis: …………………………………………………….….…. 42 Obstetric Fistula Unit: ……………………………………….…….…... 43 PMTCT: ………………………………………………..………….…… 44-45 HIV Counselling and Testing/VCT: ……………………..….………. 46-50

Supportive: Laboratory and Blood Bank: ……………………………...…………..... 50-53 Pharmacy: ……………………………………………………....……… 53-56 X – ray: …………………………………………………..………..…… 56-57 Ultrasound: ………………………………………………………....….. 57-58 Domestic Services: ……………………………………………….……. 58-63 Ambulance Services:……………………………………..…………..… 64 Pastoral Care and Social Care…………………………………………... 65-68 Preventive and Promotive Services: Community Based Health Care & Nutrition Unit:…………………..…. 69-72 Kitovu Community Health Insurance Scheme: …………………….….. 72-77 Health Training Institution: Laboratory Training School: ………………………………………………...….. 77-79 Conclusion: ………………………………………………………………..…… 80 -83 Future Plans: ……………………………………………………………..…... 83 -84 Acknowledgments: …………………………..…………….……….…… 84-86 Annexes: HMIS: …………………………………………………………… ………….…. i Board of Governors: …………………………………………………………..... ii (a) Members of the Finance and Planning Committee ………………….………..… (b) Member of Management Team: ……………………………………………....… (c)

Kitovu Hospital Annual Report 2008/2009 3 Kitovu Hospital Annual Report 2008/2009

Hospital Staff form by end of Financial Year: ..…………………………..…..… iii Comprehensive Financial Report: ……………….……………………….….…. iv ABBREVIATIONS: AIDS - Acquired Immune Deficiency Syndrome ANC - Antenatal Care APSO - Agency for personnel services overseas. (Since 04/05 is BS - Blood Slide C VD - Cerebrol - Vascular Accident C.B.H.C - Community Based Health Care CCF - Congestive Heart Failure CHW - Community Health Workers

CPE - Clinical Pastoral Care

CS - Caesarian Section DDHS - District Director of Health Services

DHO - District Health Offices DHB - Diocesan Health Board DM - Daughters of Mary DM - Diebetes Mellitus DOT - Direct Observation Treatment E.D.P - Essential Drug Program G.E - Gastroenteritis GID - Gastrointestinal Disease GYN - Gynaecology

HAART - Highly Active Antiretrovial Treatment Hb - Hemoglobin HCT - HIV counselling and Testing HIV - Human Immune Virus HSD - Health Sub District Kitovu Hospital Annual Report 2008/2009 4 Kitovu Hospital Annual Report 2008/2009

HSSP - Health Sector Strategic Plan HTN - Hypertension IMR - Infant Mortality Rate IV - Intravenous KCHIS - Kitovu Community Health Insurance Scheme LOS - Length of stay MMM - Medical Missionaries of Mary

MMR - Maternal Mortality Rate MRC - Medical Research Council NGO - Non Government Organisations NMHCP - National Minimum Health Care Package NSSF - National Social Security Fund O.T - Operating Theatre OPD - Out patient Department PMTCT - Prevention of Mother to Child Transmission PNFP - Private Not for Profit PTB - Pulmonary Tuberculosis RTA - Road Traffic Accident RTI - Respiratory Track Infection STD - Sexually Transmitted Disease T.T - Tetenus Toxoid TASO - The AIDS Supportive Organisation TB - Tuberculosis Bacillai U.N.F.P.A - United Nations Family Population Association UCBHFA - Community Based Health Financing Association UCMB - Uganda Catholic Medical Bureau UGX - Uganda Shillings

UK - United Kingdom USA - United States of America

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UTI - Urinary Tract Infection VVF - Vesico Vaginal Fistula 1. EXECUTIVE SUMMARY:

Kitovu Hospital, established by the Diocese of Masaka, 54 years ago in , Uganda, is a two hundred bed (200) Private Not For Profit (PNFP) hospital, operating under the umbrella organization of the Uganda Catholic Medical Bureau (UCMB).

Achievements that have been made in the year according to last year’s plan:

Achievements: 1. Revision of patients’ fees for both Medical and Surgical wards, Gyne cases and OPD was done. Majority of patients were able to pay. 2. OPD utilization has increased by 14%. (5% higher than our expected number of patients. Expected visits in a year is 30,000) There was some slight improvement in customer care relationship and reducing on waiting time. 3. Review of staff establishment as well as making sure each department has adequate staff was done. 4. New Ultra Sound machine is on the way from abroad. 5. Built of new Ash/placenta pit. 6. A Grinder for cutting and sharpening metals was brought though it got broken. 7. Preparation for starting an ARV’s and HIV clinic at the hospital is underway. Ten staff have been trained in provision of comprehensive HIV/AIDS care. 8. The compound was tendered. 9. New colorimeter and water bath have been acquired for the lab. 10. Plans to start intensive neonatal unit has been completed. Funds have been secured. 11. Funds to buy one hospital vehicle has been secured, though we are still looking for more, as 2 other hospital cars are in poor condition, plus all the cars of CBHC Programme are very old. 12. The Blood Bank was relocated to a specious old classroom block which was renovated. 13. Refurbishment of laboratory staff hostels was done.

Failures: 1. No development plan for training staff for a year was made. 2. Solicit for funds for immunization for our staff against Hepatitis B, C and HIV prophlaxis; after needle stick from HIV infected patients was not accomplished though discussions were done about it.

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3. Monitoring sepsis or maternity did not take root as we had to shift mothers about 2 times during renovation this year. 4. Failed to increase number of isolation rooms at medical ward and to construct private rooms due to lack of funds. 5. Failure to carry out major repair of the hospital fence so as to contain security problems. 6. Failure to build and renovate staff houses. 7. Failure to obtain some equipment of laboratory e.g. haematology machine. 8. Failure to have full time fistula Repair services. 9. Failure to separate causality from Out-patient Department. 10. Plan to revise terms and conditions between Kitovu Hospital and Nakasero National Blood bank was not done. 11. The Budget was not well controlled

N.B Failure to achieve most of our plans was due to inadequate finance.

Other achievements:

1. We started camping sessions for Blood Bank which have boosted our blood supply. 2. Two more of our qualified midwives were properly trained for PMCT programme 3. New water reserve tank was constructed with the capacity of 55,000 litres 4. Installation of new stand alone photovoltaic solar system on Children’s Ward. 5. Refurbishment of the chemotherapy unit in Children’s Ward 6. Repair to the administration rain water collection tank. 7. New supply tanks: New polyfibre supply tanks and their towers were installed at the Laboratory Tutors House and Walungi quarters to increase on the supply of water to these houses. 8. Repairs to the existing two reserve tanks

Challenges:

1. High turnover of experienced nurses and Midwives due to low salary scales compared to the government’s scale.

2. Kitovu hospital works as referral hospital but not facilitated as such by the Government via PHC grant.

3. Working as a referral unit, raises the unit cost of managing patients yet PHC grant is stagnant as well as increasing poverty level in the community.

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4. Non-compliant with medicines many patients with tuberculosis disease and HIV refuse to go to other Health facilities which provide continuation phase for PTB and ART’s. 5. Inadequate Medical staff residences.

6. No causality department yet the biggest emergencies are ART’s

7. Inadequate isolation rooms and lack of private rooms on Medical Ward.

8. Need of renovation and expand of OPD, Pharmacy store, central store to meet the increased demand of services.

9. The hospital vehicles are worn-out and need replacement.

10. Hospital Laboratory needs Automation machines to give more reliable results.

11. The hospital’s fence needs replacement to contain security problems.

12. Lack of Autoclave and Heamatology analyzer for the Laboratory.

Important recommendations and plan for the coming year:

Future Plans: Short-term 1. Obtain heamatology analyzer so that we get more accurate results in heamatology. 2. Train more Lab Technician to improve on the service. 3. Mobilize funds so that we can provide free or subsidized immunization to all staff against infectious disease e.g. Hepatitis B. 4. Solicit funds for fridges, microscopes and autoclave for laboratory. 5. Restructuring the CBHC Programme as the main donor is phasing out 6. Consider including Fansider and Septrin prophlexis in the antenatal package. 7. To install solar system at Maternity and Surgical wards. 8. Divide the staff on maternity ward into 2 groups one to remain on admission and another to labour ward as to improve service on maternity ward. 9. To carry out Medical Audit every four months. 10. To honour the Budget and minimise costs and avoid wastage of resources. 11. Revise terms and conditions between Kitovu Hospital and Nakasero National Blood Bank 12. Monitor and document on post caesarean infection rate and waiting time on OPD. 13. Segregate the data of FSB as per definition of UCMB

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14. Separation of midwives in group one to concentrate on admission and ward another group to concentrate on labour ward. 15. Closely to monitor drug prescription by the Clinicians. 16. Follow up waiting time every four months. Long - term 17. Have a larger space for X-ray department. 18. Solicit Funds for new X-ray machines. 19. Increase OPD attendance by 5% (of targeted population of utilization) 20. Plan to intensify the sensitization of our donor targeted groups in order to curb shortages of blood. 21. To carry out Medical Audit every four months. 22. Solicit funds for private and isolation rooms on Medical ward. 23. Look for ways to improve on our ANC services.

Below are the two tables showing some of the activities and services rendered to the patients in the last five years Table showing the General Performance in four years

Year 2005/2006 2006/2007 2007/2008 2008/2009 OPD 33504 27904 28547 32622 Attendance Admissions 13067 10453 9003 11032 Deliveries 1470 1397 1179 1818 Antenatal 2150 1340 1844 1212 attendance Immunizati 9185 6862 9232 11401 on DPT3 793 (87%)

• There is an increase in all areas except Antenatal Attendance. (Most of admissions are on Children and Maternity Wards.) DPT3 is 87% which is a good return.

Table showing other services rendered: 2004/2005 2005/2006 2006/2007 2007/2008 2008/2009 X-Ray 3,090 1,654 2,011 1821 1796 Ultra Sound Scan 831 525 - 222 834 Laboratory 86,965 61,372 64,696 51,966 55154 Psycho-social care & counselling 5,881 4,529 3,271 3,487 3830 Blood Transfusion 3,410 6,023 5,492 3,728 4878 Social work activities 3,330 4,182 3,917 3,927 3,946 Obstruct Fistula (VVF) 201 312 296 235 169

There is overall increase in all services except ANC, VVF repair. There were only 3 out of 4 VVF workshops done last year.

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The decrease of ANC might be contributed to other facilities in the area such as Government hospital, private clinics but also there is need to study and improve our ANC services.

2. INTRODUCTION:

This annual report covers the period of July 2008– June 2009. The source of data is from HMIS, hospital registers, hospital medical records and Masaka Health District offices.

Trends of the hospital utilization are based on comparisons of the utilization indicators of 5 years. The number of patients getting services are increasing; expenditure continues to be high but income is going down; this puts the future existence of the hospital in jeopardy.

This report tries to convey the hospital situation i.e. its location, environment, governance, activities, achievements, challenges and future plans.

Presently, the hospital has adequate number of medical doctors with experience and Clinical Officers only one with enough experience but others are newly qualified.

The number of midwives and nurses is also adequate; though the majorities are newly qualified with little experience.

The expenditure is high and income is going down.

The key types of information this report tries to bring out, will translate what the present trends mean and be able to predict the future trends.

Methods of assessment of compliance are with faithfulness to the mission in terms of accessibility, equality and efficiency have been done using the standard unit of output (SUO) and quality indicators (fresh still birth rate, maternal death rate and percentage of qualified staff).

Some of the problems experienced in writing this report was getting the correct information in time. Thus giving feedback to the staff will be priority in future.

Inspite of the difficulties and limitations, we hope that our readers will find this document useful. We thank our readers e.g. UCMB for their feedback and we humbly request others to do the same so that we can improve our services.

Any feedback and corrections are therefore highly appreciated.

Kitovu Hospital Annual Report 2008/2009 10 Kitovu Hospital Annual Report 2008/2009

3. THE HOSPITAL AND ITS ENVIRONMENT Kitovu Health Care Complex (KHCC), known as St Joseph’s Hospital was founded in 1955 by the late Arch Bishop Joseph Kiwanuka, the first African Bishop in the South of the Sahara who visited Ireland and asked the Irish Sisters of the Medical Missionaries of Mary to come to Uganda.

From its inception in 1955 up to 2001, it was administered by the Religious Congregation of the Medical Missionaries of Mary (MMM) Sisters. The Irish Sisters handed over the administration of the Hospital to the indigenous Congregation; the Daughters of Mary sisters (Bannabikira) on 15th Dec. 2001.

St. Joseph’s Hospital, Kitovu, was established by the Diocese of Masaka about 54 years ago in Masaka District, Uganda. It is a two hundred (200) bed, Private, Not For Profit (PNFP) Hospital, operating under the umbrella organization of the Uganda Catholic Medical Bureau (UCMB)

Kitovu Health Care Complex is a general Hospital with some specialized services such as Obstetrics/Gyneacology, Surgery and Obstetric Fistula Repair and prevention.

It is composed of:

. A 200 bed Hospital (+ 28 beds for new fistula unit which are used at specific time) . A community Based / Primary Health Care Programme . A Nutrition education/Rehabilitation Unit . A Psychosocial and Counselling Unit . A Regional Blood Bank . Laboratory Assistant Training School . A training centre for doctors and nurses for VVF repair and caring for VVF sufferers; which started in November 2004 as a unit by its self. . Intern Doctors Training Programme (Makerere – linked)

Although officially it is not recognized as one of the referral hospitals, yet it shares that responsibility with Masaka Regional Referral Government Hospital that exists within the same Municipality and District. Some Health Centres in Masaka, , , and Mpigi, etc refer their patients to Kitovu Hospital.

The Hospital began with Out Patient Services, followed by a small in-Patient Unit. Over the years it has grown into a large hospital. Both curative and preventive services are offered by the hospital and an Outreach programme is associated with it.

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The Community Based Health Care (CBHC) Programme was the first major outreach service. It was followed by the Mobile Home Care, Orphans and Education Program, which was developed in response to the AIDS epidemic in this area. Now it is a separate entity located in Soweto – Masaka town.

Also in response to AIDS related problems, the Pastoral Care and Counselling Training Unit was established.

In November 2004 a unit center for training of Doctors and nurses for VVF repair and caring for VVF sufferers was established.

The Hospital, together with the outreach programme make up Kitovu Heath Care Complex, whose mission is, “To continue the Healing Ministry of Jesus, by proclaiming the Sacredness of life, providing services which foster the health and well being of the people, and caring in a special way for women, children and the poor.” This is done through the INTEGRATED ACTIVITIES of the various sectors, each with its specific Mission enfleshing the vision of the Complex.

We pursue this mission by:  Providing INTEGRATED, HOLISTIC services, which are ACCEPTABLE, ACCESSIBLE, AFFORDABLE AND SUSTAINABLE.  Respecting the dignity of each person hence treating each one with compassion and justice.  Maintaining a high standard of PROFESSIONAL COMPETENCE, ETHICS AND EFFECTIVENESS  Assisting our staff to develop professionally and personally and providing them with meaningful careers.

Location: It is located at Kitovu hill, within Masaka Municipality (which has a population of 79,200 people); within Masaka District (with a population of nearly 804,300 people); within Uganda which has a population of 30,000,000; 89% of which live in rural areas.

 The district lies immediately below the Equator in the southern hemisphere zone of Uganda.  It is 130km south of , the capital city of Uganda and 3km from Masaka Town.  The district boundaries are formed by the districts of Sembabule, Rakai, Kalangala and the southern part of Mpigi, in the west, south, east and north respectively.  The total regional population (for the districts mentioned above) is about 1,500,000 people.  In terms of the area covered by the hospital curative services, Kitovu receives patients from all the districts mentioned above.  However, in terms of the population covered at a referral status, it shares responsibility with Masaka Regional Referral Government Hospital located 4½ km away, which has a total of 330 beds.

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 For disease prevention and health promotion, a smaller catchment area has been defined nearest to the hospital for the hospital’s focus and concentration with the Primary Health Care interventions the impact of which can therefore be easily evaluated.

The target population for the hospital is estimated to be about 300,000 people.

Communication: Transport facilities are good. The hospital is partly linked to Masaka town by a tarmac road. There are commuter taxes and motorbike transport. Telephone communication; two landlines, call boxes/payphones and mobile phones are available.

Physical Environment: Masaka District covers an area of about 4,560sq km of which 30% is open water and swamps. The months of March, April and May being the season for the long rains while October, November and December are months for the short rains.

Peaks of incidences and prevalence of malaria, the number one cause of ill health in the region, tend to follow the peaks of the rainy seasons.

The hospital is within an ever green region with some rain forests and many rivers traversing the districts, as they descend towards the east to join the freshwater lakes among which is Lake Victoria one of the world’s biggest inland lakes.

4. THE COMMUNITY AND HEALTH STATUS:

The main ethnic group is the Baganda. Other ethnic groups include Banyarwanda, Banyankole and Bakiga. Luganda is the main language spoken followed by English. Language proves no barrier to provision and utilization of services because many staff can communicate in English or other Bantu languages.

There are some unique cultural practices that may affect health delivery such as

1. Belief in traditional healers. Many people come very late to seek medical help. They come after failing to get better with the traditional medicine. 2. Traditional treatment of the baby’s umbilical cord. Families may use cow dung or any other herbs to put on the umbilical stumps, thus the babies have high risk of sepsis and neonatal tetanus. We hardly miss a week without a neonatal tetanus case. 3. Many mothers during labour are given herbs which bring strong contractions which lead to ruptured uterus. 4. There is a belief that a mother should deliver naturally thus many women keep on pushing even when they cannot deliver naturally and end up with obstetric complication such as VVF.

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Economic activity: The majority of the people are poor peasant farmers with small family incomes.

Principal economic activities include animal husbandry, fishing, coffee and banana farming. These are the main sources of income.

A small percentage of the population is engaged in small-scale industries, trade or salaried employment. The cost of living is quite high, whereas income is steadily decreasing; thus many people have very little to spend on health.

The main causes of ill health are:  Communicable infectious diseases, malaria, respiratory tract infections including pneumonia and T.B, diarrhoea, worm infestations and HIV/AIDS which underlies many other diseases.  Complications of pregnancy and childbirth  Malnutrition and diseases associated with poor water supply and poor environmental sanitation.  High blood pressure, diabetes, cancer and other diseases of the affluent society are on the increase as more people are adapting the western style of living.

Demographic data for Masaka Municipality, HSD, Masaka District and Uganda

Msk Municipality HSD Masaka District Uganda (A) Total Population (Projected for the year under report) 79200 71772 304300 30,000,000

(B) Total expected deliveries (4.85% of population) = (4.85/100) x 3841 3481 39009 1,455,000 A (C) Total Assisted Deliveries in Health Facilities 1548 11016 (D) Tot. Assisted Deliveries as % of expected deliveries = 40% 28% (C/B)x100 (E) Children <1 year (4.3%) = (4.3/100)xA 3405 3086 34585 1,290,000 Children < 5 years (20.2%) = (20.2/100) x A 15998 14498 162469 6,060,000 (F) Women in Child-bearing age (20.2%) 15998 14489 162469 6,060,000 = (20.2/100) x A (G) Children under 15 years (46%) 36432 33015 369978 13,000,000 = (46/100) x A (H) Orphans (≈ 10%) = (10/100) x A 7920 7177 80430 3,000,000 The percentage of assisted delivery of the catchment area is higher than that of the district This corresponds well with the increased deliveries in the hospital, but this does not show the real picture of deliveries in the catchment areas because of increased referral outside the catchment area.

Table showing Health indicators of community and country of Uganda

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Total Population 79200 887,972 30 m IMR 76/1000 76/1000 76/1000 Under 5 MR 137/1000 137/1000 137/1000 MMR 435/100000 435/100000 435/100000 Rate of Stunting 20% 20.00% 20% HIV Prevalence (UHSBS result) 6.2 70% 6.2

% Supervised deliveries 36% 36% Total Govt. & PNFP Utilisation (new 0.8 cases) per year = Total New Attendants / Total Population % Children < 1 yr fully immunized 85%

5. HEALTH POLICY AND DISTRICT HEALTH SERVICES:

The hospital is affiliated to the Uganda Catholic Medical Bureau and its activities are guided by the constitution of that umbrella organization. At the same time it adheres to the Government policies through the partnership with the Ministry of Health.

In 1999 the Uganda Ministry of Health adopted a 10 year health strategic plan which was launched in the year 2000 with the first 5 years Health Sector Strategic Plan (HSSP), now we are following HSSP II. The national health policy emphasized Primary Health Care as the basic philosophy and strategy to address the country’s major health and other social problems.

It went further to define a National Minimum Health Care Package (NMHCP) and made it the Primary Focus for the Health Care delivery system.

Among the major components of the National Minimum Health Care package to which Kitovu Hospital subscribes and contributes greatly are:

 Control and treatment of communicable diseases e.g. malaria, STD – HIV/AIDS, T.B.  Intergrated management of childhood illnesses,  Sexual and reproductive health,  Immunization  Environmental Health  Health Education Promotion  School health  Epidemic and disaster prevention, preparedness and response  In the area of clinical care Kitovu Hospital goes beyond the provision of simple essential clinical care to offering specialized medical, obstetrical/gynecological and surgical care at a regional referral hospital status.  In the areas of nutrition and blood transfusion services, the hospital is the regional center for nutritional education, as well as the Regional Blood Bank, serving 4 to 5 districts.

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In so doing, the hospital greatly contributes to the operationalisation of the National Health policy on the government partnership with the Non Government Organisation (NGO) health care providers. That policy recognizes the Non Government Organisation (NGO) Health Care providers as major partners in health, collaborating closely with the Government to promote the shared objectives of:

 Increasing coverage  Improving the quality of health care,  Avoiding duplication of services,  Improving equity in distribution of health care services, in a special way to reach women, children and the poor which is in line with the hospital’s mission and vision. In a way of strengthening this policy based collaboration, Government sends a financial grant (subvention) to the hospital annually, and at least two Government paid medical doctors have been seconded to work at the hospital. Recently, seconded midwife from Masaka District has been sent to Kitovu Hospital to work at PMTCT

The status of Masaka District Health Services (current data not available)  Number of health sub districts (sub divisions) each with at least one doctor – 8-9  Number of Government Regional Referral Hospitals – 1  Number of NGO hospitals (including Kitovu) – 2  Total number of hospital beds – 686  Average bed occupancy – 65 – 72%  Number of Health Centres (excluding hospitals) – 81  Percentage of health facilities that are NGO – 43%  Number of new rural operating theaters – 8 not fully operational  Doctors/population ratio – 1:20,044  Nurse/population ratio – 1:5000  Midwife/population ratio – 1:6,500  People living within 5km of a health facility – 60%  Deliveries conducted by trained staff 2005/2006 – 36%  Rural safe water coverage – 87 – 93.5 depending on technology  Average pit latrine coverage – 95.1%  Schools safe water coverage – 87.5 – 93.5 % depending on technology  Schools sanitation (stance/pupil) ratio – 1:40 pupils – 50.1%  DPT3 coverage (projection) – 93%  BCG coverage (projection) 80 – 119%  Fully immunized coverage 85%

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7. GOVERNANCE AND MANAGEMENT

Board of Governors:

Effective working system facilitates the achievement of the organization’s targets and aims. Thus the hospital has an active charter which was endorsed by the Bishop of Masaka Diocese.

Following the charter, the Hospital has a board which held its meetings four times in a year under review. It was a very active board in that members were following up decisions made in meetings to see how they are implemented.

Members of the Board were not changed as it was reported in the previous annual report 2007/2008. Members of Board of Governors: See Annex ii (a)

Board Meetings:

Date of Board meeting Report presented Number of members present 8th October 2008 Hospital’s Quarterly report 9 7th February 2009 Decision on Bursary Fund 12 18th April 2009 Hospital’s Quarterly report 10 25th July 2009 Financial report and 10 Budget approval

Committees of the Hospital:

The Hospital has the following committees:

 Building committee : This held its meetings six times in the year as there was construction going on in the hospital.

 Finance Committee : This committee also sat six times in the year under review for proper monitoring of finances. Kitovu Hospital Annual Report 2008/2009 17 Kitovu Hospital Annual Report 2008/2009

 The Training Committee sat four times.

 The Grievance and Disciplinary Committee held several meetings this year although some of the issues were handled by the Management

 The interdepartmental meetings were held every Tuesday of the second week of the month.

Management Team: Members of Management: See Annex ii (b) The management Team remained the same as well as other committees. However the Management team changed its system of holding meetings twice a month to four times a month. The Team hold meetings every Wednesday of the week; unless circumstances dictate otherwise.

Internal Auditors: The internal Auditor is doing well her work. She is now one year in the office. This year she took more emphasis on stock takings and cost centres. She want to see to it that every cost centre/department or activity done is recorded systematically to gauge output production cost centre.

Compliance: The hospital was compliant with the local Government and Ministry of Health such that information was reported in time; although some of it was delivered a bit late to UCMB.

Hospital accreditation: The hospital fulfilled the accreditation programme and action agreed on during the hospital managers’ technical workshop.

Public Relations: The hospital relates well with the District, Ministry of Health Diocesan Health Board, UCMB and the local Government.

Communication: There is a staff responsible for internal communication and the Human resource Manager coordinates interdepartmental meetings which are held on every Tuesday of the second week of the month.

External Communication: There is a Secretary who is responsible for communication with all the external communications. She also delivers messages to the respective departments or members. The service is going on well.

Manuals/Guidelines:

Kitovu Hospital Annual Report 2008/2009 18 Kitovu Hospital Annual Report 2008/2009

The hospital has a finance and material resources manual plus an employment manual. The finance manual has helped us a lot to put in place all the documents recommended to ensure that proper accounting procedures are adhered to.

The employment manual has helped us to streamline the work of the Human Resource Manager and the recruitment committee. Job descriptions for each department are prepared and staff sign them on the day they start their new jobs.

Obituary: We lost our Board Member Mr. Mathias Ssendegeya (Lawyer). He died in an accident. May his soul rest in eternal peace.

Kitovu Hospital Annual Report 2008/2009 19 KITOVU HOSPITAL ORGANOGRAM

Board of Trustees of Masaka Diocese

Delegation of powers Ministry of Health

Board of Governors Kitovu Hospital UCMB

Advisory Assembly District Health Authorities

Management Team headed by a Chief Executive (Hospital Director/Financial Controller) and Consisting of Heads of the main Departments

Advisor/Head Medical Senior General Services Human Resource CBHC/PHC Principal of Clinical Superintendent Nursing Officer Accountant Manager Manager Coordinator Tutor Services

Head of Nursing Assistant Head of Responsible for Head of preventive/ Head of Head of medical doctors Services, Accountants, cleaning, staff recruitment, promotive services, Lab. and paramedical staff, Nurses and Cashiers, maintenance of welfare, nutritional education Training, Pharmacy, Statistics Nursing staff Income generating infrastructure, personal issues and rehabilitation Tutors Rehabilitation. Laboratory, projects, equipment, and transport and Regional Blood Bank, Kitovu Community ground, students. X-ray, Ultrasound scan Health Insurance security and Theatre, Chaplain, Scheme catering services Psychosocial, Counselling and ySocial work services 20 8. HUMAN RESOURCE (STAFF)

At the close of the financial year, there was a total of 200 employees. Of those 113 were medical and 87 non medical staff. The table below indicates the total number of staff by designation this year and a comparison to the past five years. Distribution of staff in the various categories over five years

Staff category 2004/2005 2005/2006 2006/2007 2007/2008 2008/2009 Consultants 2 2 2 2 2 M/O special grade 1 1 1 2 2 Senior Medical Officer 0 3 3 2 1 Medical officers 3 1 2 3 3 Intern Doctors 2 2 2 1 2 Dispenser 2 1 1 1 2 Pharmaceutical Assistant 2 2 1 1 1 Pharm. Store Assistant 1 1 1 1 2 Drug billing nurse 0 1 1 1 1 Dispensing Aides/Nurses 4 4 4 4 3 Anaesthetic Officer 2 2 2 2 2 Anaesthetic Assistant 1 1 1 1 1 Darkroom Attendant 1 1 0 0 0 Radiographer Assistants 2 1 1 1 1 Lab Technician 1 2 2 1 2 Lab Assistants 12 11 12 10 11 Phlebotomists 2 2 3 3 2 Blood Donor Recruiter 1 2 Clinical Officers 2 3 3 3 3 Chaplain 1 1 1 1 1 Social workers 2 2 2 2 2 Lab.Technologist 1 0 0 0 0 Counselors 5 6 4 2 3 Patients Care Attendant 1 Senior Nursing Officer 1 1 1 1 1 Double Registered nurse 2 3 2 2 3 Registered Nurse 6 5 5 7 7 Enrolled Nurses 36 30 31 28 27 Enrolled comprehensive Nurse 1 1 Reg. Midwives 2 3 0 2 4 Enrolled midwives 10 7 13 13 12 Nursing assistants 8 8 8 9 9 Nursery nurses (Nutrition) 4 4 4 3 3 Theatre Assistants 1 2 3 3 2 Clinical Instructors Lab. School 3 2 2 4 3 Tutor Lab School 1 Graduate Nurse/Midwife 1 Complex Director 1 1 1 1 1 Personnel Officer 1 1 1 1 1 Supplies officer 1 1 1 1 1 Kitovu Hospital Annual Report 2008/2009

Accountant 3 3 2 2 2 Accounts Ass. 6 5 7 6 6 Cashiers 3 3 3 3 4 Store keepers 2 2 2 2 2 Internal Auditor 1 1 1 1 1 Medical records Ass. 2 3 4 4 4 Secretary (typists) 3 3 4 4 4 Data Clerk 1 1 Receptionist 1 1 1 Field Officer 1 Other Administrative staff 5 7 6 6 5 Artisans 6 6 6 6 6 Office Attendants 2 2 2 2 1 Drivers 5 5 4 6 6 Askaris 9 9 8 9 9 Group workers/Casual labourers 29 29 29 23 Cooks 6 6 6 7 7 Other support staff 6 Hospital IGA Project staff 7 8 Sub Total 85 87 88 94 77 Grand Total 207 202 207 211 200

Pre-nurses 35 17 24 33 23

It is important to note that some of the staff indicated in the table above were not directly working in the hospital. These included 9 staff working in the Blood bank, 3 in Health Insurance Scheme and 8 in Hospital income generating projects. Also, the bottom line is for pre-nurses who were on exposure getting prepared to join Nurses Training Colleges. This year they were 23 in number.

According to the hospital staff establishment, the desired number for medical staff is 137, which was done on the basis of the UCMB WISN tool. So there was a gap of 27 medical staff.

Attrition of staff: During the period under review, a total of 55 staff left the hospital. Most of these, to a rate of 35.3% joined public service, and 38.2% NGOs. In order to fill the gaps a total of 45 staff were recruited. The table below shows the details and a comparison of this against the staff movements in the previous three years:-

Kitovu Hospital Annual Report 2008/2009 22 Kitovu Hospital Annual Report 2008/2009

The table showing details of staff movements for the past four years

Category 2005/2006 2006/2007 2007/2008 2008/2009 No. of No. of No. of No. of No. of No. of Departures Replacements Departures Replacements Departures Replacements No. of No. of Departures Replacements Medical Staff Medical Officer Special 0 0 1 1 0 1 Senior Medical Officer 1 0 1 Medical Officer 1 2 2 3 0 1 2 2 Intern Doctors 5 4 5 5 4 3 4 5 Dispenser 1 0 0 0 1 Pharmaceutical Ass. 0 0 1 0 0 0 Dispensing Aide/Nurse 1 1 1 3 0 0 1 Pharmacy store Assistant 1 Anaesthetic Assistant 1 1 1 1 Lab Technologist 1 0 0 0 0 0 Lab. Technician 0 1 0 0 1 0 1 Lab. Ass 2 1 2 3 1 0 3 4 Blood Donor Recruiter 2 Tutor Lab School 1 Clinical Officers 4 5 0 0 0 0 2 2 Chaplain 1 1 0 0 1 1 Counsellors 0 0 3 1 2 0 1 2 Patients care Attendant 1 Double Reg. Nurse 2 0 1 0 0 0 1 Reg. Nurses 3 2 0 1 1 3 2 2 Enrolled Nurses 7 9 9 11 10 8 5 4 En. Comp. Nurse 0 0 0 0 0 1 Reg. Midwives 1 2 2 0 0 1 1 3 Enrolled Midwives 3 0 6 12 3 3 6 4 Nursing Ass. 2 2 1 1 0 0 Theatre Assistant 0 1 0 1 0 0 1 Clinical Instructor-Lab T Sc 1 0 0 0 0 3 3 2 Graduate N/M 0 1 1 0 Darkroom Attendant 0 0 0 0 0 0 Subtotal 35 31 34 43 26 26 33 39 None Medical Staff Complex Director 1 1 Accountant 0 0 1 0 0 0 Accounts Assistants 1 1 0 1 0 0 1 Cashiers 2 1 1 2 1 1 Store keeper/ Ass. 0 1 Records Ass. 1 1 0 1 0 0 1 Blood donor recruiter 0 1 Secretaries 0 0 0 1 1 1 Data Clerk 0 1 IGA Manager 0 0 0 0 0 0

Kitovu Hospital Annual Report 2008/2009 23 Kitovu Hospital Annual Report 2008/2009

Administration Staff 2 2 1 0 0 0 1 1 Receptionist 1 1 0 0 0 0 Cooks 1 1 0 0 Artisan 1 1 0 0 Office Assistant 1 0 0 0 2 Driver 0 0 1 0 1 3 Askaris 1 0 0 0 2 3 Other support staff 3 0 16 Hosp. IGA project Staff 1 1 8 5 1 1 1 Subtotal 8 7 16 12 8 10 22 6 Grand Total 43 38 50 55 34 36 55 45

Other Support staff In an effort to improve cleanliness in the hospital the slashing, digging and cleaning both outside and inside of the building was contracted to Fore Front Company. 16 of the staff who were doing this service were terminated from the hospital but were recruited by the contractor.

Trend of Attrition of Nurse Cadre: The trend of turnover of the nursing cadre for the last 5 years has been calculated and the results are shown in table and graph below:-

Cadre 2004/05 2005/06 2006/07 2007/08 2008/2009 Total Staff 207 202 207 211 200 No. of Enrolled Nurses and Midwives 46 37 44 42 39 No. of Enrolled Nurses And Midwives Lost (combined) 14 10 15 12 11 Average No. of available Nurses between previous and current year 44 41.5 40.5 43 40.5 Trend i.e staff lost /Average 0.32 0.240 0.370 0.28 0.27

Graph showing the Trend of Turnover of Enrolled Nurses and Midwives (combined) during the past four years:-

0.4

e 0.35 t

a 0.3 r

r 0.25 e 0.2 Staff loss Trend v

o 0.15 n

r 0.1

u 0.05 T 0

5 6 7 8 9 /0 /0 /0 /0 0 4 5 6 7 0 0 0 0 0 /2 0 0 0 0 8 2 2 2 2 0 0 2 Years

As indicated in the table and graph above, the rate of nurses leaving our hospital has been varying. In 2004/05 the number was high, in 2005/06, fewer left and the highest number was in 2006/07. In 2007/08 fewer nurses left the hospital and in this reporting period the number Kitovu Hospital Annual Report 2008/2009 24 Kitovu Hospital Annual Report 2008/2009 reduced. It is also expected that the number of nurses who will leave in the following year will reduce further since the plan to improve staff terms and conditions of service is still a priority.

Observations: The trend of turnover of Enrolled nurses has been declining in the last two years. (2006/2007– 2007/08). This is a positive trend which has resulted from improvement in the employment terms and training our own staff.

Manpower planning: In the previous year, the training and recruitment committee was established and it started drawing manpower plans from a small scale and it is committed to continue doing so.

Working hours: All staff work 8 hours a day, 5 days a week with two days off. In addition, duty rosters were made for nurses, doctors and allied health professionals to cover night duties, on calls, weekends and public holidays. These were compensated for by taking day offs and overtime payments.

The hospital has a Manual of Employment which was fully followed as a guide towards handling staff issues, for instance 60 working days paid maternity leave and 4 days paternity leave were implemented and hence given to staff who delivered in the course of the year.

Regarding facilities and incentives, salaries were paid in time. Most Medical Staff are housed on hospital compound since they are required to do night duties. Houses are free and fully furnished with basic furniture plus free water and electricity.

The table below shows the categories and number of staff who benefit from this facility. Human Resource Capacity Available Recommended Gaps Number Staying in a staff house Category Comments

Medical officers 10 14 4 10 Anaesthetic Assistant 3 3 0 1 Clinical officer 3 3 0 3 Registered Nurse or Midwife 15 17 2 8 (RN, RM, RNM, RCN, other) Enrolled Nurse or Midwife 43 60 20 29 (EN, EM, ENM, ECN, other) Laboratory Technician 2 3 1 1

Laboratory Assistant 11 11 0 6 Theatre Assistants 2 3 2

Comments on the Human Resource capacity Of the 10 Doctors available, 2 are Intern Doctors.

Kitovu Hospital Annual Report 2008/2009 25 Kitovu Hospital Annual Report 2008/2009

Of the 14 Doctors recommended, 4 are Intern Doctors The total No. of recommended staff of the above categories is 114; of these, at the close of the financial year they were 86 only, hence a gap of 28 staff. Of the 86 staff available, 60 were residents and 26, non residents

Career Development: The hospital management took advantage of the opportunities available for staff career development. By the end of the period, 11 staff were sent on training. The details are shown in table below:-

Cadre of Staff No. Sent for Duration of Source of funding Duration of bonding to training training be effected post-training Friends of Radiographer 1 3 years Kitovu 3 Years Laboratory Technician 1 2 years UCMB 3 Years 1 Registered Nurses 3 2 /2 years UCMB 3 Years Friends of Registered Mid wives 2 3 Kitovu 3 Years Friends of Comprehensive Nurse 1 3 Kitovu 3 Years Friends of 1 Enrolled Midwives 3 2 /2 years Kitovu The main sources of funding: The main sources of funding were UCMB and friends of Kitovu Hospital.

Recommendation, actions/Plans: In the next financial year, it is recommended that the hospital management strives to increase staff salaries to match with government salary scales. This will minimize staff loss especially the enrolled nurses and midwives who have the highest turnover.

With the introduction of training and recruitment committee effort will be made to develop a Human Resource Development Plan for the hospital.

Obituary: During this review period, the hospital was faced with grief when its members of staff died, by the names of Kawuki Remegious. He was the chief Security Officer who had served the hospital for a period of 12 years.

Training: • School for Lab. Assistants: It was opened in 2004. For the time being we have 46 students, the graduates are 57 those who sat for their exams 23 . • Other trainees are; Medical Doctors for VVF repair, Intern Doctors, Medical students from Makerere, , Gulu University, UK and Ireland, Clinical Officers, Student Nurses

Kitovu Hospital Annual Report 2008/2009 26 Kitovu Hospital Annual Report 2008/2009

from Villa Maria and Masaka, Counsellors, Lab Assistants from Mbale and Fort Portal. Other students from Makerere and Kyambogo University for Industrial Training in Nutrition etc. We got capacity building workshop, we have on going training through carrier professional development weekly.

9. FINANCES (graphs and pie charts see Annex iv)

INTERNAL BUDGETING

Kitovu Hospital Annual Report 2008/2009 27 Kitovu Hospital Annual Report 2008/2009

A detailed master budget was compiled by the accountant All department heads were involved in the preparation of the budget

COST CENTRES Cost centre accounting is used on direct costs and income in the computer package Indirect costs are to be apportioned to different direct cost centres

EFFORT TO INCREASE INCOME For income generating projects we still have hope in Kampala building as its income is constant However we need to put maximum use on this land and building as it is in a good strategic place

We are still developing Nabulago land and we have constructed a pig-sty there to enable us look after animals as well as crops On the other hand however we need to grow perennial crops that are not labour intensive to enable us harvest more We have proposed to grow mangoes as well as extending the eucalyptus forest Annual crops are also grown though sometimes we are hit by drought

We have tendered the compound and ward cleaning as supervising workers had become a problem. This however has proved to be very expensive though the hygiene has improved so greatly

Medical sundries and drugs: The system of distributing drugs and sundries directly from Pharmacy to inpatients was implemented in Maternity, Medical and Children’s wards. Surgical ward is the only left because of inadequate number of lockable drawers.

We need to continue monitoring the usage of drugs to reduce the costs.

10. ACTIVITIES

CURATIVE SERVICES:

Kitovu Hospital Annual Report 2008/2009 28 Kitovu Hospital Annual Report 2008/2009

OUT PATIENT DEPARTMENT

The staff of OPD are fifteen (15) in number; namely, 6 enrolled nurses, 2 registered nurses, 3 clinical officers, one cashier, one patient registrar, one counselor, one medical officer who is on and off and other Doctors who run medical and surgical clinics. Special clinics:- 1. General Medical clinic ------operates on Thursdays 2. Diabetic clinic ------operates on Tuesdays 3. Surgical clinic ------operates on Wednesday and Friday 4. Gynaecological clinic ------operates on Monday and other days when the gynaecologist sees that it is necessary. 5. Paediatric clinic ------operates on Mondays

New and Re-attendances in the last 5 years

2004 –05 2005 –06 2006 –07 2007 –08 2008 - 09

New 0 – 4 Years 4065 5403 2601 2731 4255

F attendance e

m 5 Years & above 10181 7416 7360 7974 6500 a l e Re-attendance 0 – 4 Years 1012 1966 1236 1231 2133

5 Years & above 3758 3062 3520 3191 3810

New 0 – 4 Years 400 5368 2260 2581 4120

M attendance

a 5 Years & above 7550 6023 6272 6491 6161 l e Re-attendance 0 – 4 Years 1012 1940 1248 1153 2002 5 Years & above 3365 2396 3107 3195 3641 Total 31343 33574 27604 28547 32622 Referral to Unit 592 1022 981 1134 963 Referrals from Unit 57

OPD attendance has increased by 14%. This could be due to better recording and also there were two seasons of malaria outbreaks.

SEASONAL VARIATIONS IN OPD UTILIZATION

OPD ATTENDANCE BY MONTHS FOR THE LAST TWO YEARS (2007/2008-2008/2009)

Kitovu Hospital Annual Report 2008/2009 29 Kitovu Hospital Annual Report 2008/2009

CATEGORY YEARS MONTHS 2007-2008 2008-2009 JULY 3244 2962 AUG 2218 2452 SEPT 1757 2199 OCT 2024 2632 NOV 1946 2515 DEC 2061 2554 JAN 1996 2533 FEB 2437 2437 MARCH 2394 2987 APRIL 2378 2793 MAY 2547 2974 JUNE 2755 3584 TOTALS 27757 32622

OPD ATTENDANCE BY MONTHS FOR THE LAST 2 YEARS

4000 3000 L

A 2000 T O

T 1000 0 2007-2008

T V C N B 2008-2009 LY G T C E A E IL Y E U U P O O D J F CH R A N J A E N R P M U S A A J M MONTHS

In the month of March April, May, June, and July the hospital get many patients, most of them are suffering from malaria, aneamia and upper respiratory infection. • Factors influencing utilization:

1. Twenty four hours services.

Kitovu Hospital Annual Report 2008/2009 30 Kitovu Hospital Annual Report 2008/2009

2. Location: Kitovu located on Masaka–Kampala high way so many road traffic accident victims are brought at the hospital, especially on weekends and on public holidays. 3. Blood Bank: Kitovu has a regional blood bank so many patients are referred here to receive blood. 4. The presence of specialists in Gynaecology and obstetric, surgery, peadiatric and medicine attracts patients to come to the hospital. 5. V.V.F Services: Four workshops of Vesco Vaginal Fistula repair and training are carried out every year. People coming for repair are increasing year after year. This hospital is the only one offering this service in the Region. 6. Chemotherapy: Many cancer patients are referred here for treatment mainly children. 7. Poverty: Some patients fail to come for services and others are brought late at terminal stage. 8. Cultural Beliefs of our people, patients delay in coming to the hospital thinking that their diseases will only be treated with traditional medicines, thus delay in seeking health care. 9. Availability of free medicine in Government facilities.

10. Nutrition Unit: This service is found at Kitovu Hospital only in this region.

• An improvement in the areas of patient satisfaction. For this year, it was to increase space between beds in maternity ward and to divide the staff in 2 groups; one group to remain on admission and another on labour ward. This was not implemented as we had to do major repair on the ward. Mothers were squeezed in available spaces here and there during repair. We plan to implement it next year.

Referral to and from the hospital:

Many patients are referred here from the five districts of Masaka region – because of the twenty four hours services. Most cases referred are for obstetric emergencies, Gynaecological cases, Surgical and anaemia cases for blood transfusion. Referrals from the hospital are few and are mainly Neural, cardic and complicated orthopedic cases.

Quality assurance: Quality Assurance Committee, Discipline and Grievances committee are functional. Measures are in place to get information from the patients, their attendants and other clients about the services of Kitovu hospital. These include:-

Kitovu Hospital Annual Report 2008/2009 31 Kitovu Hospital Annual Report 2008/2009

1. Patients satisfaction questionnaires. 2. Suggestion boxes are in place and are opened monthly by Disciplinary and grievance committee. 3. Some patients talk to staff or members of management team about the services. 4. Meetings: Some members of management once in while hold meetings with particular departments to iron out problems on the ground. 5. Inter-department meetings are held monthly. All the above help management to know the positive and negative aspects of the hospital and this has helped us to improve; in cleanliness, communication, cooperation, team work etc.

Maternal death audits are carried out and reports are sent to the District.

Prescription Survey are done annually.

- Medical audit is irregularly done - Waiting time: We tried to reduce the waiting time by increasing numbers of Clinicians at the OPD. - There is need for documented follow-up.

TOP TEN LIST OF OPD DIAGNOSIS

2004-2005 2005-2006 2006-2007 2007-2008 2008-2009 Malaria 10912 Malaria 10,036 Malaria 8017 MALARIA 5165 MALARIA 6056 GID 2123 Aneamia 2540 Anemia 2761 ANEMIA 1865 RTI 2457 Anaemia 1690 HTN 1283 HTN 1570 HTN 1037 HTN 2367 HTN 1540 DM 835 Pneumonia 656 DM 624 ANEMIA 1534 UTI 1219 GID 738 RTI 1261 PNUEMONIA 490 DM 1259 TB 1059 UTI 614 UTI 702 UTI 420 GE 881 DM 932 Pneumonia 559 RTA 419 GE 367 PNEUMONIA 730 Skin disease 740 PTB 529 PTB 276 AIDS 324 ABORTIONS 245 Pneumonia 690 AIDS 417 ASTHMA 275 RTA 207 CCF 200 Skin AIDS 594 diseases 324 ABORTION 204 SKIN DISEASE 108 ASTHMA 186

• Malaria and Anaemia are the most causes of morbidity and mortality followed by pneumonia, RTI. • There is concern of the increased number of abortions in the area. There is a need for deliberate effort to study this condition.

IN-PATIENT: We have the following Units with their respective bed capacities. Medical ward 46 Beds Children’s ward 64 Beds

Kitovu Hospital Annual Report 2008/2009 32 Kitovu Hospital Annual Report 2008/2009

Surgical ward 39 beds Maternity ward 37 beds Nutrition ward 14 beds VVF ward 28 beds

Total 200 beds ======Please note that 28 beds of VVF ward are not included in 200 beds as these are not permanent beds. They are used at specific periods during the year.

INPATIENTS WARDS

Medical ward:

MEDICAL WARD ( 46 Beds) 2004-2005 2005-2006 2006-2007 2007-2008 2008-2009 Admission 2431 2504 1941 1686 2283 Inpatient days 12949 13316 10622 8133 10420 Average L.O.S 5 6 5 5 5 Bed Occup Rate 77% 90% 63 48% 63% Deaths 216 210 183 120 179 Death rate 9% 8% 9% 7% 8% Average Occup 35 37 29 22 29 Recovery Rate 91% 92% 91% 93% 92% Self Discharge

The Utilisation parameters of admission, bed occupancy rate, and recovery rate have increased. Average length of stay has remained the same of 5 days.

Challenges: o Lack of private and adequate isolation rooms o Admission on medical ward (80% ) have HIV/AIDS requiring much care with increased costs. The majority of these are admitted with complications of ARV’s.

Plan: o Solicit funds for private and isolation rooms o To start providing ARV’s to our patients thus giving total care.

Children’s ward:

CHILDREN WARD (64 beds) 2004-2005 2005-2006 2006-2007 2007-2008 2008-2009 Admission 5630 6279 4301 2672 3773 Inpatient days 22026 26783 19276 11899 15693

Kitovu Hospital Annual Report 2008/2009 33 Kitovu Hospital Annual Report 2008/2009

Average L.O.S 4 5 5 4 4 Bed Occup Rate 94% 113% 83% 51% 67% Deaths 367 446 419 213 173 Death rate 7% 7% 10% 8% 5% Average Occup 60 73 53 33 43 Recovery Rate 93% 93% 90% 92% 95%

The utilization parameter, death rate, and recovery rate have improved probably due to the presence of Peadiatrician and a Medical Officer on the ward. Any increase number of admission could be due to increased cases of malaria and lack of coartem for six months in the country. Admission has increased by 41%, average length of 4 days has remained the same as last year.

Maternity ward:

MATERNITY(37 beds) 2004-2005 2005-2006 2006-2007 2007-2008 2008-2009 Admission 2947 2698 2437 2782 3245 Inpatient days 12625 15410 13081 13484 14965 Average L.O.S 4 9 5 5 5 Bed Occup Rate 93% 108% 97% 100% 111% Deaths 31 19 22 21 20 Death rate 1.10% 0.71% 0.90% 1% 1% Average Occup 35 42 36 37 41 Recovery Rate 98.90% 99.3% 99.10% 99% 99%

Most of utilization parameter have increased; such as admission, bed occupancy of 111%. Admission has increased by 17%. Average L.O.S and recovery rate remained the same as last year.

Surgical ward:

SURGICAL WARD(39 beds) 2004-2005 2005-2006 2006-2007 2007-2008 2008-2009 Admission 1201 1446 1314 1347 1463 Inpatient days 10711 13181 8167 7670 8122 Average L.O.S 9 9 6 6 6 Bed Occup Rate 75% 83% 57% 54% 56% Deaths 51 48 75 66 74 Death rate 4% 3% 6% 5% 5% Average Occupancy 29 36 22 21 22

Recovery Rate 96% 97% 94% 95% 95% Surgical wards admissions have increased by 8.6% but other parameters such as ALOS, death rate and recovery rate remained the same as last year. Nutrition Unit:

Kitovu Hospital Annual Report 2008/2009 34 Kitovu Hospital Annual Report 2008/2009

NUTRITION UNIT 2004-2005 2005-2006 2006-2007 2007-2008 2008-2009 Admission 174 140 164 221 268 Inpatient days 3571 2652 3099 4325 4503 Average L.O.S 21 19 19 20 17 Deaths 7 16 12 17 23 Average Occup 10 7 9 12 12% Death rate 4% 12% 7% 8% 9% Recovery Rate 96% 88% 93% 92% 91% Bed Occup Rate 70% 50% 61% 84% 86%

All utilization parameters have declined except that of admission. Increased admission is attributed to the new programme of referrals from Caritas MADDO Nutrition programme.

Overall utilization of 200 beds in 5 years

GENERAL TOTAL 2004-2005 2005-2006 2006-2007 2007-2008 2008-2009 12,38 Admissions 3 13067 10453 9003 11032 61,88 71,34 In-patient days 2 2 57774 45511 53676 Average L.O.S 5 6 6 5 5 Bed occupancy Rate 85% 98% 79% 62% 74% 73 Death 672 9 713 437 469 Death Rate 5% 6% 7% 5% 4% 19 Average Occupancy 170 5 158 125 147 Recovery rate 95% 94% 93% 95% 96% Referrals in 818 1022 1702 1134 557 Referrals out 36 210 300 132

Overall admission has increased by 23%, average length of stay is 5 days, death rate is 4% and recovery rate is 96% (which are good trends). Bed occupancy rate is 74% 12% higher than last year. Overall utilization is better than that of last year.

TOP TEN CAUSES OF ADMISSION

2004-2005 2005-2006 2006-2007 2007-2008 2008-2009 Malaria 5515 Malaria 6456 Malaria 5461 Malaria 2336 MALARIA 3817 Anaemia 2080 Aneamia 2213 Anemia 2717 Anemia 1121 ANEMIA 1790

Kitovu Hospital Annual Report 2008/2009 35 Kitovu Hospital Annual Report 2008/2009

Pneumonia 620 Pneumonia 832 RTI 595 Pnuemonia 621 PNEUMONIA 813 AIDS 519 HTN 681 Pneumonia 435 AIDS 313 RTI 650 GID 293 AIDS 397 Abortions 258 Abortion 258 AIDS 469 RTI 286 RTA 325 AIDS 247 RTA 224 ABORTIONS 336 ACUTE TB 270 PTB 297 RTA 246 HTN 190 DIARRHOEA 224 Resp. Abortions 221 infections 248 PTB 202 PTB 185 PTB 223 RTA 220 DM 239 HTN 154 UTI 91 HTN 212 Diarrhoea- Acute 155 Abortions 232 DM 140 HERNIA 87 ASSAULT 176

TOP TEN CAUSES OF DEATH

2004-2005 2005-2006 2006-2007 2007-2008 2008-2009 Malaria 278 Malaria 548 Malaria 455 MALARIA 219 MALARIA 105 Pneumonia 74 Anaemia 292 Anemia 282 ANEMIA 147 ANEMIA 66 AIDS 56 Pnuemonia 91 Pneumonia 106 PNUEMONIA 68 PNEUMONIA 62 Kwashiokor 21 AIDS 88 AIDS 47 AIDS 49 AIDS 62 Anaemia 19 PTB 27 RTI 46 PTB 35 PTB 21 GID 18 DM 25 PTB 41 HTN 18 MENINGITIS 20 TB 17 Reapiratory 18 RTA 20 ASSAULT 15 SEPTICAEMIA 18 HTN 15 RTA 17 HTN 9 KWASHIRKOR 12 DM 11 GENITAL RTI 7 Diarrhoe 14 HEANIAS 7 RTA 11 INFECTIONS 7 RTA 7 CCF 12 ASTHMA 6 UTI 10 RTI 7

The Organisation and Management of the Wards

Each ward has a ward Doctor and a ward nursing sister who are responsible for the complete management and organisation of the ward.

Patients are admitted from OPD by Clinical Officers, Intern Doctors, Junior or Senior Doctors. Discharge is done by doctors. Admissions and discharges are recorded on the ward.

On each ward, rounds are done on Mondays, Wednesdays and Fridays. On other days new admissions and severe patients are reviewed by Doctors.

Emergencies – Doctors are called to attend to emergencies as they arise.

Treatment schedules are based on National Treatment Guidelines.

Working shifts on each ward: Nurses have three shifts o 1st shift from 8:00am – 5:00pm o 2nd shift from 8:00am – 1:00p.m and o 3rd shifts (night duty from 8:00p.m to 8:00a.m) Kitovu Hospital Annual Report 2008/2009 36 Kitovu Hospital Annual Report 2008/2009

Health care quality control mechanism: Quality control mechanism and medical audits are not regularly done. Patients’ condition on discharge, death rate, self discharge and runaway cases are recorded.

Appropriate prescription practices: Prescription survey is done every year. Good prescription behaviour is encouraged by the senior doctors to the prescribers in doctors meetings.

Patient satisfaction survey is done every year. Also patient suggestion boxes are in use and are checked by grievance and disciplinary committee members.

Hospital infections: There is an active infection control committee. Visits of specialists: we get specialists for VVF repairs at least 4 times a year. We are supposed to be visited by specialists from Masaka Referral Hospital though, they are not regular.

Relative’ hostel: Is available and free it is however, mainly used during the day for storage because relatives prefer sleeping on wards at night.

Pastoral care of patients: This is available 24 hours everyday.

Maternity ward (Additional information)

There was an increase in total admissions this year compared to last year as seen in the table of statistics. The main reason for admissions complicated of pregnancy e.g. bleeding during pregnancy and infection particularly malaria, urinary track infection infections and respiratory track infections in pregnancy. Few postnatal admissions due to anaemia and puerperal sepsis.

Gynaecological admissions are proportionate with the known etiological causes of Gynaecological diseases in Uganda.

Cancer of the cervix tops gynaecological malignancies and Uterine Fibroids are the leading cause of admissions among benign tumours.

Bed occupancy rate has gone high as we had anticipated in the previous year’s report.

Deliveries: Table showing Deliveries and Births

DELIVERIES AND BIRTHS 2004-2005 2005-2006 2006-2007 2007-2008 2008-2009 Admission 2305 2515 2291 2565 3247 Total deliveries 1377 1470 1397 1548 1863

Kitovu Hospital Annual Report 2008/2009 37 Kitovu Hospital Annual Report 2008/2009

Normal 944 1008 882 970 1101 Abnornal (CS) 433 462 515 578 708

Live births 1290 1333 1279 1395 1810

Neonatal deaths 38 29 20 28 28

Neonatal mortality 2.80% 2% 1% 2% 2% Maternal deaths 25 19 22 15 16

Still births 118 128 8 9 53

FSB 15

FSB (UCMB)

Induction 25 19 13 21 Episiotomy 135 117 113 142 Macerared still births 127 82 38

Forceps/ vaccum 13 19 6 0 30

N.B: Records for Induction and Episiotomy not available. Total deliveries increased this year compared to last year. This is in accordance with a similar increase in total admissions. Therefore there were more maternity (obstetric) admissions than gynaecological admissions. It is important to note that in Kitovu, obstetric services costs are subsidized greatly as opposed to gynaecological service costs. This implies therefore that the higher the proportion of obstetric care, the more the maternity department and probably the hospital in general is strained in terms of human resource (midwives and Doctors) and the supplies like medicines, gloves etc.

Ceasarian Section: The ceasarian section rate remained higher (37%) as last year. Again the reasons for this seems to be the trend of referral system in our region. Because of a regional Blood Bank at Kitovu and a reliable theatre with constant power available (Kitovu has a stand by generator), we receive more referrals for emergency ceasarian section.

Secondary the vacuum extraction machine we have is not functioning. There is need to have a functioning ventouse. Fetal outcomes: Total still births were 53 out of 1863 total births. This is equivalent to still birth rate of 2.8%. Fresh still births (FSB) were only 15 which is only 0.8% of total deliveries. It is practically not possible to reduce FSB to vero, because of inevitable causes like abruptio placental and cord prolapse.

Kitovu Hospital Annual Report 2008/2009 38 Kitovu Hospital Annual Report 2008/2009

Neonatal deaths: Total death of 28 neonates is significant. Commonest causes of neonatal deaths are birth asyphyxia and prematurely. There is therefore justification for a neonatal intensive care unit.

Maternity outcomes: Maternal morbidity: There is effective management of labour in Kitovu Hospital maternity. Obstructed labour and its sequence (e.g. ruptured uterus, VVF) are not evident among mothers who labour from Kitovu Hospital. However we do manage patients who are referred with obstructed labour and sometimes when the already have ruptured uterus.

Postpartion heamorrhage (P.P.H) is effectively prevented with the use of readily available oxytocixs. Postceasarian sepsis is very minimal because of availability of antibiotics.

Maternal Mortality: There were 16 maternal deaths in 2008/2009.

The respective causes of death were:

 Brain Hypoxia - 1  Endotoxic shock - 1  Ruptured - 1  Malaria with Anaemia - 1  Abruptio Placenta - 1  Gangrene of small bowel - 1  Eclampsia - 1  Encephalopathy - 1  Post partum haemorrhage - 4  Ectopic - 1  Chorio Carcinoma (Molar Preganacny) - 1

Theatre:

SURGICAL PROCEDURES

Table showing types of operations done

Kitovu Hospital Annual Report 2008/2009 39 Kitovu Hospital Annual Report 2008/2009

MAJOR SURGICAL PROCEDURES

Procedure Number Caesarian sections 698 Laparatomy 271 Tracheostomy 0 Evacuations 152 Internal fixation 1 Burr hole 0 Thoracotomy 0 VVF Repair 229 Other Major 447 Total Number Major Operations 1569

MINOR SURGICAL PROCEDURES Procedure Number Dental extractions 0 Herniorrhaphy 93 Debridement and care of wounds and skin 579 grafting Incision and drainage of abscesses 119 Plastic/ reconstructive surgery 2 Ocular surgery 0 ENT surgical procedures 59 Other Minor 724 Total Number Minor Operations 1576

Most of the operations done are for Caesarian Section, Debridement, skin grafting followed by VVF repair.

Table showing types of operation done and Anaesthesia

OPERATIONS DONE & 2004- 2005- 2006- 2007- ANAESTHESIA 2005 2006 2007 2008 2008-2009 Major Operations general obs +Gyn 927 1240 1202 1123 1589

Kitovu Hospital Annual Report 2008/2009 40 Kitovu Hospital Annual Report 2008/2009

Minor Operations O.T. labour, ward casualty 1050 1258 1659 1344 1576 Total operations 1904 2498 2861 917 3145 Emergencies 630 942 854 2470 1350 %Emergencies of major operation 0.68 0.76 0.71 0.82 86% Elective 608 1387 1450 1084 954 %Elective 0.32 0.56 0.51 0.44 30% General Anesthesia 432 1050 961 432 1140 GA Tube 755 995 464 420 520 Spine Anesthesia 150 217 409 724 670 Local ring block 0.22 30 20 57 30

Surgical Ward:

Achievements: I. November 2008 the Operating Theatre Block was modernized and modified with vast improvements in space made available (the Emergency Theatre (III) was enlarged, modified with proper scrub-up area, with its entrance to facilitate Day Surgery plus emergency Minor Surgery e.g. Drainage of Abscesses, Surgical Wound Toilet, Reduction Immobilization of Fractures, Biopsies for Histology etc. This has greatly helped to preserve cleanliness and asepsis in our main Theatre I & II. We also improved changing facilities for male/female staff and added a Staff Tea Room, Toilet & shower plus an office for the Anaesthetists. The previous office was modified to become the Recovery Room and this was funded by Guernsey Rotary Club U.K thanks to Dr. Tim Peet our dear friend and regular visiting surgeon who organised the funds. A Fourth Theatre was added to the Block with a new scrubbing area to facilitate Obstetric Fistula Repair Surgery – this building and equipment was funded thanks to AFRICARA Ireland. The Blessing and official opening of the Theatre Block modification and New Theatre was honoured by the presence of Dr. Tim Peet FRCS representing Rotary Guernsey UK and Dr. Jack Conway Obs/Gyn Ireland and Mary Gill RGN and RGN, AFRICARA Ireland. Dr. Stuart Musisi District Medical Officer (DDHS) represented M.O.H.

II. Four of our Pre-nurses were funded to study Theatre Technical course. Two have already finished and are busy Theatre Assistants helping in all 4 Theatres (Doreen Mayanja & Zobia). 2 are studying presently in Rubaga.

III. Sr. Dr. Margaret Mary Ajiko received sponsorship through A.S.O.U to present a paper on “Burkitt’s Lymphoma” to Surgeons Conference in Canada. We congratulate Dr. Margaret on successfully completing her East-African Surgical Fellowship and are very happy she continues to use her surgical skills in Kitovu.

IV. Dr. John Paul Magala received sponsorship from Belgian Embassy to do the M. Med in the Surgery Post Graduate course in Makerere and we look forward to the graduation of yet another of Kitovu’s successful Doctors.

Kitovu Hospital Annual Report 2008/2009 41 Kitovu Hospital Annual Report 2008/2009

V. Dr. Maura our Senior Surgeon celebrated the Golden Jubilee (50 yrs) of her Religious Profession as a Medical Missionary of Mary on 25th April ’09 DG and Fr. Joseph Matovu our Chaplain Celebrated Silver (25years) of Ordination on same Day.

VI. The Irish Society donated 5,000,000 Ug shs to renovate and decorate a ward in Paediatric Unit as a Chemotherapy Ward. This was Blessed and opened by His Lordship Bishop J.B. Kaggwa on our “Jubilee Day” 25th April’09. We received many gifts of T.V, Games and Donations for drugs and sundries for children with cancer from the Irish Society in Uganda, Concern and friends. We are most grateful to all. Challenges: 1. High costs of fuel and medical supplies are our increasing challenges to all departments. We need to prioritize on needs in drugs and supplies endeavoring to economise without compromise.

2. The recurrent power cuts has jeopardized the condition of our Theatre Generator and has overburdened our maintenance team and increased our fuel and overtime costs not to mention the burden caused by the fact that we still pay for electricity when the power is off and so we have double costs of generator fuel and electricity during power cuts!!

3. We need to petition an increase for delegated funds from M.O.H to help us buy medicine.

Future Plan:

1. Equip all Theatres with Better Lighting and purchase of battery-charged lights to take over during Power failure – already we have promise of funds for these from Rotary Club Guernsey U.K / Dr. Tim Peet.

2. We expect our 1st Radiographer – Michael Tamale to graduate Oct’09 and hopefully with Michael in the Department we need to equip it fully to employ his skills to 100%. We need a proper X-ray Machine (present one can only screen for Bone fracture and chest X-ray) with facilities for Barium Studies and other detailed X-rays (spines and Skulls).

SPECIAL CURATIVE SERVICE AND OTHER CLINICAL SERVICES: Tuberculosis The hospital use the national T.B/Leprosy control program guidelines. Admissions are usually via OPD and discharges are usually by doctors on ward rounds.

Kitovu Hospital Annual Report 2008/2009 42 Kitovu Hospital Annual Report 2008/2009

On T.B patients are started on the initial phase while in the hospital; At Discharge there are referred to their nearest Health Centres for CB DOTS. We do not participate in CB DOTS. Expected number of T.B patients in catchment area is 238.

Some T.B statistics for 2007/08 – 2008/09 2007/08 2008/09 Total admissions 185 223 All T.B patients 196 210 Pulmonary positive 87 87 Pulmonary negative 80 46 Pre-tested for HIV 19 97 Defaulted 1 1 Died 35 21 Relapse 3 1 Transfers in Nil Nil Transfers out 196 210 Children 22 27 X-rays 14 58 No. smear done 15 19 N.B: o Pre-testing started on 13th March 2008. o The number of transfer out is big because patients are treated in their nearest health centres following CB DOTs. o The number of PTB is on rise because of increased HIV/AIDS Detection rate: The implementation of DOTS is done by lower Health centres. Follow up activity should ideally be done after the initial phase and the continuation phase but few patients come back after each phase.

Obstetric Fistula Unit (VVF)

Obstetric Trauma , especially the occurrence of Fistula in women suffering trauma during delivery of their babies, continues to challenge but our achievements in this field must be highlighted too –

The Vesico Obstetric Fistula Unit has been recognized as a Training Unit for Fistula Repair, training for Doctors, Anesthetic Officers and Nurses since November 2004. It is financially supported by USAID through engender Health + UNFPA and private donors and recognized by Ministry of Health.

Table showing VVF patients registered and operated on in 2 years.

Years 2007/2008 2008/2009 No. of women operated 299 232 No. of women registered 319 246

Kitovu Hospital Annual Report 2008/2009 43 Kitovu Hospital Annual Report 2008/2009

Table showing number of patients and operations done for VVF for 2 years:

Total Operations 2007/08 2008/09 1. Vesco Vaginal repair 161 143 2. Rectovaginal Repair 6 11 3. Combined VVF / RVF 14 8 4. Others (Interventions) 55 67 No. of operations 236 229

Nine mothers have delivered after VVF repair. They get free Antenatal care, Ceasarean Section and transport provided by the fistula Unit.

Table showing number of trainees for Obstetric Fistula Unit2 years:

Trainees 2007/08 2008/09 Doctors 5 6 Aneasthetic Officers 5 3 Nurses/Midwives 10 4 Total 20 13

Challenge: • We do not have full time Surgeon or Gyneacologist for continuous obstetric fistula repair whereas there are many women who need this service.

Chemotherapy/Palliative care services: A renovated and decorated room on paediatric ward for chemotherapy was established. Services are still going on. Throughout the year 2008/09, 92 patients received several courses of chemotherapy (under guidance of Uganda Cancer Institute) funded by donors from Ireland. 15 had Burkittt’s Lymphoma and 77 Adults had Kaposis Sarcoma.

Patients are referred to us by; Kitovu Mobile/Palliative, Medical Research Council, TASO and Uganda Cares. We worked hand in hand with the above Organizations to care for these patients. We are grateful for their collaboration.

Prevention of Mother to Child Transmission (PMTCT) Programme:

This programme has existed since Feb 2004 (5 years). Our objectives: . Promote awareness of HIV /AIDS.

Kitovu Hospital Annual Report 2008/2009 44 Kitovu Hospital Annual Report 2008/2009

. Increase the understanding of the advantages HIV testing. . Test and counsel all new ANC mothers and their partners; offer Niverapine tablets to HIV Positive mothers to be taken at the onset of labour, to protect their babies. . Counsel on feeding options. . Encourage all HIV positive mothers to start taking Septrin daily. . Counsel on nutrition, thus improving general Health. . Encourage women to become self sufficient in areas of general health and in respect of their children. . Encourage communication between women and their sexual partners. . Encourage natural family planning. . Involve males particularly spouses in health services relating to PMTCT. . Encourage all mothers to make use of insecticide treated mosquito nets which are provided.

Clients 2005 - 2006 2006 - 2007 2007 - 2008 2008/2009 Total new ANC 1057 903 1014 990 Total No. of ANC Counselled 1057 903 1014 949 Total No. of ANC tested 912 961 981 949 Total No. of ANC tested HIV+ 103 83 86 62 Total No. of ANC HIV+ that accepted 27 73 84 46 Niverapine programme Total No. of live babies born to 16 4 mothers on Niverapine before 6 months Total No. born to mothers on 2 0 Niverapine & Tested after 6 month

Activities 2005- 2006 2006 - 2007 2007 - 2008 2008-2009 No. of Deliveries 1470 1501 1548 1863 HIV+ mothers delivered and enrolled 47 73 86 50 Mothers tested in labour N/A 106 254 244 Mothers tested HIV+ in labour N/A 18 18 10 Mothers tested HIV- in labour N/A 68 236 234

Comments: - Number of tested mothers at ANC differ from number of mothers enrolled because some of these mothers have undergone the test in other health units.

Kitovu Hospital Annual Report 2008/2009 45 Kitovu Hospital Annual Report 2008/2009

- We still get mothers to be tested in labour. This indicates that not all mothers get access to ANC services near their home areas. - More mothers have delivered from our health unit this last financial year. Though there is work load but there is a team spirit and very organized skilled staff of various categories.

Achievements: - On addition to Niverapine therapy we had in stock, we were provided with AZT - Two more of our qualified midwives were properly trained for this programme. - We observe improved and experienced staff acceptance of the programme (PMTCT). Mothers are freely expressing their concern and eagerly look for detailed information of this programme. - The counselling, testing and giving the results of HIV status are all done on the same day.

Challenges: - Poverty has caused an abuse of mosquito treated nets by those who receive them for sale to earn at least a days living. - Natural family planning is not effective because male partners do not accompany their wives at the clinic for education. - We give clients the information and refer them for ART from other Health facilities. - PCR test in babies/children is on decline. No resources for follow up. - Malaria control programme at ANC was partially performed due to lack of Fansider tablets (stock out) for some months. - No free Seprin for prophlaxis for mothers at the clinic. - We run out of stock of testing kits thus making our services incomplete.

Future Plans: - There is a need for an establishing of AIDS clinic at this health facility in the near future when the arrangements are completed.

- Consider including Fansider and Seprin prophlaxis in the Antenatal package.

HIV COUNSELLING AND TESTING/VCT

Kitovu Hospital Annual Report 2008/2009 46 Kitovu Hospital Annual Report 2008/2009

• The service is static and run daily at the hospital. • The CBHC section does some Outreaches on HIV- prevention whenever economically viable. • The service is mainly HCT/VCT. No ART clinic. The Sero-positive tested clients are referred to nearby ART clinics near their homes. • Other institutions like Kitovu Mobile Aids Organization, the prisons section – Masaka and the Hospital CBHC programme do HIV testing at the hospital laboratory. • Types of HCT : Diognostic and VCT • Staffing: 4 Counsellors 1 Laboratory technician 8 Laboratory Assistants. • HCT/VCT is one of the hospital activities. The Counselors and Laboratory staff, do HCT. The laboratory staff do other hospital required tests while the counselors do other Psychological required counseling on wards and OPD.

The actual HCT/VCT hospital output for year 2008/2009 as studied from gender, age group, TB detection and Co-trimaxazole prophylaxis is given in the table below:-

No. < 5yrs No. 5yrs < 18yrs 18yrs + Above Male Female Male Female Male Female No. Counselled 91 88 1073 2384 No. Tested for HIV 156 119 91 88 1032 2344 No. Received Results 156 119 91 88 1032 2342 No. Tested +ve for HIV(from Lab.Register) 36 60 11 10 250 393 HIV cases with confined T.B 12 4 4 2 51 49 Total TB cases tested for HIV 42 52 20 18 265 257 TB cases tested +ve for HIV 12 4 4 2 51 49 % of TB cases testing +ve for HIV 29 8 20 11 19.2 19.1 % of HIV cases confirmed having TB 29 8 20 11 19.2 19.1 HIV cases started on Cotrimoxazol Prophylaxis 35 28 20 24 188 280

The hospital laboratory tested HIV for Kitovu Mobile, Kitovu hospital, the hospital PMTCT – programme and the prisons programme – Masaka. The table below shows a tremendous increase in the number of clients demanding our services. No. < 5yrs No. 5yrs < 18yrs 18yrs + Above HIV counselled 254 257 1789 2990 HIV tested from Lab. Register 341 353 253 257 1784 2988 Received HIV results 340 351 253 255 1783 2985 HIV Positive from Lab. Register 82 91 49 45 496 684 HIV Positive cases with confirmed TB 12 4 4 2 51 49 HIV Positive cases started on cotrimaxazol 35 28 20 24 188 208 Prophylaxis

Kitovu Hospital Annual Report 2008/2009 47 Kitovu Hospital Annual Report 2008/2009

Table showing the dynamics of HCT/VCT by sex in the past five years:-

2004/05 2005/06 2006/07 2007/08 2008/2009 Number Tested Male 1862 (47.2%) 2001 (61.2%) 1100 (34%) 1153 (33.1%) 1279 (33.4%) Female 2085 (53%) 2528 (56%) 2171 (66.4%) 2334 (67%) 2551 (67%) Total (Tested) 3947 4529 3271 3487 3830 Tested +ve for HIV Male 471 864 226 203 297 Female 561 1190 396 416 463 Total (+ve tests) 1032 2054 622 619 760 Positivity Rates of HCT Male 25.3 43.2 21 18 22

Female 27 47.1 18.2 18 18.1

Depending on the above table, the line graph below presents the number of clients tested and number testing positive of HIV in percentages to give a quick understanding of the HIV infection in relation with gender through the past five years.

Below is a line graph presenting number tested and number testing positive in percentages (%):-

80

70 %

n

i 60

e %

v n i i t

i 50 Males Tested s d e o t d p Females Tested s

n

e 40 g t a

n Males testing positive i r t e s 30 b e Females testing positive t

m r u e 20 N b m

u 10 N 0 2003/04 2005/06 2006/07 2007/08 2008/09 Years

Like in 2005/2006 and 2007/2008, this year, number tested has increased due to increased human resources while the increased positivity among males is as a result of male testing due to current campaigns over discordance. Males often come alone for VCT to confirm their status while their partners often test alone in PMTCT clinics.

A trend of HCT services at Kitovu hospital by age and sex

Kitovu Hospital Annual Report 2008/2009 48 Kitovu Hospital Annual Report 2008/2009

2004/05 2005/06 2006/07 2007/08 2008/09

Kitovu Hospital Annual Report 2008/2009 49 Kitovu Hospital Annual Report 2008/2009

Number Tested Yr. 1 Yr.2 Yr.3 Yr.4 Yr.5 0<5yrs 342 159 109 97 156 Male 5<18yrs 229 408 152 92 91 18 and above 1291 1434 839 964 1032 0<5yrs 184 175 113 114 119 Female 5<18yrs 253 514 216 108 88 18 and above 1648 1839 1842 2112 2344 Total (Tested) 3947 4529 3278 3487 3830 Tested +ve for HIV Male 0<5yrs 65 47 26 9 36 5<18yrs 61 189 47 7 11 18 and above 345 628 153 187 250 Female 0<5yrs 50 111 37 19 60 5<18yrs 71 219 104 20 10 18 and above 440 860 255 377 393 Total (+ve tests) 1032 2054 622 619 760 Positivity rate of HCT Male 0<5yrs 6.3 2.23 4.2 1.5 5 5<18yrs 6 9.2 8 1.13 1.4 18 and above 33.4 31 25 30.2 33

Female 0<5yrs 5 5.4 6 3.1 8 5<18yrs 7 11 17 3.2 1.3 18 and above 43 42 41 61 52

This year, the age group 0 < 5years presents an increase in HIV testing. Thanks to PMTCT influence on Mothers and the existing effective pediatric clinic in the hospital which attract more children. The nutrition and Rehabilitation unit which digs deep in villages to bring children for health care helps a lot, coupled with the early infant Diagnosis of HIV. Quite a number of children survive death.

Age group 5 < 18 years presents a decrease in tests done. The female positivity rate has fallen while the male positivity rate has risen. This is most probably because of the misconception of protective campaigns to the girl child country wide e.g stopping Cross-general sex and Abstinence while the boy child lives in a non-clear campaign (reluctance to abstain). Many boys report to have used condoms and yet they test HIV positive a sign that not many of them abstain yet still they get little knowledge of condom use, hence HIV infection.

Among preparing couples for marriage, there is decreased HIV infection as studied from pre- marriage counseling and HCT. Contrary, the number of discordant couples increases, a clear sign of unfaithfulness of which women are more vulnerable.

Below is a graph presenting the volume of HCT/VCT in the past 5 years:-

Kitovu Hospital Annual Report 2008/2009 50 Kitovu Hospital Annual Report 2008/2009

5000 4000 d e t 3000 s

e Number Tested T

. 2000 o N 1000 0 2004/05 2005/6 2006/7 2007/08 2008/09

Ye ars

This year presents a slight increase in output due intense supervision, improved data collection and recording despite the static human resources. The OPD Counsellor received more individuals for HCT this year, thanks to all government campaigns on Radios, Television and News papers which sensitise people on HIV.

Achievements: • Increased output in HCT despite the static human resources. • Quality staff, rendering quality services, leading to increased service utelisation (increased number of clients). • Maintained relationship with the institutions where we refer our sero-positive-clients for ART. • Staff cohesion, progressing into proper client-management and record-keeping. • A maintained support system to clients through other psychological counseling services alongside HCT to interested individuals, families, students, HCT clients and any referrals from doctors and nearby authorities. • Maintained relationship with other organizations which test for HIV at our hospital laboratory.

Challenges: • Increased demand of our quality HCT, leading to increased workload onto insufficient human and economic resources. • Maintaining the current quality staff amidst the prevailing economic challenge. • Inability to provide ART to our sero-positive clients. • Wide spread poverty among our clients who some times fail to meet the required costs. • The co-existence of HCT section and the hospital breeds much workload on human resources and affects both sections’ effective work.

Implications for future planning: • Asses the meaning of increased demand of HCT at the hospital, to re-evaluate the availed budget on HCT service and its impact on the hospital economic and human resources. • The continuously regressing economic resources in this section, need attention; to determine the future of the service in the hospital. NB: Kitovu Hospital Annual Report 2008/2009 51 Kitovu Hospital Annual Report 2008/2009

The HCT human resources are broadly utilized to enhance the hospital wholistic approach to healing, by providing other Psychological counseling services alongside HCT/VCT.

The same counselors offer Psychological counseling to clients with anxiety i.e Trauma, Somato form, chronic anxiety, depression (suicidal attempts) contemplated abortion, family conflicts, guidance to students, all social misfitting-behaviours and palliative counseling before referring to the palliative team. The table below verifies:-

Year 2004/05 2005/06 2006/07 2007/08 2008/2009 No. counseled (Psychological) 1234 1501 889 688 1146 No. of follow up sessions 8638 1057 6223 4816 16278

This supportive counselling has proved more vital to our HCT service and clients often desire to do their HIV testing with us to get the chance of coming to terms with the rest of their experiences

Graphic representation of the dynamics of psychological counseling done alongside HCT for the past 5 years.

20000

15000 No. received psychological counselling 10000 No. of follow up sessions 5000

0 2004/05 2005/06 2006/07 2007/08 2008/09

There is an increase in output services mostly in numbers of follow up sessions.

This supportive- psychological counseling has maintained and attracted more clients to our HCT service since it communicates unique concern to our clients than our other competitors. The only challenges lies with following our clients after discharge. We realise progress in this section and strive to have it financed for the great future.

Supportive Services

LABORATORY This year a total number of test was 55154 laboratory statistics were done according to the directives the ministry of health as follows:-

Table showing laboratory tests in five years.

Kitovu Hospital Annual Report 2008/2009 52 Kitovu Hospital Annual Report 2008/2009

2005/200 2002 /03 2003/04 2004/05 6 2006/07 2007/08 2008/09 PARASITOLOGY

Stool 878 1217 1614 925 995 1485 1256 Urine 7542 5217 5459 3472 3672 4191 5781 Blood smear 9598 13298 17156 17084 13540 10183 13573 HEAMATOLOGY

Hb. Estimation 5422 6541 8943 14467 10590 8582 10726 Film - 964 1436 1794 1236 2872 3860 SCT 106 145 194 222 151 164 123 WCC 738 1075 1152 745 814 2086 3709 ESR 659 922 168 907 505 970 1417 BIO - CHEMISTRY

Blood sugar 1895 2481 2973 2896 2737 3186 3415 RFT’S & LFT’S 860 1184 1118 996 389 1318 1075 BACTERIOLOGY

CSF 240 248 128 121 72 135 165 Culture 251 213 188 125 128 216 124 Sputum 26292 1694 1243 851 883 775 652 SEROLOGY

Brucella 02 90 14 216 256 313 336 Widal 192 385 596 1102 798 587 814 HIV 10587 13270 14640 13559 11949 6629 5976 RPR/VDRL 167 765 1617 1392 911 1226 1352 R.A 139 42 65 68 49 66 53 ASOT 17 72 61 15 19 17 10 HCG 279 335 303 415 331 628 737 Total Lab. Staff doing tests - 10 09 09 10 07 09 Total Test 42264 50058 59068 61373 50025 45629 55154 Average test per lab staff (crude) - 5005.8 6563.1 6819.1 5002.5 6518.4 6128.2

Kitovu Hospital Annual Report 2008/2009 53 Kitovu Hospital Annual Report 2008/2009

Table showing tests done with their positive results in%

YEARS 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 7386 5933 Total Tests 3 6 74183 86965 87467 81451 53723 71810 1074 Malaria slides 0 9598 13298 17156 17084 13540 10183 13573 Positive 4004 4164 - - 6640 4723 2476 4536 37.28 43.4 % % 37% 40% 38.9% 34.9% 23.3% 33.4% 1338 1455 1694 1243 848 883 775 652 T.B Sputum 205 218 265 142 82 83 84 Positive 15.32 % 15% 16% 11% 9.7% 11.8% 10.7% 12.9% 1072 HIV 8269 2 13270 14640 13559 11949 6627 5976 1549 2095 1854 1854 1503 1464 Positive 18.73 19.5 % % 27% 49% 13.7% 11.1% 22.7% 24.5% 114 167 765 1617 1392 911 1226 1352 VDRL / RPR 6 22 23 20 43 51 Positive 5.26 13.2 % % 2% 1.5% 1.7% 2.2% 3.5% 3.8%

Achievements. . New colorimeter and water bath have been acquired to improve on the work. . Students from other trainings institutions have been able to come for their training practices e.g. students from Kyambogo University and Chemi-Quip-Ishaka. . Adequate number of staff have been recruited. . Monthly meeting are taking place at the Lab. . Some staff have been able to go for HIV training at Mild-May centre Kampala.

Challenges . Lack of adequate number of Lab. Technicians. . Lack of machines like fridges, microscopes and autoclave. . Lack of immunization for lab staff against infectious diseases like Hepatitis B meningitis. Future plans . Obtain heamatology analyser so we can improve on the accuracy of results. . Train more lab technicians to improve on the service.

Kitovu Hospital Annual Report 2008/2009 54 Kitovu Hospital Annual Report 2008/2009

. Get funds so that we can provide free or subsided immunization to all staff against infectious diseases. Blood bank:

The following are the number of transfusion in comparison with 3 previous years

Years 2006/2007 2007/2008 2008/2009 Total number of 5806 3925 4878 transfusion

There were 4878 transfusion in Kitovu during this year.

Achievements: 1. The blood bank relocated to the old classroom block which was renovated and it is now spacious for the screening of transfusion transmissible infections (TTI) and storage of blood. 2. The blood donor recruiter Ms. Nantabi Lilian was transferred to Jinja and Mr. Akankwasa Paul replaced her in March 2009. 3. We started doing camping sessions which boost our supply of blood as there was a redemarcation of operation areas between Kitovu Blood Bank and Masaka collecting centre. 4. Plan to intensify the sensitization of our donor targeted groups in order to curb shortages of blood.

Challenges: 1. There is still shortage of staff 2. We still have on and off shortage of Supplies for blood bags especially quadruple blood bags and testing kits; though not as bad as for previous years. 3. There is shortage of blood supply especially during school holidays

Plan: 1. There is plan of Nakasero to deploy more staff soon. 2. Donor clubs should be alerted and targeted as one of our major sources of blood especially during holidays.

Pharmacy Pharmacy staff: • Dispenser 1 • Pharmacy Assistant 1 • Enrolled Nurse 4 • Nurse Assistant 1 • Store Assistants 2 • Record Assistant 1

Kitovu Hospital Annual Report 2008/2009 55 Kitovu Hospital Annual Report 2008/2009

• Other 1

Ordering system: All the drugs are ordered from Joint Medical Store except a few items which sometimes are out of stock in JMS are purchased from other pharmacies in Kampala (Meta and Abacus) and in Masaka Byansi Clinic.

Availability of supplies: Since five years ago, we had very few stock outs due to global crisis such as coartem which was out of stock in whole county for quite some time, but we had stocked enough which catered that period when it was out stock. Now we have enough supply in our stores. Joint Medical Stores has improved their way of serving customers, such that we order drugs send the order through Fax or Telephone and indicate the day of collection. So they check and pack themselves which is a very good method because it saves time spent in Joint Medical Stores. They call and inform us the items available and those out of stock, which help us to make better decisions where to get other drugs. The credit line money for drugs is reducing each quarter and the drugs purchased using credit line, with their prices are high compared to other orders. By the end you find that very few drugs consume all the credit line available.

Store keeping: The store lacks a big fridge which can accommodate all drugs, thus other drugs are kept in pharmacy fridge dispensing area. The store now has a store assistant who is looking after the condition of drugs daily and reports to in-charge pharmacy. Control of drugs for being expired is done by the store assistant and in-charge pharmacy as follows:- • Exchange near drugs to expire to the nearest institutions like Masaka Hospital. • Avoid overstocking by using maximum stock, minimum stock, buffer stock and amount to order calculations. • Daily routine of informing prescribers drugs near to expire. • Procuring drugs having long expiry dates. • Using first expiry first out (FEFO) and first in first out (FIFO) methods.

Losses and loss reduction/ Prevention: Whenever necessary, we try to handle drugs with care and put up labels showing how to handle the drugs like (keep cool, fragile handle with care) sometimes using different colours like red colour showing danger, poisonous, harmful. In doing all these we try to avoid misuse, breakage, spoilage, corrosion and irritation of eyes.

Frequency of stock taking: Usually in main and sub-pharmacy we carry out daily physical count so to see that the physical drugs correspond with the balance in the bin card. Also we carry stock taking organized by accounts department quarterly.

Kitovu Hospital Annual Report 2008/2009 56 Kitovu Hospital Annual Report 2008/2009

Treatment Schedules: Most prescribers have improved their way of prescribing since BNF and Uganda Clinical Guidelines are available in each prescribers’ room.

Problems of drugs resistance: Nowadays drug resistance is not common since the government introduced coartem which is combination of Artemether 20mg and Halofentrine 120mg (20/ 120mg).

Hospital Production: The hospital produces drugs calamine lotion, Zinc oxide ointment these products are not available in Joint Medical Stores and other pharmacies.

Possibilities of economizing drug expenditure: Drugs are issued using a bin card. In patient system of supplying drugs per request of prescription has been introduced which has reduced the wastage, misuse expiry of drugs in the wards. Exchange near drugs to expire to the nearest institutions like Masaka Hospital.

List of essential drugs: The list of essential drugs is available in pharmacy hence most drugs in pharmacy are essential drugs.

Twenty (20) Most used drugs June – July 2009 No. Name Drug Cost 1. Ceftriaxone 1g 80,531,220 2. Dextrose 5% 122,671,160 3. Normal Saline 0.9% 10,474,770 4. Quinine Injection 15,498,520 5. Quinine Tablets 27,473,850 6. Ampicillin Injection 33,964,550 7. Insulin Isophane 24,540,430 8. Insulin Soluble 20,092,860 9. Flagyl I.V 38,617,270 10. Amoxycline caps 250g 34,590,130 11. X-pen 29,409,550 12. Chloramphenicol Injection 20,303,880 13. Pethidine Injection 74,580,720 14. Metformin Tablest 500mg 51,219,210 15. Ringers Lactate 15,052,020 16. Gentamycin Injection 7,217,620 17. Erythromycin Tablets 250g 35,220,640 18. Nifedipine Tables 20mg 63,972,620 19 Omeprazole Tablets 20mg 33,026,810 20. Ciprofloxacin Tablets 500mg 25,782,040

Kitovu Hospital Annual Report 2008/2009 57 Kitovu Hospital Annual Report 2008/2009

Total expenditure 764,239,870 The most used drug cost 51% of the total cost for drugs. Changes in the departments: • Pharmacy received one dispenser from Spain through (V.M.M) organization • An enrolled nurse left for further studies. • A store assistant was employed to take care of main pharmacy and other duties in pharmacy department. 2003/2005 2005/2006 2006/2007 2007/2008 2008/2009 Spinal Column 108 55 110 56 38 Skull and Mandible 63 5 20 18 6 Abdominal Contrast - - - 16 - Screening (chest and - - - 28 13 other) Abdominal – Plain 16 12 36 24 30 Pelvis and hip 161 100 - 73 66 Chest 1870 1130 1239 1193 1400 Shoulder and clavicle 72 22 79 57 33 Upper extremities 231 104 54 80 133 Lower extremities 568 225 285 248 258 Total examination 3089 1653 1823 1793 1977

Challenges: • We changed the method of issuing drugs to in-patients. First we were using stock method controlled by the Nurse but due to its disadvantages, we decided to introduce another method known as individual drug order system (controlled by the pharmacist and Nurse). • The store is old, it needs renovation. • Lack of large fridge in the pharmacy store to accommodate medicines.

Future plan: • To build a new pharmacy and main pharmacy store. • To start a project which can help to increase funds for purchasing medicines. • To solicit money for a big fridge for Pharmacy store.

X-ray/Imaging

Staffing: One Assistant Radiographer

Total number of x-rays done this year is 1977 Table showing x-rays taken in the last five years Top 3 commonest x-rays done in the past five years Year 2004/2005 2005/2006 2006/2007 2007/2008 2008/2009 Chest 1870 1130 1239 1193 1400 Lower extremities 568 225 285 248 258 Kitovu Hospital Annual Report 2008/2009 58 Kitovu Hospital Annual Report 2008/2009

Upper extremities 231 104 54 80 133

commonest x-rays done in the last five years

2000 1800 1600 1400 Chest

s 1200 r

e Lower extremities b 1000

m Upper extremities u 800 N Series4 600 400 200 0

r 5 6 7 8 9 a 0 0 0 0 0 e 0 0 0 0 0 Y /2 /2 /2 /2 /2 4 5 6 7 8 0 0 0 0 0 0 0 0 0 0 2 2 2 2 2 Years

The commonest x-rays done are those of chest x-ray mostly to confirm pulmonary tuberculosis.

Achievements: o There is an increase in the total x-rays done compared to 3 previous years.

Challenges: o Space for operation is still very small o Inadequate staff only one staff runs the department o We are no longer doing spinal column x-rays because the machine is old.

Future plan: o Training more staff o Have a larger space. o Buy a new x-ray machine and screen Ultrasound: Ultrasound and other imaging investigations done in the last five years. JUNE - JULY 2004/05 2005/06 2006/07 2007/08 2008/09 Total for 5 Yrs ABDOMINAL 406 293 239 97 266 1301 PELVIC/GYN 215 122 146 54 244 1301 OBSTETRIC 211 113 109 87 324 2602 TOTAL OF 5 YEARS 832 528 494 238 834 5204 HOSPITAL OPD/ INPATIENT 424 330 408 216 762 2140 REFERRALS 408 198 86 22 72 786

Kitovu Hospital Annual Report 2008/2009 59 Kitovu Hospital Annual Report 2008/2009

N.B: There is a great increase to a numbers of US done as the staff was available at regular hours and for emergencies.

450 400 350 300 S Abdominal T

N 250 Pelvic /Gyn E I 200 L Obstetrical Scan C 150 100 50 0 2004/05 2005/06 2006/07 2007/08 2008/09 YEARS The commonest scan done are those of Obstetrical cases followed by Pelvic/ Gynaecological cases because mothers want to know the welfare of their babies, others come due to complications of pregnancy.

Challenges: o The old machine has many functions which are missing. o More training of staff is needed for better diagnostic skills.

Future plans: o Have at least two people trained so that if one is missing, the work can continue. o Get new Ultra Sound Machine.

Domestic Services:

Catering: The Hospital prepares break tea for staff, totaling to a number of 200, including laboratory students, pre-nurses, private patients, needy patients and workshop attendants. They take break fast, break-tea, lunch and supper. Private patients have been paying fifty thousand Uganda shillings per day for food and room. Workshop attendants have been paying thirty thousand Uganda shillings for food and accommodation per day.

Cleaning: Cleaning compound and wards is done by the contractor. Compound cleaning involves treaming fence flowers, slashing, sweeping, planting flowers cleaning toilets, birth rooms, Kitovu Hospital Annual Report 2008/2009 60 Kitovu Hospital Annual Report 2008/2009 washing bays, cleaning and emptying dust bins. Cleaning wards and offices is also done by a contractor. There has been great improvement in cleanliness of the hospital since we contracted the cleaning of compound.

Laundry Services: There are two laundry attendants who wash all Theatre linen and linen for private patients. There is one seamstress who does the sawing as well as washing bed sheets for people who come for workshops.

Sanitary facilities:  There is a full time incinerator operator  Pit and septic tanks are available for waste disposal  New Ash pit and placenta pits were constructed  We have toilets for each ward (total of 7) of which 6 are pit latrines.

Animal husbandry is practiced. There are 5 cows 3 for the hospital and 2 are for milk of malnourished children in Nutrition Unit.

Hospital Vegetable Garden: We have a banana plantation at the hospital and another one at Nabulago farm.

We have eucalyptus forest of 7 acres at Buyanja village one at Nabulago farm for firewood as well as an income generating project

Technical Services: The hospital uses water from National and Sewerage cooperation and rainwater. We have many underground tanks as well as above ground tanks for rain water harvesting.

Electricity supply is from . We have 3 standby generators, inverters and one photovoltaic solar system.

Future plan: - To install solar system at Maternity and Surgical wards.

Construction/New structure at the hospital.

Hospital Chapel: The construction of a new hospital chapel commenced and the church is designed to seat 186 people. It will include a raised Alter with sanctuary and separate rooms for the vestry and office. Apparently the construction work is still on. It is about to reach the level of the beam. We are facing shortages in the supply of half bricks necessary for the construction.

Ash pit: A new ash pit was constructed. The new ash pit was dug and constructed using a well reinforced concrete slab, plastered and provided with an opening on top.

Kitovu Hospital Annual Report 2008/2009 61 Kitovu Hospital Annual Report 2008/2009

Renovations/Refurbishments: Refurbishment of the chemotherapy Unit in children’s ward One of the children’s ward was developed into a chemotherapy unit. The roof was repaired using silicon sealant around the roof nails. Burgler proofing was installed at three locations and insect proof mesh was provided on all the external windows.

Doctors’ residence renovation at valley view: This is one of the houses that provide residence to our Intern Doctors. The house was repainted with three coats of paint, one door frame was replaced and the ceiling boards which were damaged were replaced. The leaking roof was also treated with bond to remove the leakages.

Renovation of the Blood Bank: The blood bank was relocated to the old classroom where a wooden frame work and coffee tray were constructed and insect proof mesh was provided in all the windows.

Refurbishment of the Laboratory staff Hostel: This included the plastering of old walls in the house, installation of missing louvres and mosquito proof nets in all the windows. The ceiling boards were painted and replaced where necessary. Replacement of two windows and repainting of the house. New electrical wiring was also provided to the hostel.

New concrete gutter for the maternity ward: A new reinforced concrete gutter was constructed in between the old maternity ward and its extension. The original gutter that was constructed was leaking and therefore needed replacement. The ceiling was also renovated as it was with grave cracks.

Administration Building: The hospital administration building was provided with white paint on the external front walls. The existing walls paint had become old and thus needed repainting to give a warm welcome and good and appealing first visual impression. The walls around the reception were also provided with silk paint as it had peeled off in some areas.

Water Solar Project:

New water reserve Tank: Through the water system improvement project at Kitovu Hospital, a new reserve water storage tank was installed at the hospital premises. This will greatly help in maximizing the collection and use of rain water at the Complex.

The new reserve tank has a nominal tank capacity of approximately 55,000 liters. It has been constructed next to the original two old reserve tanks. The new reserve tank was connected to the existing water system and works well.

Kitovu Hospital Annual Report 2008/2009 62 Kitovu Hospital Annual Report 2008/2009

Repair to the administration rain water collection tank: The financial year 2008/2009 also witnessed the refurbishment of the old Administration water collection tank. The plates on level 2 had been greatly acted upon by the high water pressure and coupted with the little binuminous paint applied on them, it resulted into corrosion and eventual cracking of the plates thereby inevitably calling for immediate attention.

Through the water system improvement project, the tank plates on level 2 were all removed and replaced with new plates. These were painted accordingly putting the tank back to service.

New supply tanks: New polyfibre supply tanks and their towers were installed at the Laboratory Tutors House and Walungi quarters to increase on the supply of water to these houses.

Repairs to the existing two reserve tanks: The old two reserve tanks were repaired as they had developed leakages on the plates. These were welded and repainted to remove any possible leakages and are currently working well.

Renovation of the Maternity water collection tank: This tank was also renovated and all cracks covered with strong water cement. The external walls were also provided with new rough cast and a pillar was built inside the tank to make it stronger.

New water pump: A new 3 phase water pump (pedrollo) was bought for the convent underground tank and provided with an overload, contactor and voltage sensor. A voltage sensor was also provided to the new KODS underground tank.

Other water project work included the cleaning of manholes and rainwater collection chambers. These chambers were also cleaned and painted blue to differentiate them from the sewage chambers. There was also the repair of the existing water lines with new valves, pipes, joints and other plumbing fittings for efficient water supply at he the wards and different residences.

Installation of a new stand alone Photovoltaic solar system on children’s ward. A new solar system was installed on the children’s ward with solar panels supported by 200 Ah. batteries. The panels charge the batteries to their full capacity there by providing (DC) power which after flowing through the inverter is made available for lighting in the ward and other purposes.

New 3 phase Metre: A new 3 phase metre was installed next to the UMEME main metre to facilitate a close follow- up of power consumption at the complex.

In addition, two more new electricity power metres were installed on maternity ward and surgical ward. This was done to ascertain which of the two wards consumes more power.

Kitovu Hospital Annual Report 2008/2009 63 Kitovu Hospital Annual Report 2008/2009

Challenges:

The water solar project that was funded by Mesean Cara (MDF) Electric Aid and other benefactors has been a tremendous boost as it regards the water harvesting system improvement and use of solar energy.

However the greatest challenge is the lack of funds to implement all the construction projects of the hospital as need for renovation and new structures increases everyday.

Proposed capital development plan for the Financial year 2009/2010

Constructions and renovations: - Demolition and reconstruction of the maternity ward and labour ward roof and ceiling due to the grave cracks in the ceiling and the poorly constructed roof structure. This will also include the repainting of all the internal walls - Refurbishment and expansion of valley view hostel and the Chaplain’s house. This will also include the installation of new toilet in the hostel. - Refurbishment of the hospital general kitchen and upgrading it to the required standards. - Completion of phase 2 of the construction of the new Chapel designed to seat 186 people - Conversion of the old labour ward into a premature babies unit in the maternity ward. - Modernizing and upgrading of the white house building to cater for visitors and workshops at the hospital - Installation of a stand alone photovoltaic solar system on maternity ward to reduce hydro power bills. - Renovation of the hospital canteen - Repainting of Appollo dormitory for student nurses.

The hospital income generating projects:

The Nabulago Farm: This is one of the income generating project that the hospital is running. Though not fully established, the farm has over 10 acres of banana plantation, a piggery project, and maize was also planted on over 5 acres of land in the two different seasons in the year.

There is a big plan for the project, a new banana plantation is to be planted, 5 acres of eucalyptus trees are to be planted and two acres of coffee are also to be planted.

Walungi farm project: The farm activities are also still running and the farm apparently has 5 cows of which two are milked and the rest are calves. The milk is sold to the hospital staff and MADDO dairies at a relatively cheap price. Both of the cows produces, approximately 15 litres of milk a day. However the milk that is marketed comes from one cow as the other cow supplies the Nutrition Unit at the hospital.

Kitovu Hospital Annual Report 2008/2009 64 Kitovu Hospital Annual Report 2008/2009

Kitwe Eucalyptus Trees Project: This is also another project for the hospital that was established to provide income for the hospital. It is a project with eucalyptus trees covering over 7 acres of land. There is a plan to put the tree on market in the financial year 2009/2010 to raise funds for the hospital.

Accommodation and meals for visitors: The hospital also provides accommodation services and meals for visitors and medical doctors who come to carryout internship training at the hospital. The project is still running though amidst have renovation challenges.

Challenges: - The major challenge is still capital to facilitate the growth of our income generating projects as many of them are still in their infant stages. A lot of funds are still needed to ensure the self sustainability of the projects. - Unpredictable weather changes have also been a stumbling block in the activities of our income generating projects especially at the Nabulago farm.

Way forward: - There is a plan of renovating the white house building which when renovated will help much to boost the hospital’s accommodation and meals project. - There is also a plan to provide more facilities and equipment to our different projects needed for their smooth running. - More donor funds are to be sought for so as to enable the running of the projects up to when they become self sustaining.

Central Store:

Staff:  One Storekeeper  One Assistant Storekeeper

The Hospital central store was not hundred percent stocked; due to the financial problem however, we were able to buy the needful/necessities.

Challenges o Leaking of the store. o Limited space. o Lack of adequate funds. o Two grinders were bought and got spoilt Future plan o Renovation and expansion of stores o To have a computer in place for recording daily issues.

Kitovu Hospital Annual Report 2008/2009 65 Kitovu Hospital Annual Report 2008/2009

o To have a grinder for cutting and sharpening metals.

Ambulance Service VEHICLES (Ambulance Services)

The Hospital has seven motor vehicles and one motorcycle.

With the exception of the Ambulance, the other vehicles are all old and need replacement in the near future. Suzuki Pajero and the Red car are the worst ones. They break down frequently and are now very costly to maintain.

Each vehicle’s age and the distance traveled by the end of the period under review are indicated in the table below:-. Table showing Age and Mileage of each Vehicle as at 30/6/2008 Vehicle Name Make Reg. No. D-O-Purchase / Age – Kms For Dept. current Years Traveled Registration Suzuki Suzuki UG 1405M 14-Uug-1989 19.9 75,531 CBHC Motorcycle Suzuki TF 125 544 UAD 6-Jun-1994 15 HOSPITAL Red Car Subaru Legecy UAD 702B 16-Oct-2000 8.6 20,9417 HOSPITAL Pajero Pajero Mitsubishi UAD 821F 7-Feb-2001 8.4 205,456 CBHC Double Cabin Nissan UAD 172U 28-Nov-2001 7.6 232,814 HOSPITAL Ambulance Toyota Land cruiser UAA 507Y 11-Dec-2002 6.5 89,097 HOSPITAL Minibus Toyota Hiace UAF 069F 14-Apr-2004 5.2 139,037 VVF

For the Ambulance Services: As indicated above, the hospital has got an ambulance which is used mainly for transferring patients, referred from Kitovu Hospital to Masaka Hospital, and Mulago Kampala National Referral Hospital. It is still in good working condition. During this report period, it made 12.5 trips after traveling a total distance of 14,494km.

Referred patients are asked to make a contribution towards the maintenance cost of the ambulance. Challenges: There are two major challenges of operating ambulance services. The first is that sometimes patients do not have the money to make a contribution towards the cost of the service. Yet these cases, are normally emergency and need immediate action. These are transported at the expense of the hospital.

The second one occurs when two patients need the ambulance service at the same time, yet the facilities available may not be enough to cater for the two.

Future plans: The plan is to sell off the two old hospital vehicles – the Subaru and the Double Cabin Nissan. The Nissan shall be sold after getting a replacement. The Subaru car has been very handy and

Kitovu Hospital Annual Report 2008/2009 66 Kitovu Hospital Annual Report 2008/2009 useful. Selling it will affect our transport services since by the close of the report period the Hospital had not yet secured funds for its replacement. PASTORAL CARE • Existing in Kitovu hospital since 1986. • Provided by a Clinical Pastoral Educated resident Chaplain. • With two helping staff, oriented to Clinical Pastoral Care of the sick. Organisation: • Under the Psychosocial Care and Counselling Section. • In the immediate supervision of the hospital chaplain. • Trained staff do needs assessment, attend to them or make appropriate referrals to the chaplain and other authorities as required. • The entire hospital staff trains in wholistic care of the sick so as to assist in identifying pastoral needs and to make appropriate referrals. • Counsellors liaise with the chaplain and the pastoral team to see that pastoral services are provided. • The pastoral service providing team includes:- Chaplain 1 Oriented staff 2 Helping counselors 4 • It is a responsibility per staff on different wards including out patient, to help patients access pastoral help immediately when need is realized.

Benefits: • Ward – stability due to patients’ peacefulness despite their sufferings. • Proper and peaceful termination from life to embrace death, if inevitable. • There is improved patient care from spiritual trainings attended by the staff. • Individual spiritual growth per staff leading to staff cohesion. • Appreciated hospital care service due to attention given to the whole person. • Increased vocations to religious life and to the health field by our Junior Nurses.

The Pastoral care output for the past 5 years Activity/Indicator 2004/05 2005/06 2006/07 2007/08 2008/09 No. visited or counselled 400 333 416 657 3181 No. Baptised 216 203 293 232 192 No. Confirmed 5 2 2 15 20 No. given sacrament of marriage 3 3 4 1 7 No. Anointed 145 75 86 109 212 Compared to the past years, 2008/2009 shows an increased output. Thanks to Chaplain’s availability for the patients and to the two oriented staff to Pastoral Care of the sick, for the good work, appropriate referrals and the improved system of record keeping.

Challenges: • Limited number of trained pastoral ministers.

Kitovu Hospital Annual Report 2008/2009 67 Kitovu Hospital Annual Report 2008/2009

• Declining economic resources to maintain the human resources of Pastoral Care and its activities. • Unclear boundaries between Pastoral care and HCT Section as determined by the hospital setting.

Implication for future planning: Mobilising economic resources for the Pastoral section to sustain the unavoidable services while at an institutional level we assess the meaning of merging HCT and the pastoral section and the possible effects to current economic and human resources, so as to define a fruitful, independent an self sustained pastoral service.

SOCIAL CARE In the year 2008/2009, the two full time Social Workers continued to address needs and anxieties of various clients of the hospital.

Depending on the patient’s background, type of illness and age, various problems of the above clients manifested in form of social, economic, mental, psychological etc. which called for social workers’ intervention in terms of social care. And the social care so provided, had a profound effect on the patients’ response to medical care.

Through team work and organized referral system which exist in our Hospital, all clients who were identified with social, psychological and economic problems were referred to Social workers’ office by Doctors, Ward sisters, Counsellors, Cashiers and by other categories of staff. These led to various social work activities of the year.

Activities therefore, involved assessments, through physical encounters and dialogue with each of the clients, careful listening and probing; sensitizing patients on their obligation to pay the Hospital bills working out plans with these patients and attendants as to how the hospital bill can be paid and help them to plan for their future sustainability in relation to the socio- economic situation alongside the imperative need for proper medical care. Other activities, involved networking with patients’ relatives, friends, employers, local councils via telephone calls, radio announcements, written communication over patients’ condition and the relevant hospital bills. Social work office also, sometimes made referrals for some of the clients to Good Samaritans or other service providers for necessary help or assistance.

Kitovu Hospital Annual Report 2008/2009 68 Kitovu Hospital Annual Report 2008/2009

The table below gives a summary of social work activities for the past five years:- CATEGORY OF PATIENTS PERIOD /YEAR 2004/05 2005/06 2006/07 2007/08 2008/09 (i) In-patients: Allowed to go with invoices 564 562 437 279 204 Who later came back to clear their bills after discharge. 174 139 213 130 91 Enabled to clear their bills on or before discharge. 362 911 1080 1153 1340 Partly waived 97 146 90 104 93 Enabled to link with family system 920 872 951 1023 1300 Allowed to feed on hospital food 167 201 199 195 196 Assisted with transport money back home 132 114 94 38 10 Radio announcements to family relatives Telephone calls/written communications to patients’ 44 51 34 30 12 relatives, employers or LCs Home assessments 11 14 07 - 05 Burials organized for needy/Destitute cases 12 13 10 09 03 (ii) Out-patients: Completely unable to pay their medical bills 268 350 283 252 221 Out-patients invoiced 663 450 328 410 193 Out-patients who came back later and cleared their bills 236 177 130 216 166 Out-patients who were partly waived 24 91 41 68 32 (iii) Other Activities: Cross referrals i.e patients/clients referred to NGOs or other service providers for resettlement, rehabilitation or some other help 56 91 20 20 24 Referrals to Good Samaritan(s) and had their bills cleared 48 Total 3,330 4182 3917 3927 3946 As per statistics of the past 5 years it looks certain steady progress has been registered in terms of:- • Steady decrease in the number of in-patients and out-patients invoiced. • Steady increase in the number of patients enabled to clear their bills before they leave the hospital. • Steady increase in the number of patients enabled to link with family system, employers and local community over patients’ problems. • Steady decrease of number of patients who get stranded and seek for transport back home.

The above positive aspects certainly imply that the day to day sensitization and planning with patients/clients on issues of sustainability, improved welfare and health; as well as proper counseling and guidance, all help a lot, not only to reduce on the suffering of our patients/clients but also, improve payments of the medical bill(s) and reduce on the hospital loss. The dependency syndrome, also seems to be on decrease.

Kitovu Hospital Annual Report 2008/2009 69 Kitovu Hospital Annual Report 2008/2009

There is no doubt also, that team work and organized referral system of patients/clients to Social Workers’ Office as well as networking with patients’ family system, employers and the local communities and the cross referrals of our patients/clients by social workers to Good Samaritan(s)/ other service provides, are all yielding positive fruits for both the patient and the hospital.

The physical encounters with clients/patients, follow-ups on wards the and planning and different counseling sessions before discharge, enable social workers, clearly to understand the patient(s) and the most problem area on part of the patient/client. And so, different kind of support and advice are given like:- • Encourage the patient/client to make proper use of his/her available resources like land or “Kibanja” – Plot of land when he returns home, for improved earnings and future sustainability. • Make the patient clearly understand the need for proper medication and the importance of paying the Hospital bill, in case he/she is given an invoice. • For the HIV positive and Chronic illness, make them understand and accept their sickness and advise them to keep in touch with Mobile Home Care or Uganda Cares, for further necessary medicate on and palliative care services. • Encourage them to take on membership with Kitovu Community Health Insurance Scheme.

Against the above background, social workers propose on the following recommendations/way forward for the next 5 years:- • Maintain team work and regular follow-ups of patients on wards. • Continue to educate our regular clients on issues of sustainability and the need for proper medical care. • Maintain the day to day sensitization, counseling and assessments of all patients referred to the office, so as to determine the proper course of action. • Continue to collaborate and network with patients relatives, employers, friends and local communities over patients’ problems. • Maintain a healthy relationship with Good Samaritan(s) and other service providers. • Continue collaborate with Mobile Home Care, Uganda Cares, Rakai Health Science Programme, MRC etc. over the HIV terminally ill. • Encourage our regular clients to join KCHIS for accessible and affordable medical care. • Strive to reduce on the number of patients invoiced.

Kitovu Hospital Annual Report 2008/2009 70 Kitovu Hospital Annual Report 2008/2009

Prevention and Health Promotion services

Community Based Health Care and Nutrition Unit: The programme provides Community Health Care Services for communities and at the hospital. The health care package includes maternal and child health care; Ante-natal, Immunization of children, Nutrition Unit Care and Health Education. Promotion of home hygiene and sanitation, HIV prevention, revolving loans to CORPs for IGAs and strengthening community development by starting a Mango Project at household level in Buwunga and Subcounty.

The Progromme has the following staffing totaling to 13.

CBHC Programme Coordinator 1 Nurse 1 Midwife 1 Assistant Nurse/ Community trainers 2 Drivers 2 Nutrition Unit Registered Nurse 1 Children Nurses 3 Assistant Nurse 2

Attendance to preventive and promotive services at the hospital and outreach areas of the hospital July 2008/ 2009.

Table showing immunization for 3 years Vaccine Under 1 year 1 – 4 years 2006/07 2007/08 2008/09 2006/07 2007/08 2008/09 BCG 1415 1804 2207 66 40 72 Polio 2932 3430 4405 68 46 61 DPT, HEPS & HIB 1831 2016 2555 67 46 60 Measles 486 576 651 50 46 50 Tetanus - Preg. 1473 1081 1090 - - 1213 “ - Non Preg. 48 147 94 - - 109 Total 8185 9054 11,002 251 178 1,565

The total doses for Polio was 4466 The total doses for DPT, HEPB + HIB 3 was 2615

Health education is given at every outreach clinic so that mothers go back with key health message to their homes.

The programme participated in mass measles immunization in June, this was a big contribution towards district performance.

Kitovu Hospital Annual Report 2008/2009 71 Kitovu Hospital Annual Report 2008/2009

Vitamin A and Deworming: 2006/07 2007/08 2008/09 Vitamin A 406 1174 1557 Deworming 1-4yrs 406 1147 1056 5-14yrs 6 1130 562 Training of Village Health Teams: The training was done in Makonzi Parish Bukakata Subcounty. 3 Village health teams were trained from Mitando, Makonzi, Kisuku and Bbale.

The table below shows Antigens given for 5 years:- 2004/2005 2005/2006 2006/2007 2007/2008 2008/2009

7753 8603 7958 9232 11401

Table showing the training centre and number of people trained: Training Centre Male Female Total Mitando 10 8 18 Makonzi & Kisuku 6 8 14 Bbale 4 8 12 Total 20 24 42

On completion of the training the trained people are expected to carry out health education and health activities in their communities and involve themselves in other.

Development programmes:

Nutrition Unit: The Nutrition Unit has a bed capacity of 14 beds. The severely malnourished children are admitted and others are given Nutrition education and advice plus food supplements as out patient. Table showing utilization at Nutrition Unit

NUTRITION UNIT 2004-2005 2005-2006 2006-2007 2007-2008 2008-2009 Admission 174 140 164 221 268 Inpatient days 3571 2652 3099 4325 4503 Average L.O.S 21 19 19 20 17 Deaths 7 16 12 17 23 Average Occup 10 7 9 12 12% Death rate 4% 12% 7% 8% 9% Recovery Rate 96% 88% 93% 92% 91% Bed Occup Rate 70% 50% 61% 84% 86%

Kitovu Hospital Annual Report 2008/2009 72 Kitovu Hospital Annual Report 2008/2009

The number of children increased due to shortage of food in the community as a result of bad climate.

Increased admission is attributed to the new programme of referrals from Caritas MADDO Nutrition Programme.

Counseling and HIV testing: This was done in a communities, 245 clients came for pre-counselling, 231 were tested, 209 clients received results, 155 were negative and 76 were positive. Post counseling was done to all 231 were tested, results were given to each client and the 76 who were positive were referred to Kitovu Mobile Home care and Uganda cares for further management.

Pre- Client Received Negative Positive Post counseling counseling Tested results and referral M F M F M F M F Bunaddu 13 10 13 10 13 10 17 6 76 were Nakitokoro/Kabasese 33 11 33 11 33 11 10 34 referred Bukibonga 32 7 25 7 25 7 24 8 Kitovu Mobile Kigo 21 7 14 7 14 7 17 4 and Uganda Birinzi 18 26 18 26 8 24 39 5 Cares. Nakigga 11 8 11 8 10 7 12 7 Nakitokoro 13 11 13 11 10 8 16 8 Bukayi 6 10 6 10 5 9 13 3 Kasanje 3 5 3 5 3 5 7 1 150 95 136 95 121 88 155 76 245 231 209 231

IGA

Seminars/Training: Five trainings were held in 3 communities i.e Birinzi, Nakigga and Makonzi. The trainings aimed at equipping beneficiaries with knowledge and skills on how to manage income generating Project and payments of the loan. After verification of beneficiaries and projects, 200 people were given loans. Loans were used in different projects such as banana and coffee rehabilitation, mango growing and piggery.

Sanitation project: One Hundred (100) slabs were given out to 50 households to construct latrines. Fifty latrines have been constructed which has increased the latrine coverage in Buwunga Subcounty.

Sustainable IGA project: Four thousand five hundred (4500) mango seedlings and 1305 hoes were given out to beneficiaries (households) in Buwunga and Bukakata subcounty.

Kitovu Hospital Annual Report 2008/2009 73 Kitovu Hospital Annual Report 2008/2009

Challenges: • Shortage of food and prolonged dry seasons has crippled the Income Generating projects, especially those who could not apply irrigation methods. • Malnourished children are brought in late stages with infections e.g. 7% of children in 2008/2009 were infected with HIV. • A threat to future sustainability of the programme as the main donor (SCIAF) is phasing out.

Future Plan: • The Programme is faced with the challenge of funding which demands restructuring of the core projects. • To continue with Nutrition Unit Services , Revolving loans and Immunization programme. • Sanitation programme to supply 100 latrine slabs to 50 households.

KITOVU COMMUNITY HEALTH INSURANCE SCHEME

Kitovu Community Health Insurance Scheme (KCHIS) formally known as Kitovu Patients Pre payment Scheme (KPPS) was opened in October 1998. It is one of the many schemes established in the country to enable the poor and low-income earners to access medical care without paying large sums of money. It aims at promoting equity in all classes of people whereby the poor can also access expensive medical care, which they could not have afforded if they had not joined the health insurance scheme.

Area of operation Currently, the scheme is actively operating in Masaka and Ssembabule district and the service providers are Kitovu Hospital in Masaka District and Katimba Health Centre in Ssembabule District. Both service providers are under the supervision of Masaka Diocesan Health Office.

Funding The scheme started with funding form DFID until 2001 when its contract phased out and the entire burden was left to Kitovu Hospital, which is the service provider. In 2007, CORDAID an organization based in Netherlands came to the rescue of the scheme and its members. CORDAID is funding all the activities of the scheme i.e. it covers: the operations costs; sensitization costs; preventive measures; gives a premium subsidy of shs.2500 per member per year; and on top of that pays a full premium for the poorest of the poor.

At the end of the year 2008, CORDAID boosted the premium subsidies by 2500/= for Kitovu Hospital Scheme and 2000/= for Katimba LLU scheme. As shown in the table below.

Kitovu Hospital Annual Report 2008/2009 74 Kitovu Hospital Annual Report 2008/2009

Members Kitovu 1,822 Extra Subsidy @ Ugx 2500 per member 4,555,000 Membership details On the 30th of June 2009, Kitovu Members Katimba 1,997 Hospital scheme had 2734 Extra Subsidy @ Ugx 2000 per member 3,994,000 beneficiaries. And Kitimba H/C - scheme had 1223 beneficiaries. Total extra Subsidy 8,549,000 Premium setting Premium calculations were highly based on the services offered by the service providers. And payments are based on the family size. A family of 1 to 5 people pays a full premium where as each extra person pays half the premium. This was done to enable those with bigger families to register all the household members at an affordable cost.

As shown below. Kitovu Hospital – (Hospital Based Scheme) Family size Monthly Six months’ premiums Annual premiums (Shs) Premium (Shs) (Shs) 1 to 5 people 4,000 24,000 48,000 Each extra person 400 2,400 4,800 6 people 4,400 26,400 52,800

Katimba – Lower level Unit (LLU) scheme Family size Monthly Six months’ Annual premiums Premium (Shs) premiums(Shs) (Shs) 1 to 5 people 2,500 15,000 30,000 Each extra person 250 1,500 3,000 6 people 2,750 16,500 33,000

Benefit package The scheme caters for all services offered within the reach of the service providers excluding Dental services, Optical services; Open health surgery; private services, Referrals to other hospitals and self inflicted problems.

Provider payments This scheme pays flat rates for all members given health care by the provider. The rates are as follows.

Kitovu Hospital: OPD – 8,000/=; per a single visit IPD – 40,000/=; per a single admission Major surgery – 80,000/= per a single surgery

Below are Flat rates Vs the Fee for service (Jul 2008- June 2009)

Kitovu Hospital Annual Report 2008/2009 75 Kitovu Hospital Annual Report 2008/2009

Period Category # cases Flat rates Actual (Shs) Surplus/deficit (Shs) (Fee for service) (Shs) TOTALS 1601 12,808,000 15,072,640 -2,254,640

AVERAG OPD Jul 08 8000 9,415 -1,415 thro IPD TOTALS 107 4,280,000 4,809,850 -529,850 Dec 08 (normal) AVERAGE 40,000 44,952 -4,952

IPD Total 11 880,000 843,900 36,100 ( surgery) AVERAGE 80,000 76,718 3,282 TOTALS 2084 16,672,000 20,291,770 -3,619,770

AVERAG OPD 8,000 9736.9338 -1736.93 IPD TOTALS 201 8,040,000 9,205,650 -1,165,650 (normal) AVERAGE 40,000 4,5799.254 -5799.25 TOTALS 12 960,000 1,430,400 -470,400 Jan 09 thro IPD AVERAG Jun 09 ( surgery) 80,000 119,200 -39,200

Katimba CHIS Like Kitovu, the scheme pays a flat rate for any single service offered to the scheme patients. OPD - 3,000/= per a single visit IPD - 17, 000/= per a single admission. By the time these flat rates were calculated, they were enough to cover the treatment costs. But now due to the increasing cost of drugs and cost of leaving, they have become too low compared to the Fee for service charged by the service providers.

As shown in table below

Kitovu Hospital Annual Report 2008/2009 76 Kitovu Hospital Annual Report 2008/2009 Category Flat rates Actual cost Surplus/deficit Period # cases (shs) (Shs) (shs)

Total 1,918 5,754,000 8,928,700 (3,174,700) OPD Average 3,000 4,655 (1655) Total 199 3,383,000 4,643,000 (1,260,000 Jul 08 - Dec 08 IPD Average 17,000 23,332 (6,332) Total 1541 4,623,000 8,478,500 (3,855,500) OPD Average 3,000 5,502 (2,502) Total 122 2,380,000 3,861,000 (1,481,000) Jan 09 -Jun 09 IPD Average 17,000 31,648 (10,579)

The big difference is coming from:

The high cost of drugs, which has forced the health center, increased prices of services. High utilization of service due to increased sickness during this drought, which hit the area.

Challenges Faced By Kitovu scheme and Katimba scheme 1. Poor understanding of the concept of pooling risks by the community. Because this concept is still new in Uganda not many people really grasped the value of pooling health risks. So there is need for continuous sensitization in order to change the attitude of our people. 2. Shortly before we started health insurance, there were fake projects in the area which run away with people’s money, so some people still have fears of losing their savings thinking that this CHI can also close abruptly. For this reason, there is still need for continuous sensitization about the scheme in order to convince people in the community.

Therefore the scheme staff, together with the group leaders, and the health service providers have to work hand in hand in order to instill confidence in the community.

3. Low treatment cost recovery due to high utilization of services by patients with chronic diseases especially those with diabetes, hypertension, and sickle cells. These patients are really expensive because they are on daily treatment and make monthly consultations. This is one of our major challenges:

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 Excluding them is like we are condemning them for having a chronic disease, yet they are the very people who survive on some other peoples’ mercy.  If during sensitization we say that they join and be treated for other diseases they feel and see no sense in joining the scheme even though their other family members will access treatment at any time.

4. Provider Payments : the flat rates offered by the scheme are too low compared to the Fee for service offered by the Health service providers. Because of the changing cost of drugs (high cost of drugs) since last year - 2008, the service providers have been forced to increase the cost of their services. However, the schemes have not changed their Flat rates. For this reason, the Administrator of the Health unit are always requesting us to raise the flat rates. Raising flat rates means raising Premiums hence members will drop out. 5. Poverty : this hinders some people from joining and also some from renewing their membership. 6. Existence of ambulant drug vendors in the community who sell drugs to people anyhow without even taking the necessary laboratory tests, and proper prescriptions. So there is need for continuous sensitization about the effects of taking drugs from unprofessional drug vendors.

Achievements We are still in good terms with our FUNDERS - CORDAID 1. Increased membership in Kitovu scheme due to increased sensitization 2. Fewer dropouts due to good health care given and good relationship with the members. 3. Good working relationship with the service providers. Despite the low flat rate they are still giving health care to the scheme members. 4. Good working relationship with the Diocesan health office, which keeps on advising us. 5. Expansion to the 2nd LLU – Nkoni. And sensitization is in progress.

Recommendations: 1. Continuous intensive and comprehensive sensitizations and Re-sensitization. 2. Collaborate with the Medical personnel to control over prescription in case it develops. 3. Give health talks to our people in order to prevent some diseases and also going in crisis for those with chronic diseases. This will keep our treatment costs low. 4. Everybody to participate in sensitization especially the religious people because people listen to them and always trust their words. 5. During sensitizations we should always encourage the community to save for health care. They can even bring their savings to the scheme office so that by the time of renewal, they already have a good sum and need little money to top up.

Way forward  Increase sensitization, which will lead to increased membership.

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 Start sensitization in the catchment area of Nkoni health center in October 2009.  Increase health talks to scheme members in order to control/prevent some repercussions resulting from poor health-living habits. This we hope will help us to reduce the high treatment costs.

Conclusion All in all I wish to extend my sincere thanks to CORDAID our funding agency for all the support it is giving the scheme. And in addition many thanks go to all our service providers for giving good quality health care to all the scheme members.

11. HEALTH TRAINING INSTITUTION

Laboratory School.

The school is located within Kitovu Hospital compound 1 km from St. Henry’s College Kitovu. Kitovu Medical Laboratory Training School takes Senior Four (S.4) leavers who passed sciences, English and mathematics at S.4. The school trains Laboratory assistants (Technicians) for a period of two years. The school is licensed with MoES.

Our school started way back in 1986 by Sr. Davnet O’kane MMM sisters with four (4) students. The school started on the condition/ purpose of availing trained staff to the hospital laboratory. Later the demand for the staff increased and more were trained for health centres like Makondo H/C, Bikira H/C, Mushanga Dispensary, Kiteredde etc.

The school was operating on donor funds from its beginning 1998 when the donors pulled out. The school could not continue since there were no more funders. A lot of thanks go to CAFOD, MISEREOR and CEBEMO for the support given by then. The school stopped operating in 1999. Later in 2004 the ministry of Health wrote a letter to the hospital management requesting to revive the school.

The Hospital Management team and Board of Governors welcomed the idea and made arrangements for revival of the school.

In January 2005, the school officially started with 11 students, in August 2006, we had the first sitting, 10 students passed. Since the school’s revival 65 students have been trained. Students are performing wherever they want.

Type of Course The school has one type of course (Laboratory training Programme) only. So far, no changes have been made, we only hope to start diploma programme in the near future after establishing the personnel (trained tutors). There is also a plan to build a dining or multipurpose hall.

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Total HTI Capacity The total capacity of the school is 40 students. This was decided in comparison to tutor- students ratio and the buildings which were in place by the time of reopening the school (2004), but as per today the school is equipped with enough infrastructure i.e. hostels and classrooms with the capacity of 50 students. The school has trained two tutors hence the capacity of 1:25.

Course No of No of No of No of No of Success students students students students students rate enrolled 2nd year 3rd year sat for passed in the final final year (new exams exams intake) Laboratory 20 21 N/A 21 Results Results Assistants not yet out not yet Course out

Achievements ● 2 Full time teaching staff were recruited ● The computer laboratory is functional ● We have office Internet services ● Two staffs trained under sponsorship of AMREF Uganda. ● AMREF continues to sponsor students in our school. ● We received a donation of 2 PH meters

Constraints ● Self-sponsored students are unable to meet their school fee in time. ● Price hiking of commodities on market ● Computers are not enough for the students.

Faithfulness to the mission Indicator 2005/06 2006/07 2007/08 2008/09 Access (percentage of total 80% 133% 133% 108% capacity used) Equity (average student fee) 1,798,387 1,518,962 1,631,604 1,366,070 Efficiency( average recurrent cost 1,837,710 1,513,767 1,517,868 2,216,142 per student) Quality (average rate of students 91% 41% 91% Results not passing their final exams = yet out success rate). Quality (qualified tutor - student 0:32 0:53 0:53 1:43 ratio).

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Number of Tutors Employed last year: 1 Tutor The qualified tutor – students ratio is 1: 43 The ratio of qualified teaching staff – unqualified teaching staff and support staff is 5: 3

Training and workshops 2 teaching staff attended an injection safety workshop in hotel Brovard.

Governance and Management of the School The school is governed by Kitovu Health Care Complex. In every Board of Governor’s (BOG) meeting the hospital Medical Superintendent reports on the progress and issues of the school.

The school has a functional School Management team, which meets quarterly and discusses issues concerning the progress of the school.

The Principal Tutor attends 75% of the Hospital Management Team meeting.

The school is a cost centre and compiles a feasible financial report and budget.

Plans • To Train one Tutor • Improve the quality of training • Strengthen staff-students relationship by holding regular meetings and assembly. • To improve students’ co-curricular activities.

Performance of the Health Training Institution Course / subject 2006/07 2007/08 2008/09 2009/10 Lab Assistants course No new admissions 33 21 20 24 No lost during the year 1 0 0 No dismissed during the year 0 0 0 Number of student who sat 11 22 42 23 Success rate 91% 41% 91% Results not yet out No succeeded exam at first attempt 10 8 30 As above No succeeded exam at second attempt 0 1 12 As above

Key Events:

● Golden and Silver Jubilee of our 2 staff, Consultant Surgeon in religious life and the Chaplain in priesthood respectively on 25th April 2009. ● First graduation ceremony for the Laboratory Assistants was held on 13th February 2009. ● Opening of the reconstructed and extended Theatre plus a new Theatre for Fistula Unit.

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12. Concussion:

The role of Kitovu Hospital is to carryout prevention, promotive, supportive and curative services on Primary Health Care. We aim at providing a National Minimum Health Care Package (UMHCP) following a 5 year Health Strategy plan HSSP.

We train health workers e.g. Intern Doctors, Nurses from Villa Maria Comprehensive Nursing School, Laboratory Assistants students and carryout special training of Fistula Repair Trainees.

The hospital is PNFP for Masaka Diocese, owned by the Board of Trustees, Governed by the Board of Governors and managed by the Management Team.

Human Resource Capacity: The hospital is run by a total of 200 employees; including qualified and non-qualified medical and non medical, plus support staff. Once in a while we get expatriates from overseas who are of great help.

Laboratory school: Reopened in 2005. Since its revival 65 students have been trained. The capacity of the hospital is 40 students but could be raised to 50. Two Tutors have been trained. Quality has been good for the two years. The passing rate of 91% for 2006 and 2008 except 41% of 2007.

Sustainability of the school is visible so long as the majority of students are sponsored by AMREF and the Government bursaries but self sponsored students find it hard to meet their fees in time Achievements/Failures:

Achievements: 1. Revision of patients’ fees for both Medical and Surgical wards, Gyne cases and OPD was done. Majority of patients were able to pay. 2. OPD utilization has increased by 14%. There was some slight improvement in customer care relationship and reducing on waiting time. 3. Review of staff establishment as well as making sure each department has adequate staff was done. 4. New Ultra Sound machine is on the way from abroad. 5. Built a new Ash pit. 6. A Grinder for cutting and sharpening metals was bought. 7. Preparation for starting an ARV’s and HIV clinic at the hospital is underway. Ten staff have been trained in provision of comprehensive HIV/AIDS care. 8. The compound was tendered.

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9. New colorimeter and water bath have been acquired for the lab.

10. Two more of our qualified midwives were properly trained for PMCT programme

11. Plans to start intensive neonatal unit has been completed. Funds have been secured. 12. We started camping sessions for Blood Bank which have boosted our blood supply. 13. Funds to buy one hospital vehicle has been secured though we are still looking for more, as 2 other hospital cars are in poor condition, plus all the cars of CBHC Programme are very old. 14. Maternity roof was renovated. 15. Refurbishment of the chemotherapy unit in Children’s Ward 16. The Blood Bank was relocated to a specious old classroom block which was renovated. 17. Refurbishment of laboratory staff hostels was done. 18. New water reserve tank was constructed with the capacity of 55,000 litres 19. Installation of new stand alone photovoltaic solar system on Children’s Ward. 20. Extension and reconstruction of main Theatre and building a theatre for fistula Unit.

Failures:

Short term 1. No development plan for training staff for a year was made. 2. Solicit for funds for immunization for our staff against Hepatitis B, C and HIV prophlaxis; after needle stick from HIV infected patients was not accomplished though discussions were done about it. 3. Monitoring sepsis on maternity did not take root as we had to shift mothers about 2 times during renovation this year. Long term 4. Failed to increase number of isolation rooms at medical ward and to construct private rooms due to lack of funds. 5. Failure to carry out major repair of the hospital fence so as to contain security problems. 6. Failure to build and renovate staff houses. 7. Failure to obtain equipment of laboratory e.g. haematology machine. 8. Failure to have full time fistula Repair services. 9. Failure to separate causality from Out-patient Department.

N.B: Most of the failures were due to failure to secure enough funds.

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Faithfulness to the Mission: Accessibility: Accessibility improved as indicated by the increases in OPD attendance by 14%, admission by 23%, deliveries by 54% and immunization by 23%

Equity Majority of admissions were on Paediatric and Maternity ward, probably this is due to the flat fees on both wards which are affordable. Also equity slightly went up as the cost per SUO came down from 3,414 to 3,368 that is (1.3%)

Efficiency: This has increased because expenditure per SUO has decreased from 11,488 – 10,853 a decrease of 5.5%. This might be due to increased number of patients.

Staff productivity has increased from (790 – 1,050) per staff. An increase of 33%. This can be contributed to two factors; one the number of both OPD and inpatients has increased and the number of staff was decreased from 211 to 200.

Quality Indicator:  Maternity death audit have been carried out and reports are sent to the District monthly. Recovery rate is nineties.

 The number of qualified staff has increased.  MMR rate is 0.9%

 Monitoring drug prescription by clinicians, though the number of Medicines has decreased but the use of antibiotics is still high.

 Follow and documentation on post caesarean infection did not materialize as there was change of incharge on maternity ward.

Quality improvement to be tackled this fiscal year are:

1. Monitor and document on post caesarean infection rate and waiting time on OPD. 2. Segregate the data of FSB as per definition of UCMB 3. Separation of midwives in group one to concentrate on admission and ward another group to concentrate on labour ward. 4. Closely to monitor drug prescription by the Clinicians.

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Sustainability of the Hospital: Financial Support: Inadequate funds is still a problem. Donation have decreased. The income generating activities of the hospital have a long way to go before we can test on their positive effects. Thus the unreliable sources of funds, sustainability of the hospital is at a stake. Infrastructure: Inspite of expansion and renovation of Maternity ward space is not enough for the increasing number of expecting mothers coming to our hospital.

Critical issues that need attention in the next Financial year Continue lobbying and advocating for rights; partnership at district level; attention and intervention of UCMB with the Government and with developing partners.

14. PLANNING FOR THE FUTURE:

Short-term 1. Obtain heamatology analyzer so that we get more accurate results in heamatology. 2. Train more Lab Technician to improve on the service. 3. Mobilize funds so that we can provide free or subsidized immunization to all staff against infectious disease e.g. Hepatitis B. 4. Solicit funds for fridges, microscopes and autoclave for laboratory. 5. Restructuring the CBHC Programme as the main donor is phasing out 6. Consider including Fansider and Septrin prophlexis in the antenatal package. 7. To install solar system at Maternity and Surgical wards. 8. Divide the staff on maternity ward into 2 groups one to remain on admission and another to labour ward as to improve service on maternity ward. 9. To carry out Medical Audit every four months. 10. To honour the Budget and minimise costs and avoid wastage of resources. 11. Revise terms and conditions between Kitovu Hospital and Nakasero National Blood Bank 12. To increase staff salaries to match government salary scale especially the enrolled nurses and midwives 13. To develop a Human Resource Development Plan. 14. Monitor and document on post caesarean infection rate and waiting time on OPD. 15. Segregate the data of FSB as per definition of UCMB 16. Separation of midwives in group one to concentrate on admission and ward another group to concentrate on labour ward. 17. Closely to monitor drug prescription by the Clinicians.

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Long - term 18. Have a larger space for X-ray department. 19. Solicit Funds for new X-ray machines. 20. Increase OPD attendance by 5% (of targeted population of utilization) 21. Plan to intensify the sensitization of our donor targeted groups in order to curb shortages of blood. 22. To carry out Medical Audit every four months. 23. Follow up waiting time every four months. 24. Solicit funds for private and isolation rooms on Medical ward

ACKNOWLEDGMENT:

We deeply acknowledge donations of Finances, Sutures, Medical supplies and services from many friends of Kitovu Hospital namely:-

a) DONORS - Dr. Peter Doherty - U.K - Mr. Tim Peet - Guernsey, U.K - Dr. Brian Hancock - U.K - Dr. Mike Bishop - UK - Dr. Shane Duffy - U.K Ireland - Dr. Chris Manning. - U.K - Dr. John Kelly - U.K - Dr. David Tibbutt - U.K - Dr. Bill Goldthorpe - U.K - Dr. Martin Radford - U.K - Colin Legge - U.K - Rotary Doctor Bank - G.B, + Ireland - Rotary International - U.K - Medical Missionaries of Mary - Ireland - Electric Aid / Willie Roche - Ireland - Orla Clery + Friends - Ireland

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- Breda and Seamus Rogers + Family - Ireland - Brendan Lynch + Family - Ireland - Susan Begley + Family - Ireland - Jane Byrne + Family - Ireland - Janet + Conor Pitts + Sandra Lynch - Ireland - Tom Dooley Fund – Sheila Mc Glouglilin - Ireland - Duleek Women’s Group - Ireland - Staff of “Bubbles” Finglas Dublin - Ireland - VMM - Ireland - Hand in Glove - Channel - Isles - Deirdre + Hughie Larkin and Friends - Navan Ireland

- Nursing Tutors and Students - Dundalk Nursing College, Ireland - Mary and Pat O Carroll - Ireland

- All Friends and Donors of Dr. Maura - Ireland, U.K, Germany & U.S.A - Dr. Muris Fitzgerald Dublin - Ireland - Medical Students U.C.D, T.C.D - Ireland / U.K. - Dr. Linda Waters - U.S.A. - Dr. Hilary Clegg & Soroptomists Club - U.K.

- Mrs. Rosa Lynch & Friends - Christ the King Parish, Chingford London /U.K - Michael Lomas and Friends - U.K. - Mr. Werner Reiter and Family - Heiden – Germany - Mrs. B. Walter and Friends - Heiden – Germany - St. Elizabeth’s School - Germany - Mr. Franz Neblich - Germany - Mr. Helmut Cuntze - Germany

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Organizations Internal funded - CORDAID - Netherlands - AMREF - Uganda - IMRS (Ireland) Irish Missionary Resource Services - USAID - Engender Health - Fistula Funding - UNFPA

- Electric Aid - Inverter Emergency lighting system

- AFRICARE - Obstetric Fistula Funding - Fentam Trust (UK) - Maternity Buildings

- SCIAF - CBHC Programme - UCMB - Human Resource Development & Technical support b) The Management wishes to thank the Ministry of Health Government of Uganda for the continuous support of delegated funds and EDP credit line, which have enabled us to run the hospital in this financial year. c) The Hospital Management also wishes to thank Uganda Catholic Medical Bureau (UCMB), JMS, Donors and the Bishop of Masaka Diocese, Rt. Rev. John Baptist Kaggwa for the wonderful spiritual, Financial, Material, Technical Support and Guidance which they have continually extended to this hospital.

d) Staff: The Hospital Management Team, finally wishes to appreciate the very good services rendered by all professional and non-professional (support) staff.

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