THE REPUBLIC OF

Annual Health Sector Performance Report

Financial Year 2009/2010 ii Annual Health Sector Performance Report Foreword

The Annual Health Sector Performance Report for 2009-10 provides a review of sector performance in the 2009-10 financial year, and an overall assessment of sector performance against the targets set in the second Health Sector Strategic Plan (HSSP II). It also reports on implementation progress against the sector priorities set at the 7th National Health Assembly and the 15th Joint Review Mission with stakeholders.

The Government of Uganda recognizes the contribution of Health Development Partners, Civil Society, the Private Sector and all Ugandans in the achievement of the progress reported in the sector performance. The sector also appreciates the constructive criticism, useful guidance and inputs that the said stakeholders put in correcting inadequacies in the health sector. The sector cannot afford to continue with the usual way of doing things in the face of unacceptable failure to improve indicators in maternal and child health.

This report coincides with the launching of the new National Health Policy II (NHP II) and the Health Sector Strategic and Investment Plan (HSSIP). These have been aligned to the National Development Plan to enable holistic implementation of the Development agenda of Government.

The sector will continue to prioritize interventions defined in the Uganda National Minimum Health Care Package under a Sector-Wide Approach arrangement, so as to maximize gains from invested resources. This will further be supported by the International Health Partnerships Plus framework. However, this will require concerted efforts by all stakeholders in health systems strengthening, including, crucially, the leadership and management capacity development in the sector. It is only by strengthening the health system that we can deliver on strategies in the HSSIP and NDP.

Dr. Stephen O. Mallinga, MP

MINISTER OF HEALTH Annual Health Sector Performance Report iii Dr. Stephen Mallinga, MP Minister of Health

Hon James Kakooza MP Dr. Richard Nduhuura MP Minister of State for Health, Minister of State for Health (Primary Health Care) ( General Duties) iv Annual Health Sector Performance Report Dr. Asuman Lukwago Ag. Permanent Secretary / Deputy PS

Dr. Nathan Kenya-Mugisha Dr. Isaac Ezati Ag. Director General Director Health Services of Health Services Planning and Development

Annual Health Sector Performance Report v Table of Contents List of Tables ...... vii List of Figures and boxes ...... ix Annexes ...... xi Acronyms ...... xii Execuve Summary ...... xvii Chapter One: Introducon ...... 1 1.1 Background ...... 1 1.2 The framework for achieving sector goals & objecves ...... 1 1.3 The Annual Health Sector Performance Report FY 2009/10 ...... 1 1.4 The draing process ...... 2 1.5 Sources of Informaon ...... 2 1.6 Outline of the Report ...... 3

Chapter Two: Overview of Health Sector Performance (Summave Evaluaon of HSSP II) ...... 5 2.1 Performance against HSSP II Indicators ...... 5 2.2 Performance for the HSSP II indicators ...... 12 2.3 Summary Financial Report for the HSSP II ...... 14 2.4 Comparing Local Government Performance ...... 16 2.5 Hospitals performance assessment ...... 18 2.6 Conclusion ...... 20

Chapter Three: Delivery of the Uganda Naonal Minimum Health Care Package ...... 21 3.1 Health promoon, disease prevenon and community health iniaves ...... 21 3.2 Maternal and child health ...... 50 3.3 Prevenon and control of communicable diseases ...... 69 3.4 Non-communicable diseases/condions cluster ...... 104

Chapter Four: Integrated Health Sector Support Systems ...... 133 4.1 Health Financing ...... 133 4.2 Human Resources for Health ...... 147 4.3 Health Infrastructure Development and Management ...... 168 4.4 Management of Essenal Medicines and Supplies ...... 172 4.5 Diagnosc and Blood transfusion services ...... 187 4.6 Informaon for decision making ...... 193 4.7 Health policy, research and development ...... 198 4.8 Legal and Regulatory Framework ...... 207 4.9 Public Private Partnership in Health ...... 235

Chapter 5: Implementaon Monitoring of the HSSP II...... 237 5.2 Monitoring of the HSSP II Indicators ...... 240 5.3 Quality of Care ...... 245 5.4 Health Services and health status in recovery areas ...... 248 5.5 Funconality of Health Centre IVs ...... 251

vi Annual Health Sector Performance Report List of Tables TABLE 1: PERFORMANCE AGAINST THE 8 PEAP INDICATORS FOR THE HSSP II PERIOD ...... xvii TABLE 2.1: PERFORMANCE AGAINST THE 8 PEAP INDICATORS FOR THE HSSP II PERIOD ...... 5 TABLE 2.2: PERFORMANCE OF THE HSSP II INDICATORS ...... 12 TABLE 2.3: HSSP II INDICATORS WITH NO INFORMATION ...... 14 TABLE 2.4: MTEF ALLOCATION TO THE HEALTH SECTOR DURING THE HSSP II PERIOD ...... 14 TABLE 2.5: DISTRICT RANKING AND LEAGUE TABLE ...... 17 TABLE 2.6: DISTRICT RANKING FOR NEW DISTRICTS ...... 18 TABLE 2.7: DISTRICT RANKING FOR HARD TO REACH DISTRICTS ...... 18 TABLE 3.1: HEALTH PROMOTION AND EDUCATION ACHIEVEMENTS OVER THE HSSP II PERIOD ...... 22 TABLE 3.2: ACHIEVEMENTS OF THE ENVIRONMENTAL HEALTH PROGRAMME DURING THE HSSP II PERID . 25 TABLE 3.3 ACHIEVEMENTS OF THE CDD PROGRAMME ...... 35 TABLE 3.4: ACHIEVEMENTS OF THE SCHOOL HEALTH PROGRAMME ...... 36 TABLE 3.5: INTEGRATED DISEASE SURVEILLANCE AND RESPONSE INDICATORS ...... 39 TABLE 3.6: MAJOR OUTBREAKS INVESTIGATED IN UGANDA FROM JULY 2009 TO JUNE 2010 ...... 40 TABLE 3.7: ACHIEVEMENTS OF THE OCCUPATIONAL HEALTH AND SAFETY PROGRAMME ...... 45 TABLE 3.8: SEXUAL REPRODUCTIVE HEALTH AND RIGHTS KEY OUTPUTS ...... 51 TABLE 3.9 BI-ANNUAL CHILD DAYS PERFORMANCE ...... 54 TABLE 3.10: PERFORMANCE AGAINST NEWBORN HEALTH AND SURVIVAL INDICATORS OVER THE HSSP II PERIOD..56 TABLE 3.11: IMCI PROGRAMME PERFORMANCE OVER THE HSSP II PERIOD ...... 58 TABLE 3.12: UGANDA NATIONAL EXPANDED PROGRAMME ON IMMUNIZATION KEY OPUTS ...... 63 TABLE 3.13: NUTRITION PROGRAMME KEY OUTPUTS ...... 65 TABLE 3. 14: THE HIV/AIDS EPIDEMIOLOGY IN 2009 ...... 69 TABLE 3.15: ACHIEVEMENTS OF THE ACP OVER THE HSSP II PERIOD ...... 71 TABLE 3.16: ACHIEVEMENTS OF THE TB CONTROL PROGRAMME ...... 73 TABLE 3.17: THE PERFORMANCE OF THE MALARIA SPECIFIC HSSP II INDICATORS OVER THE PAST FIVE YEARS .....78 TABLE3.18: THE IMPLEMENTING PARTNERS AND FUNDING SOURCES FOR NETS ...... 79 TABLE 3.19: PERFORMANCE OF IRS 2009-2010 ...... 81 TABLE 3.20: IRS PERSONNEL TRAINED IN 2009/10 ...... 81 TABLE 3.21: UGANDA POLICE BARRACKS SPRAYED FROM JUNE TO AUGUST 2009 ...... 82 TABLE 3.22: VETERINARY PUBLIC HEALTH KEY OUTPUTS –FY 2009/10 ...... 90 TABLE 3.23 : ACHIEVEMENTS OF THE GUINEA WORM ERADICATION PROGRAMME...... 91 TABLE 3.24: PROGRESS OF LEPROSY CASE NOTIFICATION OVER THE HSSP II PERIOD ...... 93 TABLE 3.25: ACHIEVEMENTS OF THE ONCHOCERCIASIS CONTROL PROGRAMME FROM 2005 TO 2010 ...96 TABLE 3.26: THERAPEUTIC COVERAGE FOR PEOPLE AFFECTED BY LYMPHATIC FILARIASIS ...... 99 TABLE 3.27: PERFORMANCE ACCORDING TO SET TARGETS FOR ELIMINATION OF LYMPHATIC FILARIASIS ... 99 TABLE 3.28: PERFORMANCE TO SET TARGETS FOR ELIMINATION OF SLEEPING SICKNESS ...... 101 TABLE 3.29: PERFORMANCE ACCORDING TO SELECTED INDICATORS FOR SCHISTO/STH COTROL .....103 TABLE 3.30: PROGRESS ON IMPLEMENTATION OF INTERVENTIONS PLANNED IN HSSP II ...... 105 TABLE 3.31: PROGRESS ON IMPLEMENTATION OF INTERVENTION PLANNED IN HSSP II ...... 106 TABLE 3.32: SUMMARIZES THE PROGRESS OF OTHER IMPORTANT MILESTONES ...... 107 TABLE 3.33: PROGRESS ON IMPLEMENTATIONS PLANNED IN THE HSSP II ...... 110 TABLE 3.34: HOSPITALS IN UGANDA 2009/2010 ...... 112 TABLE 3.35:. STAFFING POSITIONS IN GENERAL HOSPITALS ...... 114 TABLE 3.36: OUTPUTS FROM THE GENERAL HOSPITALS FY 2009/10 ...... 114 TABLE 3.37: SELECTED EFFICIENCY PARAMETERS 2009/10 ...... 115 TABLE 3.38: STAFF IN 14 REGIONAL REFERRAL AND LARGE PNFP HOSPITALS...... 116 TABLE 3.39: OUTPUTS OF REGIONAL REFERRAL AND LARGE PNFP HOSPITALS ...... 117

Annual Health Sector Performance Report vii TABLE 3.40: EFFICIENCY PARAMETERS OF REGIONAL REFERRAL HOSPITALS AND LARGE PNFP HOSPITALS...... 119 TABLE 3.41: SUMMARY OF REPRODUCTIVE AND MENTAL HEALTH ACTIVITIES IN HOSPITAL ...124 TABLE 3.42: BUDGET PERFORMANCE FOR THE FY 2009/2010: ...... 125 TABLE 3.43: PERFORMANCE AGAINST ORAL HEALTH PROGRAMME INDICATORS ...... 127 TABLE 4.1: MTEF ALLOCATION TO THE HEALTH SECTOR FROM 2000-2009 ...... 134 TABLE 4.2: CENTRAL GOVERNMENT TRANSFERS FY 2009/10 ...... 135 TABLE 4.3: DISTRICTS WITH SIGNIFICANT CHANGES IN EFFICIENCY SCORES BETWEEN 2008/0 AND 2009/10 ...... 142 TABLE 4.4: MAIN ACHIEVEMENTS OF THE HUMAN AND DEVELOPMENT DIVISIONS ...... 147 TABLE 4.6 (I): POST BASIC / POSTGRADUATE 1ST. YEARS GOU SCHOLARSHIPS AWARDS IN FY 2009/10 ...... 152 TABLE 4.7: POSTBASIC AND POSTGRADUATE GOVERNMENT SPONSORSHIP IN HTIS FY 2009/10 .....153 TABLE 4.8: THE ACHIEVEMENTS ON KEY HRD INDICATORS FY 2009/10 ...... 155 TABLE 4.9: POSTBASIC AND POSTGRADUATE GOVERNMENT SPONSORSHIP ...... 157 TABLE 4.10: HUMAN RESOURCES FOR HEALTH ...... 162 TABLE 4.11: THE TOTAL NUMBER OF HEALTH WORKERS RECRUITED PER FINANCIAL YEAR OVER A PERIOD OF 6 YEARS ...... 163 TABLE 4.12: STAFFING LEVELS FOR DIFFERENT SELECTED NRHS & RRHS ...... 164 TABLE 4.11: ACHIEVEMENTS IN HEALTH INFRASTRUCTURE OVER THE HSSP II PERIOD ...... 170 TABLE 4.12: AVAILABILITY OF ESSENTIAL MEDICINES AT VARIOUS HEALTH FACILITY LEVELS ...... 173 TABLE 4.13: AVAILABILITY OF ESSENTIAL MEDICINES BY HSSP INDICATOR DRUG ...... 174 TABLE 4.14: FUNDING FOR ESSENTIAL MEDICINES AND HEALTH SUPPLIES IN 2009/10 ...... 176 TABLE 4.15: UTILIZATION OF VOTE 116 IN 2009/1 ...... 176 TABLE 4.16: LABORATORY CREDIT LINE OVERVIEW BY BENEFICIARIES ...... 182 TABLE 4.17: LABORATORY CREDIT LINE OVERVIEW BY LEVEL OF CARE ...... 182 TABLE 4.18: LABORATORY CREDIT LINE OVERVIEW BY AUTHORITY ...... 183 TABLE 4.19: ESSENTIAL MEDICINES AND HEALTH SUPPLIES UTILIZATION BY AUTHORITY ...... 184 TABLE 4.20 ESSENTIAL MEDICINES AND HEALTH SUPPLIES SUMMARY OF UTILIZATION ...... 185 TABLE 4.21 PERCENTAGE UTILIZATION TREND OVER FOUR FINANCIAL YEARS ...... 185 TABLE 4.22: ACHIEVEMENTS OF THE CPHL DURING THE HSSP II PERIOD ...... 189 TABLE 4.24: HEALTH POLICIES/BILLS AND THEIR STATUS ...... 198 TABLE 4.25: ACHIEVEMENTS OF THE UGANDA VIRUS RESEARCH INSTITUTE IN 2009/10 ...... 201 TABLE 4.26: ANALYZED DRUG SAMPLES AT THE LABORATORY ...... 208 TABLE 4.27: A SUMMARY OF ADVERSE EVENT REPORTS ...... 212 TABLE 4.28: A SUMMARY OF PERFORMANCE FOR EACH BUDGET LINE DURING THE FINANCIAL YEAR 2009/2010 ...... 215 TABLE 4.29: HEALTH SECTOR ANNUAL PERFORMANCE REPORT FOR 2009/2010 ...... 218 TABLE 4.30: ACHIEVEMENTS OF THE PHARMACY COUNCIL ...... 220 TABLE 4.34: PHARMACY COUNCIL ...... 222 TABLE 4.31: SUMMARY OF THE MAIN ACHIEVEMENTS OF THE COUNCIL DURING THE FY 2009/2010 ...... 225 TABLE 4.32: ACTIVITIES CARRIED OUT DURING 2009/2010 FISCAL YEAR ...... 229 TABLE 5.1: GROUPING OF THE FORTY DISTRICTS IN NORTHERN UGANDA UNDER PRDP AS OF 2007 ...... 248 TABLE 5.2: PROVISION OF SELECTED KEY HEALTH SERVICES BY HC IVS FY 2009/10 ...... 252 TABLE 5.3: INDICATORS SHOWING THE FUNCTIONALITY OF H/C IVS FY 2009/10 ...... 253 TABLE 5.4: HUMAN RESOURCE IN HC IV 2009/10 ...... 254

viii Annual Health Sector Performance Report List of Figures and Boxes FIGURE 2.1: MEDICINES SPENDING BY DISTRICTS AT NMS FY 2009/10 ...... 7 FIGURE 2.2: VARIATIONS IN OPD ATTENDANCE BY DISTRICT ...... 8 FIGURE 2.3: PROPORTION OF EXPECTANT MOTHERS DELIVERING IN HEALTH UNITS FY 2009/10 .....9 FIGURE 2.4: VARIATIONS IN DPT3/PENTAVALENT VACCINE COVERAGE BY DISTRICT FY 2009/10...... 10 FIGURE 2.5: VARIATIONS IN HOUSEHOLD LATRINE COVERAGE BY DISTRICT FY 2009/10 ...... 11 FIGURE 2.6: DISTRICTS WITH AN EFFICIENCY SCORE BELOW 80%: ...... 15 FIGURE 2.7: DISTRICT LEAGUE TABLE 15 TOP AND BOTTOM PERFORMERS FY 2009/10 ...... 16 FIGURE 3.1: HOUSEHOLD LATRINE COVERAGE BY DISTRICT 2010 ...... 28 FIGURE 3.2: NATIONWIDE SANITATION COVERAGE OF SELECTED DISTRICTS ...... 29 FIGURE: 3.3: DYSENTRY CASES VS SANITATION COVERAGE 2008 ...... 31 FIGURE 3.4: DYSENTRY CASES VS SANITATION COVERAGE 2009 ...... 31 FIGURE 3.5: DYSENTRY CASES VS SANITATION COVERAGE 2010 ...... 31 FIGURE 3.6: MAP OF UGANDA SHOWING DISTRICTS WHICH HAD CDD TECHNICAL SUPPORT SUPERVISION VISITS DURING FY2009/10 ...... 34 FIGURE 3.7: HON. MINSTER FOR HEALTH GIVING A SPEECH AT THE COMMEMORATION OF THE WORLD BREAST-FEEDING WEEK ...... 66 FIGURE 3.8: MALARIA CASES SEEN IN OPD FROM 2000/01 TO 2009/10...... 77 FIGURE 3.9: THE DISTRIBUTION OF NEW LEPROSY CASES AND HIGHLIGHTING THE “LEPROSY HOT SPOTS” IN RED ...... 92 FIGURE 3.10: VOLUME OF OUTPUTS FOR REGIONAL REFERRAL AND LARGE PNFP HOSPITALS ...... 117 FIGURE 3.11: ADMISSIONS AND OUTPATIENT VISITS IN 2009/2010 ...... 121 FIGURE 3.12: TRENDS OF ADMISSIONS AND OUTPATIENT ATTENDANCES FROM 2000-2009 ...... 122 FIGURE 3.13: ADMISSIONS IN FROM 2007/08 TO 2009/10 ...... 123 FIGURE 4.1: GRAPHICAL ILLUSTRATION OF GOVERNMENT’S ALLOCATION TO THE HEALTH SECTOR \ FROM 2005-2009 ...... 134 FIGURE 4.2: DONOR SUPPORT TO THE HEALTH SECTOR 2007 TO 2010 ...... 136 FIGURE 4.3 : CENTRAL GOVERNMENT TRANSFERS PERFORMANCE FY 2009/10 ...... 138 FIGURE 4.4 : CENTRAL GOVERNMENT GRANTS PERCENTAGE SHARE OF VARIOUS GRANTS FY 2009/10 ...... 139 FIGURE 4.5: DISTRICTS WITH AN EFFICIENCY SCORE BELOW 80% ...... 141 FIGURE 4.6: TWENTY NINE (29) DISTRICTS WITH AN EFFICIENCY SCORE RANGING BETWEEN 80% - 98% ...... 142 FIGURE 4.7: TRENDS IN INCOME FOR RECURRENT COST IN THE PNFP HEALTH SECTOR (HOSPITALS + LOWER LEVEL FACILITIES) ...... 144 FIGURE 4.8: RELATIVE SOURCES OF INCOME OVER TIME – FB PNFP HOSPITALS ...... 145 FIGURE 4.9: RELATIVE SOURCES OF INCOME OVER TIME - PNFP LLUS ...... 146 FIG 4.10: GENERAL TREND OF ATTRITION AMONG CLINICAL STAFF IN THE PNFP HOSPITALS ...... 159 FIGURE 4.11: GENERAL TREND IN ATTRITION OF CLINICAL STAFF IN PNFP LOWER LEVEL HEALTH FACILITIES ...... 159 FIGURE 4.12: TREND OF ATTRITION OF KEY CLINICAL CADRES IN PNFP HOSPITALS 2003/04 TO 2009/10 ...... 160 FIGURE 4.13: ATTRITION OF KEY CLINICAL CADRES IN LOWER LEVEL PNFP HEALTH FACILITIES ...... 161 FIGURE 4.14: STAFF ATTRITION IN PNFP HOSPITALS IN HARD-TO-REACH DISTRICTS ...... 161 FIGURE 4.15 STAFF ATTRITION RATES IN PNFP LOWER LEVEL UNITS IN 12 HARD-TO-REACH DISTRICTS ...... 162 FIGURE 4.16: VOTE 116 UTILIZATION BY DISTRICTS IN 2009/10 ...... 177

Annual Health Sector Performance Report ix FIGURE 4.17: VOTE 116 UTILIZATION BY GENERAL HOSPITAL IN 2009/10 ...... 178 FIGURE 4.18: VOTE 116 UTILIZATION BY REGIONAL REFERRAL IN 2009/10 ...... 179 FIGURE 4.19: VOTE 116 UTILIZATION BY NATIONAL REFERRAL IN 2009/10 ...... 179 FIGURE 4.20: DISTRIBUTION OF BENEFICIARIES OF LABORATORY CREDIT LINE ...... 183 FIGURE 4.21: LABORATORY CREDIT LINE UTILIZATION BY AUTHORITIES ...... 184 FIGURE 4.22: EMCL UTILIZATION IN MILLION UGX ...... 185 FIGURE 4.23: EMCL UTILIZATION OVER THE LAST FOUR YEARS ...... 186 FIGURE 4.24: UBTS UNITS COLLECTED PER REGIONAL BLOOD BANK ...... 191 FIGURE 4.25: TRENDS OF HEPATITIS C AMONG BLOOD DONORS JULY 2009 TO JUNE 2010 ...... 192 FIGURE 4.26: TRENDS OF MEDICINES TESTED FY 2010 ...... 209 FIGURE 4.27: TRENDS OF ANALYSIS OF CONDOMS TESTED ...... 209 FIGURE 4.28: TRENDS OF OUTCOMES OF GLOVES TESTED IN FY 2010 ...... 210 FIGURE 4.29: ADVERSE DRUG REACTION REPORTS FROM 2005 TO 2009...... 211 FIGURE 4.30: ADVERSE DRUG REACTIONS IN FY 2009/10 ...... 211 FIGURE 5.1: TRENDS IN NATIONAL PERFORMANCE IN THE DISTRICT LEAGUE TABLE DURING HSSP II ...... 240 FIGURE 5.2: , ONE OF THE 8 STAFF HOUSES IN FINAL STAGES OF CONSTRUCTION USING PRDP FUNDS ...... 249 FIGURE 5.3: TRENDS IN CAESAREAN SECTION AND BLOOD TRANSFUSIONS IN HC IVS ...... 252

BOX 3.2: SOME OF THE GOOD PRACTICES FOR SANITATION AND HYGIENE IMPROVEMENTS IN SELECTED DISTRICTS ...... 27 BOX 3.3: TIPPY TAP SURVEY ...... 30 BOX 3.4: HEPATITIS E RESPONSE IN NORTHERN UGANDA BY UNICEF ...... 32 BOX 3.5: LESSONS LEARNT FROM THE NULIFE PROJECT ...... 67

x Annual Health Sector Performance Report List of Annexes ANNEX I: HSSP II MONITORING INDICATORS ...... 257 ANNEX 1I: GENERAL HOSPITALS’ OUTPUTS ...... 258 ANNEX III: EFFICIENCY SCORES AND RETURNS TO SCALE FOR THE DIFFERENT DISTRICTS FY 2009/10 ....259 ANNEX IV: CHANGE IN THE EFFICIENCY SCORE BETWEEN 08/09 AND 09/10 ...... 260 ANNEX V: RESOLUTIONS OF THE 7TH NATIONAL HEALTH ASSEMBLY ...... 262 ANNEX VI: PRIORITIES OF THE 15TH JOINT REVIEW MISSION FOR THE HEALTH SECTOR ...... 265 ANNEX VII: AREA TEAM REPORTS...... 266

Annual Health Sector Performance Report xi Acronyms ACT Artemisinin Combination Therapies ADB African Development Bank AFP Acute Flaccid Paralysis AHSPR Annual Health Sector Performance Report AIDS Acquired Immuno-Deficiency Syndrome ANC Ante Natal Care APH Ante Partum Haemorrhage ART Anti-retroviral Therapy ARVs Antiretroviral Drugs AT Area Team AZT Azidothymidine BCC Behavioural Change and Communication BCG BACILLE Calmette Guerin BFHI Baby Friendly Health Initiative BOP Best Operational Practices CAOS Chief Administrative Officer CB-DOTS Community Based TB Directly Observed Treatment CDC Centre for Disease Control CDD Control of Diarrhoeal Diseases CDP Child Days Plus CMD Community Medicine Distributor CPHL Central Public Health laboratories CSO Civil Society Organization CYP Couple Years of Protection DANIDA Danish International Development Assistance DCCAs District Cold Chain Assistants DDT Dichlorodiphenyltrichloroethane DHO District Health Officer DHT District Health Team DLT District League Table DOTS Directly Observed Treatment, short course (for TB) DPs Development Partners DPT Diphtheria, Pertussis (whooping cough) and Tetanus vaccine DTLS District TB/Leprosy Supervisor EID Early Infant Diagnosis EMHS Essential Medicines and Health Supplies EmOC Emergency Obstetric Care ENT Ear, Nose and Throat EQA External Quality Assessment FP Family Planning FY Financial Year GAVI Global Alliance for vaccines and Immunisation

xii Annual Health Sector Performance Report GLRA German Leprosy Relief Association GoU Government of Uganda HAART Highly Active Anti-Retroviral Therapy HBMF Home Based Management of Fever HC Health Centre HCI Health Care Improvement HCT HIV/AIDS Counselling and Testing HDP Health Development Partners Hib Haemophilus Influenzae type B HIV Human Immuno-Deficiency Virus HMIS Health Management Information System HPA Hospital /HC IV Performance Assessment HPAC Health Policy Advisory Committee HRH Human Resource for Health HSD Health Service District HSD Health Sub-Districts HSSIP Health Sector Strategic Investment Plan HSSP Health Sector Strategic Plan HUMC Health Unit Management Committees ICN International Council of Nursing ICT Information Communication Technology ICU Intensive Care Unit IDSR Integrated Disease Surveillance and Response IEC Information Education and Communication IMAM Integrated Management of Acute Malnutrition IMCI Integrated Management of Childhood Illness IST In-service training ITNs Insecticide Treated Nets IVM Integrated Vector Management IYCF Infant and Young Child Feeding JAF Joint Assessment Framework JBSF Joint Budget Support Framework JICA Japan International Cooperation Agency JMS Joint Medical Stores JRM Joint Review Missions LF Lymphatic Filariasis LLINs Long Lasting Insecticide Treated Nets LTIA Long Term Institutional Arrangements MCH Maternal and Child Health MDGs Millennium Development Goals MDR Multi-drug Resistant MH Mental Health MMA Mass Medicine Administration Annual Health Sector Performance Report xiii MMR Maternal Mortality Rate MOFPED Ministry of Finance, Planning and Economic Development MoGLSD Ministry of Gender, Labour and Social Development MOH Ministry Of Health MOLG Ministry of Local Government MOPS Ministry of Planning and Survey MOPS Ministry of Public Service MOU Memorandum of Understanding MTEF Medium Term Expenditure Framework NCD Non Communicable Diseases NCRL National Chemotherapeutic Research Laboratories NCRL National Chemotherapeutics Research Laboratory NDA NGOs Non-Governmental Organisations NHA National Health Assembly NHP National Health Policy NMCP National Malaria Control Strategic Plan NMS National Medical Stores NTDs Neglected Tropical Diseases NTLP National Tuberculosis and Leprosy Control Program OH &S Occupational Health and Safety OPD Outpatients Department OPM Office of the Prime Minister OPV Oral Polio Vaccine ORS Oral Rehydration Salt ORT Oral Rehydration Therapy PEAP Poverty Eradication Action Plan PHA People with HIV/AIDS PHAST Participatory Hygiene and Sanitation Transformation PHC Primary Health Care PLWHA People with HIV/AIDS PMI President's Malaria Initiative PMTCT Prevention of Mother to Child Transmission PNFP Private Not for Profit PRDP Peace Recovery and Development Plan PWD Persons with Disabilities QAD Quality Assurance Department RDT Rapid Diagnostic Test RH Reproductive Health RPF Re-use Prevention Features RRH Regional Referral Hospital RUTF Ready to Use Foods SER Socio- Economic Rehabilitation SHSSPP Support to the Health Sector Strategic Plan Project xiv Annual Health Sector Performance Report SIDA Swedish International Development Agency SMER Supervision, Monitoring, Evaluation and Research SP Sulfadoxine/Pyrimethamine STI Sexually Transmitted Infection SUO Standard unit of Output SWAP Sector-Wide Approach TB Tuberculosis TMC Top Management Committee TT Tetanus Toxoid TWG Technical Working Group UBOS Uganda Bureau of Statistics UBTS Uganda Blood Transfusion Services UCMB Uganda Catholic Medical Bureaux UDHS Uganda Demographic and Health Survey UGFATM Uganda Global Fund for AIDS, TB and Malaria UNEPI Uganda Expanded Programme on Immunisation UNFPA United Nations Fund for Population Activities UNHRO Uganda National Health Research Organisations UNICEF United Nations Children’s Fund UNMHCP Uganda National Minimum Health Care Package UPMB Uganda Protestant Medical Bureaux USAID United States Agency for International Development UVRI Uganda Virus Research Institute VCT Voluntary Counselling and Testing VHT Village Health Teams VPH Veterinary Public Health WHO World Health Organisation YSP Yellow Star Program

Annual Health Sector Performance Report xv xvi Annual Health Sector Performance Report Executive Summary

Since FY 2009/10 marks the end of the Health Sector Strategic Plan II, this Annual Health Sector Performance Report (AHSPR) not only focuses on the progress of the final year (2009/10) of the HSSP II objectives but also serves to provide an overall summary for the whole of the HSSP II period. As for all the previous reports in the period, the drafting process used a number of strategies to ensure participation of stakeholders including Technical Working Groups, Senior and Top management, Health Policy Advisory Committee, Development Partners and sectors. Overview of the health sector performance Table 1 summarizes the performance of the sector during the HSSP II (2005/06-2009/10) as measured against 8 PEAP targets. Most of the indicators showed an upward trend. This is particularly noted with proportion of districts submitting timely HMIS reports, Couple Years Protected (CYP), percentage of households with at least one insecticide treated net and latrine coverage. This can in part be attributed to improvement in technical efficiency scores for the majority of districts; which shows that with adequate resources, targeted to priorities using evidence, the sector can make marked progress. The target for deliveries managed at government level and PNFP facilities improved slightly from base-line but stagnated throughout the HSSP II period and remained unmet in 2009/10. There was no current information on the national prevalence of HIV although sub-surveys at antenatal clinics indicated that the prevalence had slightly increased. New information on this indicator will be available from the latest HIV/AIDS sero-prevalence survey. Although the target for proportion of positions filled was attained, overall there are still substantial gaps in human resources, coupled with an inequitable distribution related to geographical location and service and delivery needs. Indeed, the lack of human resources contributes largely to the non-attainment of service delivery targets such as facility based child birth and immunization of infants. The ‘Hard to reach’ strategy has been designed to attract staff to otherwise unappealing areas. Inadequate financial resources also contribute to the end of HSSP II performance. While the level of resources to the sector increased in absolute terms, and an improvement in efficiency of resource use in 2009/10 compared to the previous FY was registered, this funding fell far short of that needed to implement strategies within the HSSP II. For instance, the per capita funding over the last ten years has averaged at USD 8.9 which is barely 25% of what was estimated to fully implement the HSSP II.

Annual Health Sector Performance Report xvii Table 1: Performance against the 8 PEAP indicators for the HSSP II Period Indicator Baseline Achieved Achieved Achieved Achieved Achieved Target FY 2004/05 FY 2005/06 FY 2006/07 FY 2007/08 FY 2008/09 FY 2009/10 HSSP II (09/10)

Proportion of approved Posts 68% 75% 38.4%[1] 38.40% 56% 56% 65% filled by Trained Health workers

Proportion of Health facilities 35% 27% 35% 28% 26% 41%[2] 70% without stock –out of 5 tracer medicines & supplies

OPD Utilization in Govt & 0.9 0.8 0.9 0.8 0.8 0.9 1 PNFP Units

Percentage of deliveries taking 38 29 32 40 34 33 50 place in health facilities (Govt and PNFP)

Couple Years of protection 234,259 309,757 357,021 361,080 549,594 460,825 494,908 (CYP)[i]

DPT 3 /Pentavalent vaccine 89% 89% 90% 82% 85% 76% 95% coverage

Household latrine coverage 57% 58% 58.50% 62.40% 67.50% 69.7 70%

National Average HIV Sero- 6.20% 6.20% 9.70% 7.00% 5-10%[3] No6-7%6.5% data 4.4 % Prevalence at ANC Surveillance sites

[1] There was a change in staffing Norms by MOLG [2] This analysis excludes availability of Coartem® which is procured through the Global Fund [3] ANC surveillance data 2008 Local Government Performance Local government health sector performance is assessed by a league table that incorporates 10 areas of core performance – information and financial management; selected aspects of service delivery. Over the HSSP II period, an improvement was noted in the overall average score. This FY it was not possible to make a comparison since two parameters were dropped due to lack of data (% of PHC funds expended that are disbursed) and change in policy (FDS flexibility). As for the previous FY, having low latrine coverage is the one characteristic associated with districts being in the lowest position of the league table. Being a new or ‘hard to reach’ district did not necessarily negatively affect local government performance as one of these such as Abim is ranked in the top ten best performers. Districts with high technical efficiency were among the top performers and the reverse is true. Hospital performance General and regional referral hospitals continued to provide a large output of all outpatient and inpatient services. Probably because the volume of primary level services such as antenatal care and immunizations have shifted to lower levels, hospitals overall registered a lower standard units of output compared to the previous FY. Therefore, this may have created the potential for hospitals to focus on their more complex functions. However, there is a concern about the poor quality of service delivery reflected in the very high numbers of institutional maternal deaths. Hospitals like other service delivery areas in the health sector are severely under-staffed, and this could contribute to gaps in the seamless care needed for a successful birth outcome. Delivery of the Uganda Minimum Health Care Package (UNMHCP)

xviii Annual Health Sector Performance Report Health promotion, disease prevention and community health initiatives Institution of Village Health Teams (VHT) was identified as the main sector strategy for engaging with communities, in order to awareness and health literacy on disease prevention and promotion of healthy lifestyle. Complementary strategies included the development and production of relevant IEC materials, increasing the participation of political, religious and cultural institutions in promoting health; wider use of the media. The scale up of VHT functionality has been constrained by lack of adequate funding. For instance, in 2008/09 only 13/42 of the planned VHTs were established. In 2009/10, there were plans to establish an additional 42 VHT but less than 50% of the budgeted resources were released. Experiences from functional VHTs demonstrate that they are viable structures with potential to contribute to improved community health. The production of IEC materials also suffered from reduced budgetary disbursement, receiving less than one third of what had been planned. Thus the production of IEC materials depended very much on support from Development Partners. Similarly, although the number of radio stations has increased, there have not been adequate funds to maximise use of this avenue to broadcast health promotion messages. The improvement in latrine coverage from 67.5% in the previous FY to 69.73% has been due to enactment and enforcement of ordinances and bye-. Notably, political support plus good coordination of the National Sanitation Working Group (NSWG) has played a big role in this achievement. Over 1,600,000 new people are estimated to now have access to adequate sanitation. However, one of the challenges faced by communities is the lack of sustainability of the toilet facilities constructed. For instance, many of the toilets in water logged districts last 2 to 3 years which makes it expensive to the households to replace them, yet most of them cannot afford to use more permanent materials for construction. The issue is exacerbated in flood prone areas, where toilets were destroyed by the recent floods. In district, after the recent floods the sanitation coverage dropped from 90% to 65%. Due to inadequate funding, the target for scaling up water quality surveillance and safe water consumption could not be met. For instance, districts are greatly hindered in their delivery of services by very low staffing levels. Data from 49 districts shows that only 44% of the required environmental health staffs are available, of which only 22% have adequate transport to facilitate their function. Furthermore, although the majority of the districts have improved the latrine coverage, scant attention has been paid to hand washing after toilet use, with the national average of access to hand washing facilities at toilets at 21%. Of the estimated UGX 1.9 billion of the DWSG spent on sanitation, only 4% was spent on promotion of hand washing. A recent survey of tippy taps in 30 districts1 showed that only 3% of tippy taps have soap and water, therefore the rates of effective hand washing are much lower than the reported 21%. Supervision reports also showed that the hand washing practice in schools had stagnated (25%) and this was even lower among rural schools compared to urban ones. The major impact of improved sanitation and hygiene has been in the reduction in diarrhoeal diseases. An analysis shows that the incidence of diarrhea of the dysentery type has reduced from 2008 with the increase in sanitation coverage. Integrated Disease Surveillance and Response reports are used in tracking the trends of epidemic potential diseases in the country. Working with the District Rapid Response teams,

Annual Health Sector Performance Report xix the ministry of health was able to investigate all the suspected disease outbreaks that were notified. In addition, case based data was collected for all the confirmed epidemics, which is critical for identification of the risk factors in outbreak that guide the implementation of the appropriate control interventions. The percentage of outbreaks notified to the Ministry timely (within 24 hours) however still fell short of the target (80%). Improvement in outbreak notification was mainly hampered by lack of community based disease surveillance, poor communication means and lack of knowledge on part of peripheral health facility staff. Only 68% of epidemics were responded to the Ministry within 48 hours of notification (target 80%). Maternal and child health A number of core interventions were identified to tackle the unacceptably high maternal mortality rate which stood at 435 deaths/ 100,000 live births at the start of HSSP II. Key among these was the operationalization of Emergency Obstetric Care (EmOC) Services at HC III, IV and hospitals. Others included the establishment of maternal death reviews, scaling up goal oriented antenatal care (ANC) including the provision of Intermittent Preventive Therapy in pregnancy (IPTp); family planning services with special emphasis on improving logistics and increasing availability to adolescents. At the end of 2009/10 63% of districts were implementing strategies outlined in the Roadmap which is an improvement of the previous FY 2008/09 where only 45% were doing so. An example of improved availability of services is demonstrated in the SHSSPP-supported districts where all HC IIIs, HC IVs and hospitals provide Basic EmOC. However, only 15 (2 HC IVs and 13 hospitals) out of 49 health facilities (30.6%) in these districts have capacity for the provision of Comprehensive EmOC (Caesarean sections and blood transfusion). Another important achievement was the revitalization of maternal death audits in 7 hospitals. Reducing the unmet need for FP was addressed by scaling up provision of services through outreach camps, and integration of FP services in other RH services at health unit level. During latter part of HSSP I, concerns about the stagnation of the reduction of child mortality in the country prompted a refocusing on child survival in the HSSP II. A number of interventions to improve child survival were prioritized including revitalization of EPI, Newborn Survival, Child Days Plus (CDP), Integrated Management of Newborn and Child Illness (IMNCI), Home Based Management of Fever, which has evolved into the Integrated Community Case Management (ICCM) and Nutrition especially Infant and Young Child Feeding and HIV/AIDS. Child Days Plus Strategy, involving vitamin A supplementation, de- worming, immunization and promotion of key family care practices have been implemented in the months of April and October, since 2004. In the FY 2009/10, some slight improvement was realized in some indicators for newborn although this was suboptimal. According to the supervision report of the last quarter, at least fifteen districts had initiated some activities to strengthen newborn health. Slight improvements were also realized in terms of processes to institutionalize IMCI and more innovative ways of implementation. For instance, efforts were stepped up to address the low number of sick children managed using IMCI guidelines by bringing services closer to the community. There was a decline in the DPT-HepB+Hib3 coverage from 82% in FY 2008/09 to 76% in FY 2009/10 which was attributed to: disruption in gas supply; lack of child health cards causing under-reporting; inadequate transport for delivery of supplies to sub-district levels; irregularity of outreaches; lack of IEC materials on EPI. In FY 2009/10, 2 rounds of polio

xx Annual Health Sector Performance Report campaigns were carried out in August and November 2009 targeting 12 high risk districts of , Moyo, Moroto, , Pader, , Amuru, Kotido, , , Abim and Kitgum. The overall coverage was 102% and 101% in round 1 and 2 respectively. There were no cases of confirmed Wild Polio Virus. However, the threat for wild polio virus importation from neighboring still exists and there is need to strengthen routine immunization activity at all levels. Mass polio vaccination may have to be carried out in districts that are high risk whenever recommended. Malnutrition remains a major public health concern in Uganda and affects almost all regions. It remains one of the single direct causes of child morbidity and mortality and the prevalence (under fives) remains unacceptably high at 60% (Lancet Series February 2008), with the set targets not being achieved. Prevention and control of communicable diseases The HIV prevalence from the ANC surveillance in 2008/09 was estimated to range from 5- 10%. Approximately 1 million people are infected with HIV with 140,000 of them being children below 15 years of age. Of the 100,000 new infections, 20,000 of them were in children from Mother to Child Transmission. The epidemic has shifted from the single younger-aged individuals to older individuals aged 30–35 years, who are married or in long- term relationships. Multiple concurrent partnerships, extra-marital relationships, discordance and non-disclosure are among the key factors driving the spread of HIV in Uganda. HIV services were scaled up to many health facilitues both in the public and private. For example HIV care PMTCT and ART services were provided in 66% and 83% of the health facilities respectively. One hundred (100) of the ART sites were in the private health facilities supported by HIPS (Health Initatives in the Private Sector), USAID funded. This is a great achievement enhanced by the MoH – PPP Policy. By March 2010, cumulatively about 218,986 (57.5%) of the eligible at this point in time (CD4 200) were active on ART, 66% adults and 24% children. In 2009/10 more than 12,000 new patients were initiated on ART, 1000 of them children. Over 800,000 pregnant women accessed PMTCT through ANC. A lot of success was made in integrating HIV services with others especially TB, RH and MCH. For example HIV Early Infant Diagnosis (EID) was integrated into Child Days Plus. This increased the Number of HIV exposed children that accessed HIV testing (EID) from about 17,000 to 43,000. While 63% of TB patients in Uganda are co-infected with HIV and TB remains the commonest cause of death among PLHIV. The annual TB case notifications have stabilized around 45,000 for several years; with more men (63%) than women. The country targets include: a case detection rate (CDR) and a treatment success rate (TSR) of 70% and 85% and to test 100% of TB cases for HIV and to start all those HIV + on CPT and ART. The coverage of HIV testing in all TB cases was high (91%), 59% had a positive test, 71% received Cotrimoxazole Prophylaxis Therapy (CPT) but only 18.5% received ART. The suboptimal performance for TB service delivery targets is attributed to weaknesses in the implementation of the Stop TB strategy and gaps in delivering services to target populations, which include: inadequate health financing, poor access to DOTS services and inappropriate implementation of DOTS/CBDOTS strategies, limited coverage and implementation of comprehensive TB/HIV collaborative activities, inadequate access to TB services by Special

Annual Health Sector Performance Report xxi Populations (especially Prisons and Army), inadequate human resources (clinical and laboratory), non-engagement of Private Health Care Providers, non implementation of ACSM strategy for TB and partners not adequately engaged. Programmatic management of drug resistant TB (PMDT) remains elusive, with a number of gaps that include; lack of second line anti-TB medicines (SLDs), lack of established DR-TB isolation unit, lack of personal protection equipments (PPE) for health workers and patients at the proposed DR-TB Isolation Unit, the current lab at the DR-TB isolation Unit lacks equipment and supplies for chemistry analyzers and lack of dedicated and motivated staff to offer DR-TB care. Malaria and malaria-related illnesses contribute 20-23% of deaths among children aged less than five years. Some of the reasons for this poor state included: limited access to effective treatment of malaria/fever; incorrect and/or inadequate malaria treatment at home or within communities. In terms of programmatic performance, most of the service delivery targets were not met apart from spraying of households with IRS. However, the improved reporting may account for the increased number of cases in this FY 2009/10. Dracunculiasis is one of the diseases targeted for eradication nationally and globally. Uganda achieved this goal and the country was certified free of dracunculiasis in 2009 by the World Health Organization. However, the country still faces a challenge of cross-border importation of guinea worm cases from Southern Sudan, the only neighboring country still endemic for the disease. Prevention and control of non-communicable diseases The increase in the incidence of chronic non communicable diseases is predicted to continue over the years fueled by the increasing exposure of our population to unhealthy lifestyles associated with urbanization. The WHO predicts that NCDs will reach epidemic proportions by the year 2025 if NCD preventive, control and surveillance measures are not undertaken immediately. In response to this, the Non communicable disease programme was established during the 2006/07 Financial Year to the plan, implement and coordinate actions aimed at prevention and control of NCDs in Uganda. A national baseline survey on NCD and their risk factors is planned. Hospitals are major contributors to essential clinical care and the recent growth in numbers is mainly from the private and institutional sectors. Compared to last year (2008/09) there has been some improvement in hospital efficiency indicators however the dispersion is great, most of the indicators being propped up by “extra busy” hospitals. Overall there has been reduction in the standard unit outputs which is largely explained by a shift of antenatal and immunization services to lower level facilities. However there remains a concern over the quality of care at hospitals exemplified by the high institutional maternal deaths averaging 9 annually with one outlier at 105 deaths in one year. Integrated health sector support systems Efforts to improve health financing were guided by concepts of universal coverage and social health protection. The health sector was financed through government revenue, private sources and development assistance under the SWAP arrangement. At the start of HSSP II, the per capita expenditure for health fell far short of the amount needed to finance the UNMHCP. For instance, provision of UNMHCP in all health facilities was xxii Annual Health Sector Performance Report estimated at USD 41.2 in 2008/09 and was expected to rise to USD 47.9 in FY 2011/12 (HSLP Africa Limited, 2008). Funds allocated to the Health Sector have steadily increased from Ushs 236 Billion in Financial Year 2006/07 to Ushs 735 Billion in Financial Year 2009/10; they are still inadequate to fund the UNMHCP. An estimated Ushs 1.5 Trillion is required annually to deliver the UNMHCP2. Whereas resources allocated to health have been increasing steadily, the public per capita expenditure has averaged at 8.9 USD over the last ten years. The percentage of government allocation to health as a proportion of the total GoU budget has not significantly increased.

Trends for improving the proportion of approved staffing positions filled by trained health workers was positive however, the target was not attained. In the PNFP sector, there has been some stabilization seen in the staff turnover over the last few years and the trend of attrition in both hospitals and lower level health facilities seem to show a downward trend. One of the strategies in place to ensure that this status in sustained and scaled up include establishment of the “Hard To Reach” strategy which includes a 30% increment to basic salary allowance with effect from July 2010.

Some progress was registered against the consolidation of existing health facilities to enhance their functionality as well as increasing accessibility to health services and quality of health care delivery within the available resource envelope. For example since 2007/08, 42/55 hospitals were supplied with ambulances and rehabilitation is ongoing for both regional and district hospitals.

There was improvement in availability of essential medicines as reflected in the analysis of some tracer medicines (Cotrimoxazole, ORS and Measles Vaccine). However, the availability situation deteriorated in the case of Medroxy progesterone inj, Sulphadoxine - Pyrimethamine and Artemether –Lumefantrine tablets. The improvement in availability of medicines can be partially attributed to the intensified routine monitoring and support supervision to hospitals and districts on medicine management activities, with special focus on forecasting and rational. The National Drug Authority also contributed to ensuring quality of medicines at the operational level through its inspectorate. A major concern for sustaining gains made in the medicines sector in the medium to long term is the withdrawal of DANIDA as a major financing and technical support partner. Timeliness and completeness of HMIS reporting (a key process indicator for the implementation of the HSSP1 and whose 5year target was set at 80%) improved during the HSSPI and II. HMIS reporting has improved from a national average of 21% in 2000, 53% in 2001, 63% in 2002, 79% in 2003 and 84% in FY 2009/10. The major challenge for the HMIS has been harmonization and streamlining of various data sources and ensuring that they are leveraged to provide a better impact measurement of health sector interventions. The on-going analysis of the old HMIS data revealed lack of accuracy, timeliness and completeness of reports, consequently affecting decision making at all levels. Lack of coordination, leadership, clear strategy, policy and guidelines, as well as shortage of skilled human resources, were the key factors affecting the HMIS performance. Furthermore, the effect of parallel reporting with multiple and redundant formats compromised data quality and increased administrative workload.

Annual Health Sector Performance Report xxiii Supervision & monitoring of the HSSP II The supervision and monitoring of National Referral Hospitals, central level programs and other autonomous or semiautonomous institutions (e.g. Uganda Chemotherapeutic Research Laboratories, Uganda Blood Transfusion Services, National Drug Authority (NDA), National Medical Stores (NMS) and Uganda Virus Research Institute (UVRI) has been carried out within the long term institutional arrangements (LTIA) which is one of the mechanisms adopted by the Top management of the MoH. During the FY under review most of these structures carried out their functions effectively. All the planned four quarterly reviews were conducted (one review per quarter), the TWG, SMC and HPAC meetings were held regularly. The reports of the sector quarterly reviews were finalized in time, printed and disseminated to stakeholders. TMC has also used the process of preparing Ministerial Policy Statements to critically review the performance of MoH programs and institutions. Integrated support supervision, mentoring and monitoring of Local Governments and Referral Hospitals continued to be carried out through the Area Team Strategy in line with the UNMHCP. The participation of members of TMC is in line with the HSSP II Mid Term Review Report which recommended top leadership of the MoH to play a more active role in supervision activities. In addition the Political Leadership of the MoH carried out several impromptu inspections of health facilities. Technical programmes also carried out their own technical support supervision to the Local Governments and referral hospitals. Internal supervision of health facilities though very effective in improving service delivery has not been effectively done during the period under review. There have been attempts to build capacity for internal supervision of health facilities and districts by several quality improvement initiatives/programmes. These programmes have supported the districts to supervise HSDs and lower level facilities. The challenge is lack of harmonized performance measurement tool and supervision framework to guide the different stakeholders. This is compounded by inadequate human resource even at district level and lack of transport. The YSP strategy was designed for this purpose but presently will have to be reviewed and institutionalized in the new sector strategic plan for sustainability. Functionality of Health Centre IV The health sub-district strategy remains crucially important in getting essential services nearer to the people and increase service utilization. The key feature of the HSD Strategy was that each HSD of approximately 100,000 people would have a Hospital or a Health Centre IV with the capacity to provide basic promotive, preventive and curative services, including Emergency Surgical and Obstetric Services and to supervise and support planning and implementation of services by the lower health units in the zone. Just like the previous 2 Financial Years, the factors that constrain functionality are related to the absence of: appropriate infrastructure and equipment; qualified health workers especially medical officers; and weak supervision from local governments.

xxiv Annual Health Sector Performance Report CHAPTER ONE INTRODUCTION

1.1 Background

The Annual Health Sector Performance Report (AHSPR) is an institutional requirement and since 2000 has been very useful in highlighting areas of progress and challenges in the health sector. This AHSPR for the Financial Year 2009/10 also marks the end of the HSSP II strategic period (HSSP II 2005/06 to 2009/10). Therefore this report mainly focuses on the progress of the final year of the HSSP II objectives as well as an overall summary for the whole of the HSSP II period. It takes into consideration the performance through the HSSP II period on 1) The effectiveness, responsiveness and equitableness of the health care delivery system 2) How well the integrated support systems have been strengthened 3) the status of enforcement of the legal and regulatory systems and 4) how well evidence feeds into policy as well as the status of programme planning and overall development mechanisms. These findings will be considered at the 16th Joint Review Mission in October/November 2010.

1.2 The framework for achieving sector goals & objectives

The delivery of the Uganda National Minimum Health Care Package (UNMHCP) was central to the implementation of the Health Sector Strategic Plan (II) and the attainment of the sector goals and objectives. The design of the UNMHCP was set within the overarching policy and strategic framework governing the health sector in Uganda that consists of the National Health Policy II (NHP II) and Poverty Eradication Action Plan (PEAP). Additionally, the UNMHCP core strategies were aligned to the Millennium Development Goals (MDGs), to which Uganda is a signatory. The implementation of the PEAP (through sector plans) and the HSSP II were undertaken in a sector-wide approach (SWAp), which addresses the health sector as a whole in planning and management, and in resource mobilization and allocation. The AHSPR 2009/10 is therefore one of the major SWAp management tools that assess sector progress in achieving the HSSP II outputs and outcomes.

1.3 The Annual Health Sector Performance Report FY 2009/10

The objectives AHSPR 2009/10 are twofold: to review the performance of the sector for the HSSP II from FY 2004/05 to FY 2009/10 identifying achievements and constraints; and to provide a summative assessment of the whole of the HSSP II period.

Annual Health Sector Performance Report 1 Thus, the report provides progress on:

i) Sector performance and annual trends for the HSSP II 25 annual indicators; ii) Implementation progress on the delivery of the UNMHCP basing on national, and district level indicators; iii) Status of implementation of the Integrated Health Sector Support Systems for the delivery of UNMHCP iv) District League Table that compares performance among districts v) The individual and collective contribution of the National and Regional Referral and General Hospitals as well as the PNFP hospitals at similar levels; vi) Financial Report for the HSSP II period including a donor-expenditure analysis; and vii)Progress made towards the 7th National Health Assembly Resolutions and 15th Joint Review Mission Undertakings.

1.4 The drafting process

The development process of the AHSPR 2009/10 was as for other years widely consultative with stakeholders from all departments of the Ministry of Health and Development Partners. The overall coordination and technical support was provided by a MOH Task Force (TF). The composition of the TF was drawn from all departments of the Ministry of Health and included chairpersons and secretaries of the seven Technical Working Groups. The TF had representation from districts, NGOs, the Civil Society and Health Development Partners. Additional support was provided by a secretariat of staff from both the Health Planning and Quality Assurance Departments. An external full time Lead Facilitator (Consultant) was recruited and provided overall leadership of the preparation process, in close collaboration with the Secretariat and TF. Meetings were held weekly, to assess progress of development of the AHSPR and provide feed-back on the drafts. Draft submissions were made by secretaries of TWGs/heads of Divisions and sections; the lead facilitator then reviewed, analysed and collated reports. Gaps identified were rectified by the relevant submitting authority. The draft was presented to SMC, HPAC and TMC for comments and approval.

1.5 Sources of Information

As with the previous reports, this AHSPR relied heavily on the traditional sources of information, in particular the Health Management Information System (HMIS). One of the challenges identified with HMIS data was the inconsistency between district data submitted through the monthly HMIS and that submitted through the district annual reports. The variation for all indicators varies between 15-25%. Whilst this may be partially attributed to continuous data updating throughout the year, it also indicates that the accuracy of information from the HMIS is not foolproof. In order to maintain consistency with previous

2 Annual Health Sector Performance Report reporting periods, this AHSPR uses the HMIS aggregated monthly reports for the entire financial year. Data errors in the annual reports submitted included … (how were these handled?)

Other key sources of information included:

i) FY 2009/10 quarterly review reports ii) Departmental technical and Area Team supervision reports iii) Ministry of Health Quarterly Submissions to the Ministry of Finance iv) Previous AHSPR for the FY 2004/05, 2005/06, 2006/07 and 2008/09 as well as the Midterm Review of the HSSP II v) Draft HSSIP III vi) MoH programmes and other central level institutions reports were mainly obtained from quarterly and annual reports; vii)Additional sources of information are included in the reference list at the end of each chapter/the main document.

1.6 Outline of the Report

The AHSPR 2009/10 is divided into five chapters. Chapter 1 is an introduction that covers the background to the HSSP and AHSPR, the process of drafting the AHSPR 2009/10 and a brief description of the report contents.

Chapter 2 covers an overview of the sector performance for FY 2009/10 and includes the overall performance of the sector against HSSP indicators; comparison of district performance using the District League Table; comparison of hospital performance using the Hospital League table; a summary of the financial report; and a summative evaluation of the HSSP II which incorporates a conclusive overview and discussion of the attainments of HSSP II goals and objectives.

Chapter 3 details implementation status of the Uganda National Minimum Health Care Package whilst.

Chapter 4 outlines the performance of the Integrated Health Sector Support Systems.

Chapter 5 details the Monitoring of the Implementation of the HSSP II focusing on three areas of particular interest namely: HC IV functionality; status of health services in recovery areas; monitoring of SWAp implementation, and a review of the Supervision, Monitoring and Mentoring framework; Each of chapters 3-5 ends with a section on lessons learned as well as key recommendations for enhanced programmatic performance.

Annual Health Sector Performance Report 3 4 Annual Health Sector Performance Report CHAPTER TWO OVERVIEW OF HEALTH SECTOR PERFORMANCE (SUMMATIVE EVALUATION OF HSSP II)

This chapter presents an overview of the sector performance for FY 2009/10 as well as the four financial years of the HSSP II period. It therefore includes an assessment of the progress of the PEAP and HSSP indicators, comparison of district performance using the district league table, a summary of the financial report and review of hospital performance. In addition, it includes a summative evaluation of the HSSP II which incorporates a conclusive overview of the attainments of HSSP II goals and objectives. 2.1 Performance against HSSP II Indicators

Twenty five (25) core indicators with annual targets have provided the basis for monitoring of the HSSP II. Out of these, eight indicators were used to monitor the progress of the health sector towards the Poverty Eradication Plan (PEAP)3. Table 2.1 summarizes the performance across the HSSP II period for the PEAP indicators.

Table 2.1: Performance against the 8 PEAP indicators for the HSSP II Period Indicator Baseline Achieved Achieved Achieved Achieved Achieved Target FY 2004/05 FY 2005/06 FY 2006/07 FY 2007/08 FY 2008/09 FY 2009/10 HSSP II (09/10)

Proportion of approved Posts 68% 75% 38.4%[1] 38.40% 56% 56% 65% filled by Trained Health workers

Proportion of Health facilities 35% 27% 35% 28% 26% 41%[2] 70% without stock –out of 5 tracer medicines & supplies

OPD Utilization in Govt & 0.9 0.8 0.9 0.8 0.8 0.9 1 PNFP Units

Percentage of deliveries taking 38 29 32 40 34 33 50 place in health facilities (Govt and PNFP)

Couple Years of protection 234,259 309,757 357,021 361,080 549,594 460,825 494,908 (CYP)[i]

DPT 3 /Pentavalent vaccine 89% 89% 90% 82% 85% 76% 95% coverage

Household latrine coverage 57% 58% 58.50% 62.40% 67.50% 69.7 70%

National Average HIV Sero- 6.20% 6.20% 9.70% 7.00% 5-10%[3] No data 4.4 Prevalence at ANC Surveillance sites

[1] There was a change in staffing Norms by MOLG [2] This analysis excludes availability of Coartem® which is procured through the Global Fund [3] ANC surveillance data 2008

3 The PEAP Uganda’s comprehensive national development framework is linked to a monitoring and evaluation framework the PEAP Matrix which includes health and health-related indicators.

Annual Health Sector Performance Report 5 2.1.1 Proportion of approved posts filled by trained Health Workers

The sector has had improvements in ensuring adequate HRH are recruited and retained, however the target has not yet been achieved. This can be attributed to a number of factors including: i) Poor attraction and retention of staff across the country remains critical. The situation gets even worse for cadres like-; Doctors, Midwives, Anesthetic staff, Radiographers Pharmacists and Dispensers. ii) Limited funding for recruitment, Salaries and wages has resulted into high vacancy levels. iii) Inequitable distribution of Health Workers to districts due to peculiar disadvantages of such districts has resulted into some districts not performing to the minimum staffing levels. iv) Inadequate tools and equipment result into staff not applying their skills thus leading to de-motivation. A number of strategies are in place to ensure that approved posts of trained health workers are filled. Most important are: i) Hard To Reach” strategy was defined by MOPS, and a 30% of basic salary allowance has been incorporated into salary of health workers in designated “Hard To Reach areas” with effect from July 2010 ii) Districts were guided to submit recruitment plans to fill up to 65% for the FY 2010/2011

2.1.2 Proportion of facilities without stock-outs of 6 tracer medicines and supplies

There was overall improvement in availability4 from 26% to 41% when Coartem®5 is not include in the analysis with the improvements seen at level III health centers. When Coartem® is included the availability fell to 21%. For comparison when Coartem® is dropped from the analysis of 2008/2009 results, the improvement is negligible from 26% to 28% but in 2009/2010 when Coartem® is dropped the availability improves from 21% to 41%. This is important to note because availability of Coartem® largely depends on the GFATM honoring its obligations and not the performance of NMS or Health facilities.

4 Availability is measured as percentage of facilities with no stock out of any of the 6 tracer drugs (Cotrimoxazole, ORS, Measles Vaccine, Medroxy progesterone inj, Sulphadoxine -Pyrimethamine and Artemether –Lumefantrine tablets in a month 5 See table 4.13 that shows that on average, Coartem® was absent from half of the facilities on a monthly basis.

6 Annual Health Sector Performance Report Figure 2.1: Medicines spending by districts at NMS FY 2009/10

There was improvement in availability of Cotrimoxazole, ORS and Measles Vaccine. The availability situation deteriorated in the case of Medroxy progesterone inj, Sulphadoxine - Pyrimethamine and Artemether –Lumefantrine tablets. The creation of Vote 116 that transferred all funds for procurement of medicine and health supplies from districts to NMS assumed that there would be marked improvements in the supply chain. However, it removed the option of procuring medicines from JMS in the event that NMS failed to supply. Also, not all districts were able to utilize the funds allocated to them. The figure 2.1 shows the performance in use of the medicines (Vote 116) at NMS. The improvement in availability of medicines can be partially attributed to the intensified routine monitoring and support supervision to hospitals and districts on medicine management activities, with special focus on forecasting and rational drug use. The re- introduction of pre-packaged kits at HC II and III where capacity to forecast medicines in a timely manner was an additional factor for improved availability of medicines at this level. Although, the HSSP II target was surpassed, a number of constraints remain which impede efforts to ensure a regular supply of medicines and other supplies. Some of the factors noted included: i) inadequate financing of medicines and health supplies, and ii) poor medicine management at health unit level. A major concern for sustaining gains made in the medicines sector in the medium to long term is the withdrawal of DANIDA as a major financing and technical support partner.

2.1.3 New outpatient attendance in Government and PNFP health units The national average for OPD attendance almost made the HSSP II target of 1.0 per capita. 32.5% of districts (see League table for all districts) attained the national average target.

Annual Health Sector Performance Report 7 Thirty three percent (33%) of the 16 districts that had below 0.6 attendances per capita were new districts created after 2005(see figure 2.2). Figure 2.2: Variations in OPD attendance by district

2.1.4 Family planning uptake

The sustained improvement in addressing the unmet need for FP was attained and maintained by scaling up provision of services through outreach camps, and integration of FP services in other RH services at health unit level. The continued support from Development Partners helped to ensure a steady supply of contraceptives. Several health care providers were trained in various reproductive skills in a bid to improve a critical mass of service provides with family planning knowledge.

2.1.5 Percentage of deliveries taking place in health facilities (Govt and PNFP)

A number of strategies were initiated and implemented to scale the proportion of deliveries at health facility level. Key among these was scaling up infrastructure and functionality for the provision of emergency obstetric care.

8 Annual Health Sector Performance Report Figure 2.3: Proportion of expectant mothers delivering in health units FY 2009/10

Failure to attain the HSSP II target of 50% of deliveries taking place at facility level is largely explained by the HRH gaps for midwives, doctors and anesthetists within the districts which compromise the much needed EmOC service provision. Although 81 (90 %) of 90 hospitals were reported to have carried out Caesarean sections only 20 (15 %) out of 132 HC IVs had done so. The performance of different districts is shown in figure 2.3. Additionally, the inadequate resources to manage ambulances at district level constrain referrals and could further limit access by mothers. In order to attain the target it would be important to also consider if mothers’ perceptions of quality of health facility services and the costs of the getting services are significant factors in discouraging women from having deliveries in health facilities.

2.1.6 DPT3 / pentavalent vaccine coverage

A number of efforts have been implemented to ensure continuing provision of quality immunization services and the performance of different districts is shown in figure 2.4. However, non-attainment of the HSSP indicators especially in the final year was influenced by several factors which included:

Annual Health Sector Performance Report 9

Figure 2.4: Variations in DPT3/Pentavalent vaccine coverage by district FY 2009/10

i) Irregular gas supplies whereby distribution of vaccines were halted ii) Lack of Child Health Cards and tally sheets for recording child immunization which may be causing under reporting by the health facilities carrying out immunization. iii) Inadequate transport at district level for delivery of supplies to the lower levels. iv) Irregularity of outreaches in almost all districts causing dropouts.

2.1.7 Latrine coverage

A review of the sanitation coverage over the last 5 years shows that the country is on track to meet the national sanitation target of 77%, with an average increment of 2.4 percentage points. A large proportion of the districts, (47%) are unlikely to meet the target. Traditionally, monitoring indicators for rural sanitation have focused on physical outputs such as toilet constructed. However, this means that the focus is on incremental increases in physical achievement (house by house or school by school) rather than collective outcomes such as 100% usage of improved sanitation in a village or community. The figure 2.3 shows the latrine coverage performance of all the districts. Although many districts are doing well in latrine coverage, and are at or over the HSSP II target of 70%, most districts have very poor hand washing coverage as well as school sanitation, which affects the health outcomes.

10 Annual Health Sector Performance Report Figure 2.5: Variations in household latrine coverage by district FY 2009/10

Special attention needs to be paid to the Karamoja region which is lagging behind the rest of the country (figure 2.3). This could be addressed through funding and implementation of the Karamoja strategy which was developed last year.

2.1.8 HIV/AIDS

The HIV prevalence from the ANC surveillance in 2008/09 was estimated to range from 5- 10%. In 2009/10, the ANC HIV prevalence shows that there is an upward trend in the prevalence of infections amongst pregnant mothers. There were more than 100,000 new infections 20,000 of them in children from Mother to Child Transmission. The AIDS Information Survey will provide the most current estimate for the HIV prevalence in the general population. Integrating HIV services with others especially TB, RH and MCH has been successful e.g. example HIV Early Infant Diagnosis (EID) was integrated into Child Days Plus which has increased the Number of HIV exposed children that accessed HIV testing (EID) from about 17,000 to 43,000. Additionally, over 800,000 pregnant women accessed PMTCT through ANC. In 2009/10 more than 12,000 new patients were initiated on ART, 1000 of them children. By March 2010, cumulatively about 218,986 (57.5%) of those who were eligible (< CD4 200) at this point in time were active on ART.

Annual Health Sector Performance Report 11 2.2 Performance for the HSSP II indicators

This section outlines the performance trends for HSSP II indicators from 2005/06 to 2009/10.

2.2.1 Attainment of HSSP II targets for 2009/10 and performance trends The performance of the HSSP II indicators is summarized in table 2.2 that is color coded to show if the target was attained or not attained & whether the trend was positive or stagnated/dropped. Compared to the previous FY 2008/09 where targets were met for three indicators, the target for 1 indicator “percentage of disbursed PHC funds that are expended quarterly” was attained in 2009/10 and 12 of the core HSSP II indicators showed a positive trend even though the target was not met in most of these cases. There was negative or stagnated performance over the HSSP II period for 7 of the core indicators that had complete information. Further information on the HSSP II monitoring indicators is shown in Annex I.

Table 2.2: Performance of the HSSP II indicators Type of indicator Indicator Attainment of Performance 2009/10 target[1] Trend[2] for the HSSP II period Percentage of government of Uganda (GoU) 9.6 (13.2) Positive trend allocated to the health sector

Total public (GoU and donor) allocation to 11.1 (18.0) Positive trend health per capita (USD) Inputs Proportion of health facilities with no stocks (%)[3] 21 (80) Positive trend

Percentage of population residing within 5km … (85) of a health facility (public or PNFP)

Proportion of approved posts filled by trained 56 (65) Positive trend health workers (%) Inputs Percentage of PHC conditional grants released -100 on time to the sector (non-wage, recurrent and capital by quarter)

Percentage of disbursed PHC funds that are 100 (100) Attained Process expended quarterly

Proportion of districts submitting HMIS 84 (100) Positive trend monthly returns on time

Proportion of districts submitting quarterly assessment reports in time

Process

12 Annual Health Sector Performance Report OPD utilization in Govt &PNFP units 0.9 (1.0) Flat trend

Proportion of deliveries in a health facility (%) 37 (50) Positive trend

Caesarean section rate per expected 2.8 (7) Flat trend pregnancies (%)

CYP 460,825 (494,908) Positive trend

Proportion of pregnant women receiving IPTs 47 (75) Positive trend (%)

Outputs Percentage of households with at least one 54 (70) Positive trend insecticide treated net (%)

Proportion of children receiving 3 doses of 76 (95) Flat trend DPT3/Pentavalent vaccines (%) Proportion of TB cases notified compared to 56 (70) Positive trend expected (%) TB cure rate (%) - (85) Positive trend Latrine coverage 69.7 (72) Positive trend

HIV/AIDS seroprevalence (%) No data (4.4) Flat trend

Proportion of children under five years with 13.7 (80) Flat trend fever who receive malaria treatment within 24 hours from a community drug distributor

Percentage of fever / uncomplicated malaria 13.7 (85) Flat trend cases correctly managed at health facilities

Output

[1] The HSSP II target is included in parentheses. Red indicates that the target was not attained, whilst green shows that the HSSP II [2] Key: Yellow – Positive trend through the HSSP II period; Red – stagnant or generally downward trend [3] 35 health facilities included in survey of which 11 HCII, 13 HC III, 11 HC IV

Annual Health Sector Performance Report 13 Table 2.3: HSSP II indicators with no information Indicator Proxy source of information Remarks (performance) Proportion of population expressing satisfaction with health services Percentage of health units by level providing all components of the UNMHCP Percentage of health units Reproductive Health Division All HC IIIs, HC IVs and hospitals providing EmOC (SHSSPP-supported districts) provide Basic EmOC. However, only 15 (2 HC IVs and 13 hospitals) out of 49 health facilities (30.6%) in these districts have capacity for the provision of Comprehensive EmOC (Caesarean sections and blood transfusion).

2.3 Summary Financial Report for the HSSP II

2.3.1 The HSSP II Resource Envelope Table 2.4: MTEF allocation to the Health Sector during the HSSP II period Year GOU DONOR/GHI TOTAL Per capita Per capita GoU allocation to expenditure in expenditure in health as % of Ushs USD total GoU allocation 2005/06 229.86 268.38 498.24 26,935 14.8 8.9 2006/07 242.63 139.23 381.86 13,518 7.8 9.3 2007/08 277.36 141.12 418.48 14,275 8.4 9 2008/09 375.46 253 628.46 20,810 10.4 8.3 2009/10 435.8 301.8 737.6 24,423 11.1 9.6 Source: MoFPED approved estimates and Budget performance reports.

Whereas resources from both Government of Uganda and donor projects that are allocated to health have been increasing steadily, the public per capita expenditure has averaged 8.9 USD over the last ten years. Moreover, the percentage of government allocation to health as a proportion of the total GoU budget has not significantly increased. Thus, throughout the HSSP II period, the sector’s budget as a proportion of the GoU budget at 9.6% remained far below the HSSP II target of 13.2% and Abuja target of 15%. Subsequently, working with

14 Annual Health Sector Performance Report just slightly over 25% of the required resources9 the health sector has struggled to meet set goals and objectives. Several factors contribute to the failure to meet financing targets. i) High population growth puts pressure on existing resources since some activities are for universal coverage e.g. immunization. ii) The non-alignment of donor project support to HSSP II objectives iii) Unpredictability of donor disbursements due to challenges in fulfilling conditionalities for disbursement, iv) Relationship of budget performance and HSSP II outputs, shortfalls and efficiency measures

2.3.2 Efficiency and equity of resources The first efficiency analysis was undertaken in FY 2008/09 and it showed that only 30 districts had an efficiency score of 36%. Between the two years, there has been improvement in technical efficiency scores for the majority of districts. The highest reduction in efficiency score between 2008/09 to 2009/10 was registered in Kibaale at 40% while the highest improvement was registered in Masindi at 43%. Nineteen (19) districts10 had an efficiency score of below 80% implying that with the current level of inputs, the output level can be increased by 20%. Details for other districts are shown in annex II.

Figure 2.6: Districts with an efficiency score below 80%:

2.3.3 Financial management monitoring

The sector continues to conduct financial management monitoring using laid down frameworks. The budget and finance division conducts quarterly financial management reviews of implementers both at the centre and in the districts. This process is also conducted

9 11.1 USD per capita compared to about 41 USD needed to deliver the UNMHCP 10 Pader, Kaabong, , , Kaberamaido, , Amuru, , , apac, , , Adjumani, , , , , , Masindi

Annual Health Sector Performance Report 15 by the auditor general at both levels mentioned above in order for an independent opinion to be made. 2.4 Comparing Local Government Performance

2.4.1 District league table performance

The league table ranks district performance across several management and service delivery indicators. The final ranked score weights the separate parameters into a single composite indicator. The individual parameters provide some indication for district performance. Since there was an adjustment in the number of parameters used to rank districts11, this report does not make comparisons between the current year and previous years. Nonetheless, three districts – , and maintain their positions among the top five performers (see figure 2.7). Similarly, Kaabong remains at the bottom of the league table in the 80th position. Figure 2.7: District League Table 15 top and bottom performers FY 2009/10

Kaabong district that is at the bottom of the league table is both new and hard to reach. It’s poor performance was also affected by the very low latrine coverage, percentage of deliveries at facility level – factors that could be related to low infrastructure. However, being new and hard to reach does not seem to have affected the performance of other districts such as Abim which is in the 7th position (see table 2.5). Also, three of the new districts are in the top ten 11 There was no information for two of these parameters – i) % of PHC funds that are expended and ii) FDS flexibility gain - so districts are given a similar flat score across board for each of them. The proxy information used for ‘The Proportion of PHC funds spent on drugs (at NMS and JMS)’ is the ‘% of funds utilized by districts from vote 116’ which is for the period of three quarters.

16 Annual Health Sector Performance Report best performers whilst three of the hard to reach districts are among the best twenty performers.

Table 2.5: District ranking and league table Total Total District Score Rank District Score Rank KAMPALA 91.0 1 NEBBI 69.0 21 LYANTONDE 79.6 2 69.0 21 MITYANA 78.4 3 BUSIA 68.7 23 74.8 4 68.5 24 JINJA 74.1 5 68.5 24 KABAROLE 74.1 5 68.4 26 ABIM 73.5 7 MANAFWA 68.4 26 73.3 8 68.3 28 73.0 9 BUTALEJA 68.2 29 72.6 10 KITGUM 68.1 30 72.3 11 PADER 67.7 31 GULU 72.3 11 67.2 32 72.2 13 66.9 33 MUKONO 72.0 14 66.5 34 71.9 15 KUMI 65.7 35 70.3 16 AMURU 65.5 36 RAKAI 70.2 17 IBANDA 65.4 37 70.0 18 65.3 38 LIRA 69.6 19 KASESE 65.3 38 OYAM 69.1 20 NAMUTUMBA 65.0 40 WAKISO 64.6 41 58.4 61 63.1 42 58.4 61 KALANGALA 63.1 42 BUKEDEA 58.2 63 LUWERO 62.8 44 58.2 63 62.4 45 58.0 65 KAPCHORWA 62.1 46 MOROTO 57.2 66 APAC 61.9 47 BUNDIBUGYO 56.7 67 SSEMBABULE 61.9 47 YUMBE 56.7 67 KIBAALE 61.7 49 MOYO 56.6 69 61.5 50 56.0 70 KATAKWI 61.5 50 MUBENDE 55.4 71 KABERAMAIDO 61.3 52 BUKWO 55.3 72 IGANGA 61.1 53 NAKAPIRIPIRIT 55.2 73 60.6 54 KAMULI 55.1 74 KOTIDO 60.0 55 BULIISA 54.2 75 BUDAKA 59.9 56 NYADRI 53.7 76 BUGIRI 59.5 57 MASINDI 52.4 77 PALLISA 59.1 58 ADJUMANI 49.5 78 58.5 59 AMURIA 48.3 79 KIRUHURA 58.5 59 KAABONG 47.6 80

Annual Health Sector Performance Report 17 Table 2.6: District Ranking for New Districts Table 2.7: District Ranking for Hard to Reach Districts Total National District Score Rank Rank Total National LYANTONDE 79.6 1 2 District Score Rank Rank MITYANA 78.4 2 3 ABIM 73.5 1 7 ABIM 73.5 3 7 GULU 72.3 2 11 DOKOLO 72.3 4 11 KANUNGU 71.9 3 15 AMOLATAR 72.2 5 13 KITGUM 68.1 4 30 PADER 67.7 5 31 OYAM 69.1 6 20 AMURU 65.5 6 36 MANAFWA 68.4 7 26 KALANGALA 63.1 7 42 BUTALEJA 68.2 8 29 KISORO 62.4 8 45 NAKASEKE 66.9 9 33 KOTIDO 60.0 9 55 BUDUDA 66.5 10 34 MOROTO 57.2 10 66 AMURU 65.5 11 36 BUNDIBUGYO 56.7 11 67 IBANDA 65.4 12 37 BUKWO 55.3 12 72 ISINGIRO 65.3 13 38 NAKAPIRIPIRIT 55.2 13 78 NAMUTUMBA 65.0 14 40 ADJUMANI 49.5 14 78 BUDAKA 59.9 15 56 KAABONG 47.6 15 80 KALIRO 58.5 16 59 KIRUHURA 58.5 16 59 BUKEDEA 58.2 18 63 KOBOKO 58.2 18 63 BUKWO 55.3 20 72 BULIISA 54.2 21 75 NYADRI 53.7 22 76 AMURIA 48.3 23 79 KAABONG 47.6 24 80

2.5 Hospitals performance assessment

Hospitals are major contributors to essential clinical care and the recent growth in numbers is mainly from the private and institutional sectors (such as prisons and army). This report includes data from 128 hospitals12. The Standard Unit of Output (SUO)13 is a composite measure of outputs that can allow fair comparison of volumes of output of hospitals that have varying capacities in providing the different types of patient care services. However, the absence of complete information from hospitals in health systems inputs such as financial data makes it difficult to measure efficiency and to make meaningful comparisons. Nevertheless, a summary is made of the performance highlights at each level of care.

12 The national hospital policy definition of ‘hospital’ is not strictly adhered and this number is an estimate 13 SUO stands for standard unit of output an output measure converting all outputs in to outpatient equivalents. SUO total = Σ(IP*15 + OP*1 + Del.*5 + Imm.*0.2 + ANC/MCH/FP*0.5) based on earlier work of cost comparisons.

18 Annual Health Sector Performance Report 2.5.1 General Hospitals Quality of health care is compromised by an overall shortfall in staff, which is worse for the medical cadres. For instance, only 55% of these positions are filled on average. Nursing staff faces the largest gaps in absolute numbers (-3,380) and these positions are filled by nursing aides especially in private hospitals. In spite of this, outputs for core hospital functions such as admissions, outpatient attendances and deliveries have increased compared to the previous year. A reflection of the poor quality of care is reflected in the very high number of maternal deaths which occurred in general hospitals last year e.g. 9 maternal deaths on average per hospital with one outlier, Bugiri Hospital reporting 105 deaths. Also there has been a reduction in the average SUOs which could be attributed to shifting of primary level services such as antenatal care and immunization to lower level units.

2.5.2 Regional Referral Hospitals Regional referral hospitals are better staffed than the general level with about 72% of positions filled for medical staff. Compared to the year before, there was improvement in the following outputs: Outpatient attendance, admissions and major operations including the overall standard units of output. As for the general hospitals, there are a very high number of maternal deaths at regional referral hospitals with an average of 37 maternal deaths per hospital. had an extremely high number with 285 maternal deaths in the year.

2.5.3 National Referral Hospitals

Mulago Hospital

Mulago Hospital is still the main referral hospital for those who require super specialized health care. During 2009/10, the centre provided care to 614,223 out patients and 120,848 in patients. This has been an increase from those served in the past years. The Hospital has made progress in strengthening of management structures and systems including harmonization of the procurement systems across departments; streamlining and strengthening of the supply chain management process and strengthening of the Hospital security system There have also been efforts made to scale up the integrated super-specialized healthcare package with the training and recruitment of Super specialists; ensuring that continuous Professional Development is taking place and providing a platform to ensure exchange visits with several universities. The hospital has enhanced infrastructural and space capacities to enable Mulago provide more services including super-specialized healthcare. These include establishment of a telemedicine centre, sickle cell clinic; plans for the Mulago III and for which bills of quantities have been made; construction of the PPS pharmacy and construction of staff restaurant Progress towards achieving the objective of formalizing collaborative partnerships include the development of monitoring mechanism for collaborations; development of a framework for collaboration and review of existing MoUs using accreditation criteria with a Memorandum of Understanding (MoU) template now in place.

Annual Health Sector Performance Report 19 Butabika Hospital Butabika Hospital is still the only National Referral Mental Health Institution in the country. During 2009/10, the centre provided mental health inpatient care to 4,394 first time admissions and 1,752 readmissions. 95,106 patients were seen in the various clinics at the Outpatients unit. Through the community mental health services programme, a total of 1,225 patients were resettled in to their homes; 2,114 patients were seen at four of the mental health outreach clinics at , Kitetika, Nkonkonjeru and Maganjo-Nkonkojeru; also, 21 forensic clinics were conducted in prison; 959 patients were re-integrated with their families whilst another 475 were rehabilitated. One thousand, eight hundred and twelve (1,812) students from various Institutions were trained and technical support supervision to regional referral hospitals. 6 journal articles were published in the areas of mental health. The process of developing a master plan for the hospital has started and various infrastructures were developed and or rehabilitated. Challenges faced were in relation to inadequate staffing across all cadres, inadequate provision of finances to match the growing burden of mental health patients, lack of psychiatric medicines are not readily available in most centres, lack of community and social support for the discharged patients

2.6 Conclusion

Measured against the monitoring indicators, the health sector has performed considerably well in view of the shortfalls in the required health system inputs. Most of the indicators showed an upward trend. This is particularly noted with proportion of districts submitting timely HMIS reports, Couple Years Protected (CYP), percentage of households with at least one insecticide treated net and latrine coverage. This can in part be attributed to improvement in technical efficiency scores for the majority of districts; which shows that with adequate resources, targeted to priorities using evidence, the sector can make marked progress. The most notable shortcomings in health system inputs are chronic low under-funding to the sector which affects the procurement of essential health commodities and maintenance of an effective work force.

20 Annual Health Sector Performance Report CHAPTER THREE DELIVERY OF THE UGANDA NATIONAL MINIMUM HEALTH CARE PACKAGE

The delivery of the Uganda Minimum Health Care Package (UMHCP) is organized around the four clusters of i) Health Promotion, Disease Prevention and Community Health initiatives ii) Maternal and Child Health iii) Prevention and control of Communicable diseases iv) Prevention and Control of Non-Communicable Diseases (NCDs) This section describes and assesses the progress towards the attainment of the set targets over the HSSP II period. In addition it outlines the achievements, challenges faced. 3.1 Health promotion, disease prevention and community health initiatives

3.1.1 Health promotion and education

The main objective of health promotion and education was to increase community awareness and health literacy on disease prevention and promotion of healthy lifestyle in order to have a healthy and productive population. Thus the implementation of health promotion and education was envisaged as cardinal to the attainment of the overall health sector mandate. Institution of Village Health Teams (VHT) was identified as the main sector strategy for engaging with communities. Complementary strategies included the development and production of relevant IEC materials, increasing the participation of political, religious and cultural institutions in promoting health; wider use of the media. All these were expected to result in a 30% increase of the population seeking health services according to national standards14. The mid-term report of the HSSP II indicated that unless commensurate resources were provided, it was unlikely that the set targets would be attained by the end end of strategic period would be attained. For instance by 2006/07 the number of fully functional VHTs had not substantially increased from the 2004/05 baseline15. Table 3.1 summarizes the programmatic performance using indicators that were agreed upon during the HSSP II implementation.

Progress The specific priorities identified for this Division during the 15th JRM included – scaling up VHTs from 25 districts to all. During the last year of the HSSP II, scale up has been attained using the following strategies

14 Health Sector Strategic Plan II (2005/06-2009/2010) 15 Mid-term review report of the Health Sector Strategic Plan II

Annual Health Sector Performance Report 21 i) Establishment and training of VHTs in all districts to ensure services reach household including development of motivation and sustainability mechanism in the VHT Strategy and Operational Guidelines ii) Involvement of district political and cultural leaders in health activities iii) Involvement of radio stations in the dissemination of health messages. Although the JRM had desired to scale up functionality of VHTs nationwide, the Ministerial Policy Statement for 2009/10 provided resources to establish teams in 42 districts only. The Division was allotted Shs 1.13b for establishment and training of VHTs but only Shs 543.02m was actually released. The Division therefore trained teams in only 13 districts instead of the 42 planned. Table 3.1: Health promotion and education achievements over the HSSP II period 2004/05 HSSP II Indictor 2005/06 2006/07 2007/08 2008/09 2009/10 baseline target Proportion of 30 districts 34 districts 20 districts 20 districts 30 districts 13./42 100% districts with VHTs partially supported to fully covered supported to supported to districts coverage established covered with train VHTs and 40 districts train VHTs establish and were with trained trained VHT (25% partially (25%) train VHTs supported to VHT (25%) covered establish and train VHTs (31 %) Proportion of health 20% of health 50% of all 100% of all 50% of 90% of 75% health 40% of facilities and facilities with health hospitals and health health facilities health community IEC materials facilities health centres facilities facilities displaying facilities institutions with displaying display IEC provided displaying IEC displaying health promotion IEC materials with IEC IEC materials IEC materials materials materials materials materials Proportion of 58% 100% (all 100% DLCs 100% DLCs 50% of political and cultural DLCs and cultural and cultural cultural leaders promoting sensitized to leaders leaders leaders health support sensitized on sensitized on supported Child days Child days Child days to interventions interventions implement health activities Proportion of media 20% 75% of 75% of radio 70% of radio 80% of institutions radio stations stations radio participating in stations supported to supported to stations health promotion have formal provide provide running and education health information health health activities programs on Child information programs days

In 2008/09, the MTEF budget catered for the establishment of 13 VHTs. The District leaders i.e. (District councilors and Executive, RDCs and heads of departments, DHMTs, NGOs, Religious and Cultural leaders)and Training of Trainers of VHTs selected from all sub counties in the district were established in the following districts; Iganga, Bugiri, Kaliro, Kamuli, Kayunga, Mayuge,, Namutumba, Pallisa, Rakai and Butaleja, In 2009/10, District leadership sensitization and TOTs were conducted in Kibaale, Buliisa, Hoima, Mityana, Lyantonde, Mubende,Budaka, Busia, Bududa, Kiboga and Nakaseke. HTs have been established and trained in Bududa, Butaleja and Lyantonde districts in the past financial year. Out of shs 500m allotted for General for Health Promotion, only 316 million released. Out of 316m released only 100m was used to support mass media programs. This is not sufficient for full involvement of the media i.e. Radio, Television and Newspapers. In total, 1060 radio spot adverts were run, 3 ministerial statements made on Television, 3 supplements were published in newspapers, 15 Press conferences, and there was coverage for 10 different health related activities were carried out and published in media.

22 Annual Health Sector Performance Report Box 3.1: Report on support supervision on village health teams in , May 2010 1 Background

Village Health Teams (VHTs) were established by the Ministry of Health (MoH) in 2003 to mobilize communities for health programs, sensitize and educate the community on health matters, as well as home visiting to implement health programs and strengthen the delivery of health services at house hold level.

The Ministry of Health has been encouraging Partners, NGOs and other organizations to support the implementation of VHT in Uganda and across the country, a number of NGOs have given a hand in training, and roll out of the VHT program. Uganda Health Cooperative on its part has supported Bushenyi district by implementing Village Health Team in two Health Sub-Districts of Buhweju and Bunyaruguru as they sought to implement three of their projects namely:-

1. Malaria Community’s Program

2. Child Survival

3. Community Health Financing

Reports from Uganda Health Cooperative indicate that a total number of 889 and 856 VHTs in Bunyaruguru and Buhweju respectively were trained and equipped with a Register, VHT Booklet and Flip Chart both in Runyankole, Job Aids and Bags. Support supervision findings during May 2010 showed that:

Findings

1. VHTs fill registers with little or no mistakes at all. However VHTs said the exercise of filling the register is so tiresome

2. Most VHT members were selected by the community which is in line with the implementation guidelines.

3. All VHT members have undergone the mandatory VHT basic 5 days training in health promotion and this training was conducted by the trained health workers who had earlier on undergone a Training of Trainers workshop in adult learning methodologies and VHT

4. VHTs know their responsibilities very well and they conduct such activities like Home Visits, Health Meetings, refer patients for treatment, community mobilization, and health education and are also showing a good example.

5. Quarterly meetings are in place conducted by Uganda Health Cooperative with health workers and community leaders.

6. VHTs have started their own saving scheme which has enhanced enhanced team work and togetherness

7. VHTs are so enthusiastic about their responsibilities and they like being VHTs. This is based on the following reasons

• They see positive changes taking place in the community all attributed to their work

• They have taught themselves to be clean. This they do by giving each other a hand that is one other day they all come ones place do the cleaning and then another week go to another person’s place.

• They have gained knowledge from the trainings they have undertaken and also from the work they are doing through sharing with fellow VHTs and the community members.

IEC materials, extent and use of the electronic media

Electronic media plays an important role in creating health awareness. In HSSP I, funding was provided for dissemination of health messages on FM radio stations in each district throughout the year. Unfortunately there has been an increase in the number of district with FM stations and yet there has been no commensurate provision of funding. There has therefore been little use of the radios except during special activities such as Child days with support from UNICEF. Annual Health Sector Performance Report 23 The Division used to produce IEC materials for all the programmes provided in the MHCP and these were distributed to all health facilities and to some communities that had VHT. There has been a reduction funding for this production and also increasing participation of the partners in production of their own materials. Those programmes that have partners supporting them have such as MCP have therefore continued to produce IEC materials while other programmes that have no partners have hardly produced any materials. Development partners have greatly supported health promotion activities as exemplified from the following partner contributions i) STOP Malaria Project: run radio spots on 4 regional radios for 3 months and provided posters, banners radio talks shows and radio spots for LLINs ii) Voice for a Malaria free Future: provided street pole adverts radio spots on United Against Malaria on 7 radio stations iii) CDFU: runs the weekly radio drama program “Rock Point 256”on 15 radio stations,(also translated into 3 local languages) ran 2 rounds of radio talk shows on 15 radio stations to promote True manhood iv) UNICEF; supported media activities for Child days by running 4712 radio spots, 10 radio talk shows and 28 newspaper adverts Human Resources for Health Promotion and Education

The Division is short of staff to provide technical support for the MHCP. This is exacerbated by the fact that the Division has lost 2 senior staff to other lucrative ventures and the structure has a limited provision for more Health Educationists The Division has its presence in all the districts in terms of District Heath Educators and Assistant Health Educators at HSD level. With the creation of more districts, the Health Educators at HSD have taken up the role of DHEs in the new districts, leaving the service level depleted. Non recognition of the cadre in some districts also made some of the Health Educators to resort to their earlier professions for career progress. The Division however in collaboration with Uganda Martyrs University has established an Advanced Diploma course in Health Promotion to train Health Educators to provide health education activities in the districts. This has not only provided a professional training ground but also ensures that the districts have quality manpower that can be recruited to provide health promotion services. Challenges and Recommendations i) Continued roll out of the VHTs to cover every community since there is evidenced improvement in health conditions of communities where they are available However; VHTs are still finding problems at the health facility. They are not recognized by the health workers nor are their referrals recognized. This can lead to VHTs getting de- motivated or losing the trust of the community members. ii) VHTs should be given skills of how to make use of the information they collect of which the primary use should be to improve the health situation in the community. For example if they collect information related to lack of latrines what happens? Do they keep it in the register and keep on collecting more? iii) Measures should be put in place to sensitize all health workers in the project areas about VHT strategy and the need for functional linkages between VHT and the formal health service. Once health workers don’t recognize VHTs in whatever way the program may not achieve its objectives.

24 Annual Health Sector Performance Report 3.1.2 Environmental health

The mandate of the health sector in maintaining and improving environmental health during the HSSP II period was on capacity building and the promotion of the Kampala Declaration of Sanitation (KDS). The KDS incorporates the scale up of basic household hygiene practices such as availability and use of latrines; safe water and food consumption16. The Ministry of Health published the Environmental Health Policy in 2006, spelling out the roles and responsibilities for sanitation, in line with the sanitation Memorandum of Understanding signed in 2001 between MWE, MoH and MoES; but also recognizing the contribution of NGOs, CBOs and the private sector. The 10 year Improved Sanitation and Hygiene Promotion Financing Strategy (MWE 2006) serves as a roadmap for the attainment of the sanitation targets. . It is based on a three pronged approach of (i) increasing demand for improved services, (ii) improving the supply of services to facilitate households to acquire improved sanitation and hygiene, and (iii) addressing the enabling environment.

Furthermore, in FY 2008/09, the need for environmental awareness and management to be on the same footing as economic and or social factors was raised. One of the fundamental concerns was the need for health decision-makers and the public to be more responsive to the potential environmental effects of sector activities and to identify ways that environmental damage can be avoided or significantly reduced. Some of the main areas for attention identified included the management of: health care waste e.g. injections and other sharps; solid waste; expired medicines; use of potentially toxic material such as DDT radiation from x-rays; medical and office equipment. The progress towards achieving targets set for the HSSP II period is shown in table 3.2.

Table 3.2: Achievements of the environmental health programme during the HSSP II period Indicator 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 HSSP II Target Proportion of 57% 58% 58.5% 62.4% 67.5% 69.73% 70% households with a pit latrine Proportion of 18% 18% 18.6% 21% 21.4% 21.7% 100% districts implementing water quality surveillance and promoting safe water consumption

Progress Household latrine coverage During FY 2009/2010 the national sanitation coverage improved from 67.5% to 69.73%. Over 1,600,000 new people are estimated to now have access to adequate sanitation. However, one of the challenges faced by communities is the lack of sustainability of the toilet facilities constructed. Many of the toilets in water logged districts last 2 to 3 years

16 Health Sector Strategic Plan II (2005/06-2009/10)

Annual Health Sector Performance Report 25 which makes it expensive to the households to replace them, yet most of them cannot afford to use more permanent materials for construction. The issue is exacerbated in flood prone areas, where toilets were destroyed by the recent floods. In , after the recent floods the sanitation coverage dropped from 90% to 65%. During the sanitation week, the district carried out activities to increase the coverage to the present 75%. The improvement in latrine coverage has been due to enactment and enforcement of ordinances and bye-laws. Also, political support plus good coordination of the National Sanitation Working Group (NSWG has played a big role in this achievement. The majority of household sanitation facilities in Uganda are constructed by local masons most of whom have not had any formal training. This has compromised the quality of toilets constructed. To address this issue, the sector started supporting the training of masons in a few start up districts. With support from partners, 103 masons were trained in the construction of improved latrines and 78 masons in the construction of ecological toilets. The masons were also equipped with marketing skills, in order to promote their services

26 Annual Health Sector Performance Report Box 3.2: Some of the good practices for sanitation and hygiene improvements in selected districts Goats and Lists make people build latrines in LEAPPS Case # 2009/1 by Aceni Albert, health assistant Lobule Subcounty, Reviewed by Jo Smet IRC, Achiro Brenda NETWAS and Grace Orishaba NETWAS In an attempt to identify appropriate strategies and interventions to combat disease outbreak and also improve hygiene and sanitation in Lobule Sub County Koboko District, the sub county authorities embarked on bye- enforcement. This case was shared during one of the Learning sessions in 2009 facilitated by Network for Water and Sanitation (NETWAS) –Uganda, SNV and IRC international Water and Sanitation Centre in Koboko District Summary of intervention Using Council Resolutions, all households with no latrines had to surrender two goats to the police and upon proven existence of built latrines, the goats would be returned to the respective owners. Secondly a list of all households who had improved their sanitation was read and put in public to encourage and motivate other households to follow the same example. These two approaches greatly contributed to the construction of latrines in Lobule subcounty. Action on defaulters Defaulters’ names were black listed and follow up was done to bring about change in their practices. This was done with support from local community leaders, whereby defaulters were given ample time, at least one month as set by the local leaders to build their toilets. After which complying families’ names were then taken off the black list and written on the white list as recognition for their efforts. Goats from persistent defaulters were confiscated and sold to compensate cost of digging pit latrines and facilities by local diggers and masons. Defaulters were also allowed to do community work like digging pits for the unable and female- headed households. Fines were also put in place to charge defaulters. In cases where a defaulter did not have animals or money to pay the fine, he/she would be detained in a police cell for a period not exceeding 24hrs.

Households with no latrines had to surrender two goats to the police

Annual Health Sector Performance Report 27 Figure 3.1: Household latrine coverage by district 2010

Safe water and sanitation One of the biggest opportunities for development in the districts is the presence of active District Water and Sanitation Coordination Committees, with 97% (57 out of 59) of Districts reporting having an active committee. A review of the district progress reports show that at least 68% of the District Water Sanitation Coordination Committee met at least three times last financial year, with only 14% meeting once in the financial year. This has improved coordination of activities, as evidenced in the utilisation of budgets from both the Primary Health Care Grant and the District Water and Sanitation Development Grant for sanitation, especially to mark the sanitation week.

28 Annual Health Sector Performance Report Due to inadequate funding, the target for scaling up water quality surveillance and safe water consumption could not be met. For instance, districts are greatly hindered in their delivery of services by very low staffing levels. Data from 49 districts shows that only 44% of the required environmental health staffs are available, of which only 22% have adequate transport. In addition some of the staffs face housing challenges in the areas they are deployed to and most are not motivated due to the lack of opportunities for career development and promotion within the local government structures.

Figure 3.2: Nationwide sanitation coverage of selected districts

Although majority of the districts have tried to improve the latrine coverage, scant attention has been paid to hand washing after toilet use, with the national average of access to hand washing facilities at toilets at 21%. Of the estimated UGX 1.9 billion of the DWSG spent on sanitation, only 4% was spent on promotion of hand washing. A recent survey of tippy taps in 30 districts17 showed that only 3% of tippy taps have soap and water, therefore the rates of effective hand washing are much lower than the reported 21%.

17

Annual Health Sector Performance Report 29 Box 3.3: Tippy Tap survey

Only 30% of existing Tippy Taps have soap and water, by National Hand Washing Secretariat

A baseline tippy-tap survey was conducted in 10 randomly selected districts from a total of 30 districts targeted by the national hand-washing campaign roll out. The districts include; Abim, Masaka, Mukono, Mbarara, Kabale, Nebbi, Bundibugyo, Hoima, Lira, and Pallisa. A total of 400 households were surveyed in 10 districts.

Household Demographics

• Over 80% of households surveyed had children aged <5 years as well as those aged 6+ years. • Majority of household members had access to free water (boreholes and protected springs/streams), although problems of water scarcity were cited during borehole breakdowns or dry periods • Soap availability and usage was very high. Findings

• 81% (325 of 400) of all households had toilets • 58% (232 of 400) reported washing hands with soap and water after using the toilet, 19% (74 of 400) reported to wash hands with water only • 3.3% (13 of 400) of all households surveyed had tippy taps. • 1% (4 of 400) of all households had functional tippy taps (i.e. had water and soap), • 2% (8 of 400) had either water or soap alone but not both while one (1) was broken.

Functional tippy-taps existed only in .

Source: Study report by the National Hand Washing Project The major impact of improved sanitation and hygiene is the reduction in diarrhoeal diseases. There are several factors that contribute to the incidences of disease, but an analysis has been made of the incidences of dysentery18 in relation to sanitation coverage over the period of 2008 to 2010, presented in the graphs below. Although the correlation is not very good with correlation coefficients of -0.42 in 2008 and -0.51 in 2009 and 2010; the coefficients show that the incidences of dysentery decrease with an increase in sanitation coverage.

18 Disease surveillance data from the Ministry of health

30 Annual Health Sector Performance Report Incidences of dysentery in relation to sanitation coverage over a period of three years 2008-2010

Annual Health Sector Performance Report 31 Box 3.4: Hepatitis E Response in Northern Uganda by UNICEF From November 2007 Hepatitis E (Hep E) broke out in of , northern Uganda. Hep E is mainly transmitted by the faecal-oral route with drinking-water as the most common vehicle. Most cases were in Kitgum and Pader (10,528 cases of with 168 deaths [CFR 1.60%]. The outbreak then spread to Karamoja region in early 2009.

Response efforts focused mainly on promoting the importance of safe water, adequate sanitation and personal hygiene. The intensive interventions by the local and central governments, together with partners, using all resources available, including public health law and by-laws resulted in a decline in cases, and final containment by March 2010. The key emerging lessons from the response were: • Intensive and extensive interventions are required to contain Hep E, considering its long incubation period. Leadership is critical (LC5 – LC1), and at all levels and in all (voluntary) ways. • Health Assistants and VHTs need to be engaged, through training and be enabled to do their work (bicycle, medicines, water purification inputs, feedback mechanism, etc). Use of VHTs, peer groups and local by-laws can encourage effective sanitation. • Empower communities and households through health and hygiene knowledge and engage youth health clubs/ community health clubs. PHAST (and CHAST) is a great tool for quick appreciation of risk and for helping people to move forward for health. Integration of community health care and SLTS helps to empower communities and schools to eliminate open-defecation. • Informing the Public on the dangers and protection measures is initially successful, but a new campaign is quickly required to fight complacency.

The key challenges observed were:

• Returning people’s priorities are with restoring livelihoods (housing, cultivation) rather than WASH. • Poverty is a major contributor to the practices that promote the spread of such diseases. • Apathy and dependency syndrome arising from the long displacement into camps with reliance on handouts, negatively affects community based improvement interventions. • Inadequate public health outreach (no medicines, no readiness to receive patients in health facilities, no staff) greatly frustrated the response efforts.

Recommendations

i) Dedicated Budget Line for Sanitation – Although the budget line for sanitation was established, it is still not funded and the local government guidelines are not yet completed. The funds spent for sanitation are still very low, with only 22 districts spending at least 6% of the DWSCG on sanitation, 50% of which is spent on facilities in public places. The ring fenced financing will ensure the much need finances. ii) In addition to funds, districts need guidance on cost effective approaches, especially on the implementation of the “10 year financing strategy for Improved Sanitation and Hygiene. “ iii) Political Support – One of the lessons from the international year of sanitation is that political leaders play a key role in the mobilisation of communities and in the enforcement of the ordinances and bylaws. It was also evident thatmore progress was made when there was continued monitoring from MWE, especially from the Minister of State for Water. Therefore there is need for the ministry to continue holding the district leadership accountable for the outputs. Districts also expressed need for increased technical supervision from the Environmental Health Division in the MoH, and also continued capacity building of district staff on new approaches.

32 Annual Health Sector Performance Report

iv) Staffing – The number of environmental health staff in the districts is very low, and districts should fill all staffing gaps as soon as possible. It is also important to ensure that the staffs on the ground are well facilitated to enable them to reach out to the communities. v) Open Defecation Free Communities – although households are building toilets, in order to realise the health benefits of improved sanitation, it will be necessary to have ODF communities. It is also important to improve the quality and sustainability of facilities through building the capacity of the private sector. vi) Hand Washing- It is necessary to improve the profile of hand washing and increase the funds spent on promotion of hand washing with soap at key junctures.

3.1.3 Control of diarrheal diseases

Diarrheal diseases rank third among the major causes of morbidity in Uganda19. The strategy adopted by the health sector during the HSSP II to reverse this trend was to support the promotion and implementation of selected interventions known to prevent and control epidemic diarrheal diseases. The four core interventions included an active surveillance and monitoring programme, prompt and appropriate case management in the community and at static health facilities; community education and mobilisation with emphasis on hygiene and sanitation; and the reactivation of the ‘Protocol of Cooperation of Countries in Great Lakes Region’ to promote cross-border cooperation. Key challenges identified during the mid-term review and the previous year (2009/10) included frequent population cross-border and internal migration especially in northern Uganda; inadequate and poorly motivated field public health personnel and clinical workers. Progress The following activities were implemented to address these challenges as well as ensure progress towards attaining the HSSP II targets. i) Guidelines and standards were provided to the cholera affected districts ii) Training of village health teams and operational level health workers on prevention and management of diarrhoeal diseases was done in the cholera affected districts. iii) Provision of supplies to the cholera affected districts was done. iv) As a special activity supported by UNICEF, two members of the village health team per village and all health workers in Lango area (districts of Amolatar, Apac, Dokolo, Lira and Oyam) were trained on the management and prevention of diarrhoeal diseases with emphasis on the use of zinc and low osmolarity oral rehydration salts (ORS). Also as part of the same project, low osmolarity ORS and dispersible tablets of zinc sulphate were supplied to those districts for use at health facility and community level.

Annual Health Sector Performance Report 33

v) Cholera taskforce meetings at district and central level to coordinate response and mobilise resources vi) During FY 2009/2010 CDD technical support supervision visits were carried out in 71 out of the 80 districts. The districts of Kigezi area (Kabale, Kisoro, Rukungiri and Kanungu) and those of Karamoja area (Kotido, Morotol, Abim, Kaabong and Nakapiripirit) were not visited due to resource constraints. They will be prioritised during the first quarter of FY 2010/2011. Figure 3.6: Map of Uganda showing districts which had CDD technical support supervision visits during FY2009/10Figure 3.6: Districts which had CDD technical support supervision visits during FY2009/10

34 Annual Health Sector Performance Report Table 3.3 Achievements of the CDD programme

2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 HSSP II target Indicator Incidence of 3.0 2.7 2.7 2.6 1.5 * 1.5 epidemic diarrheal disease per 1000

Cholera specific 2.5% 2.0% 2.0% 2.1% 2.1% * 1.0 case fatality rate (%)

Major challenges Key challenges identified included: (i) Climatic change leading to floods and landslides; (ii) Inadequate access to safe water; (iii) Low latrine coverage and use; (iv) Negative cultural practices; (v) Inadequate funding for required supplies and operations; and (vi) Cross-border and internal migration. Recommendations i) Implementation of the Kampala Declaration on Sanitation at district and lower levels should be intensified ii) Health promotion and education on prevention of diarrhoeal diseases especially in which areas that have negative cultural practices should be intensified. iii) Funding for supplies and operations should be increased. iv) Capacity building and technical support supervision focusing on districts with poor indicators.

3.1.4 School health

In partnership with the Ministry of Education and Sports (MoES) and the Department for Water Development, the health sector purposed to integrate the school health programme (SHP) within district level activities. According to the policy (yet to be endorsed), the core interventions include: health education; water and sanitation/hygiene; adolescent and sexual reproductive health; school feeding and nutrition; prevention and protection of children against abuse and violence; provision of basic medical and dental health care services; counseling and guidance; physical education; recreation and sports in all educational institutions and the active participation of parents and community in school health issues.

Annual Health Sector Performance Report 35 Some of the major constraints highlighted during the mid-term review were: the delay in completion; endorsement of the School Health Policy; as well as the Memorandum of understanding between the MoES and MoH. Additionally, the weak enforcement by the Local Governments contributed to the poor attainment of some targets at the mid-term evaluation. Table 3.4 summarizes the performance of key indicators through the HSSP II period.

Table 3.4: Achievements of the school health programme Target outputs 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 HSSP II target Proportion of primary 40% 50% 50% 50% 50% 55% 75% schools implementing the main components of health promoting school initiative, including sex education, counselling and life skills

Primary School Pupil per 61:1 45:1 44:1 43:1 No data No data 40:1 or latrine stance ratio better

Secondary school 25:1 23:1 23:1 25:1 No data No data 25:1 Students per latrine stance ratio

Proportion of primary 60% 64% 66% 61% No data No data 75% schools with safe water sources within 0.5 Km radius to the school

Percentage of secondary 75% 79% 81% 85% No data No data 95% schools with safe water sources within 0.5 Km radius of the school

Proportion of primary 20% 23% 25% 25% No data 25% 75% with hand washing facilities

Proportion of schools 30% 50% 50% 55% No data 55% 75% providing basic school health and nutrition services

Data sources: MoES Planning unit, Water and Environment sector performance report and MoH supervision reports Progress In order to support implementation of the HPSI, 300 copies of the School Health Training manual was printed and distributed to primary/secondary schools during the first quarter of FY 2009/10. In order to support implementation of good nutrition in schools, the School Health guidelines were finalized in the 3rd quarter of 2009/10 and the World Food Programme (WFP) supported the printing of 5000 copies which were also distributed.

36 Annual Health Sector Performance Report The pupil per latrine stance ratio has only improved in urban schools than in rural schools while secondary schools continue to exhibit a better pupil per latrine stance ratio than primary schools. Hand washing practice has stagnated (25%) and was reported to be lower among rural schools than urban ones. As for the provision of basic health care and nutrition, it is mostly boarding schools that are providing health care and feeding of school children. Data from Ministry of Education and Sports estimates that the pupil: stance ratio in primary schools stands at 50:1. According to the national standards, the effective coverage is 54:1. The case is much better in private schools which have an access of 1:34, although it is much worse in community schools with a pupil stance ratio of 208:1. However, progress was made to have the school going children (6-14) de-wormed during the bi-annual Child Days plus intervention. School based TT for school girls aged 15 and above was also conducted as part of the routine EPI activities but coverage still remains generally low. Major challenges i) Minister of Education and Sports has delayed to finalise the School Health Policy. This policy is needed to provide a basis for sourcing financial and logistical support plus guiding a coordinated implementation of school health programme by the different stakeholders. This will also ease the retrieval of data since it is controlled by MoES and not MoH ii) The local governments have not fully incorporated school health programme into their district work plans and subsequently, integrating School Health services into the education system remains an area of concern iii) Inadequate staff who are poorly motivated and with a low capacity to implement the school health programme all remain major constraints Recommendations i) Finalisation of the policy and the MoU between MoH and MoES is a priority issue since it is needed to support the various advocacy initiatives that will ensure that school health programme activities are incorporated in the district activities. ii) Proper sanitation and hygiene are one of the key activities for attaining the school health programme goal, hence funding for these activities needs to be availed iii) Advocacy for school health programme needs to be stepped up to ensure leadership support and commitment mostly at district level.

3.1.5 Epidemic and disaster prevention, preparedness and response

Epidemics and disasters upset even the best laid out plans for reducing morbidity and mortality if there is no preparedness for an appropriate response. The HSSP II period purposed to attain appropriate action for confirmed epidemics in less than 48 hours and also to ensure that the case fatality rate was minimized to the best international standards and practices. The core interventions included: institution of appropriate health services in

Annual Health Sector Performance Report 37 conflict and post-conflict situations; establishment of an early warning system for outbreaks and disasters; improving coordination of efforts during emergency situations; ensuring that there were financial and logistical provisions for the management of emergencies and disasters in both national and district work plans.

The programmatic response for epidemic and disaster prevention, preparedness and response is coordinated through the Integrated Disease Surveillance and Response (IDSR) division. Implementation progress has been measured based on several indicators. This is summarized in tables 3.5 and 3.6.

Progress The National Disease Surveillance System using the Integrated Disease Surveillance and Response strategy was maintained during the Financial Year 2009/2010. Weekly Epidemiological Reports were received from an average of 88% of the districts every week. These reports are used in tracking the trends of epidemic potential diseases in the country (see table 3.5). In addition, the timeliness of reporting reached a weekly average of 81% (target 80%). Working with the District Rapid Response teams, the ministry was able to investigate all the suspected disease outbreaks that were notified. In addition, case based data was collected for all the confirmed epidemics, which is critical for identification of the risk factors in outbreak that guide the implementation of the appropriate control interventions. The percentage of outbreaks notified to the Ministry timely (within 24 hours) however still fell short of the target (80%). Improvement in outbreak notification was mainly hampered by lack of community based disease surveillance, poor communication means and lack of knowledge on part of peripheral health facility staff. Only 68% of epidemics were responded to the Ministry within 48 hours of notification (target 80%).

The proportion of districts with functional Epidemic Preparedness and Response (EPR) committees continues to improve steadily, this F/Y year reaching 92%. With functional EPR committees in place, we expected better coordinated epidemic response at district level. The Ministry also compiled all the weekly epidemiological newsletters, however due to financial constraints they were not published in the print media as planned. The quarterly bulletin publications couldn’t be made either due to similar challenges. Capacity building for

38 Annual Health Sector Performance Report Table 3.5: Integrated disease surveillance and response indicators Indicator FY FY FY FY FY HSSPII Comments 2004/05 2006/07 2007/08 2008/09 2009/10 target Programme Performance Indicators Objective: Strengthen communication so as to improve timeliness and completeness of weekly reports

Percentage of districts 62% 58% 56% 82% 81% 80 Feedback through the Newspaper has submitting timely boosted timely reporting Weekly Surveillance Reports

Percentage of districts 96% 81% 83% 92% 88% 80 Percentage of Feedback through the submitting Weekly Newspaper was boosted reporting Surveillance reports Objective: Strengthen outbreak detection, investigation and response Proportion of 50 65.6 100 100% 100% 100 investigated outbreaks that include case based data % of outbreaks notified 65% 72% 74% 76% 74% 80 late outbreak detection seen in districts to MOH within 24 hours that lack community based disease of detection surveillance % of suspected 30.00% 52.00% 58% 62% 68% 80 Lack of funds for emergency response outbreaks responded to within 48 hours of notification

% of districts with 65% 76% 82% 88% 92% 100 More EPR committee became active in functional Epidemic preparedness for Influenza outbreaks and Preparedness and in response to cholera and meningitis Response (EPR) outbreaks Committees Objective: Improve sharing of surveillance information through regular dissemination and feedback No. of Weekly 52 52 24 52 52 52 Epidemiological Newsletter produced No. of Quarterly IDSR 210024Funding constraints could not allow the bulletin produced publications to be made

Objective: Strengthen capacity of health workers through training and supervision % District Health Teams 50% 73% 76% 81% 86% 100 The training is yet to be done in some of trained in IDSR the new districts Objective: Strengthen laboratory networks in all regions and initiate a system of accreditation

Proportion of Epidemics 68 75 82 100% 100% 100 All outbreak investigations are with lab confirmed laboratory backed diagnosis Objective: Improve data management, quality and utilization at all levels

Proportion of health 75 64.6 66 74% 76% 100 Districts are slowing improving towards districts that have the target current trend analysis for at least one priority disease Data Source: Ministry of Health Supervision and Monitoring Reports

Annual Health Sector Performance Report 39 Table 3.6: Major Outbreaks investigated in Uganda from July 2009 to June 2010 Condition District Period No. No. CFR Remarks cases deaths (%) Bacillary dysentery Bacillary Kyenjojo Jul 09 36 2 5.6 The cases were reported from Kitongole Village, Rwaitengya dysentery Parish in Kihuura Sub-county and Kinyantare village, Nyaibanda Parish in Nyantungo Sub-county The risk factors included: use of visibly dirty swamp water for drinking; all homes visited had no latrines hence open defecation is widely practiced; and poor household hygiene practices. Botulism Botulism Kyenjojo Apr 10 8 7 87.5 The cases were all from the same household and residents of Nkere village, Myeri Parish, Katooke sub-county. They shared a meal of matooke and white ants on April 28, 2010 before developing symptoms. Blood and stool samples from one of the cases were negative for the toxin following tests done by CDC labs in Atlanta. Plague Plague Arua April 10 1 0 The case was detected in Vura HCII, Vura sub-county. Tests done by the plague lab in Aura were negative for plague. Cholera Cholera Amudat May 10 – Jul 10 194 5 2.6 The initial cases were reported from the sub-counties of Karita, Loroo, Amudat, and Kenya sub-county. Vibrio Cholerae El tor Ogawa was isolated from the specimens. The outbreaks attributed to the very low latrine coverage in the district and low access to safe water. Cholera Bugiri Sept 09 – Nov 09 192 12 6 The cases were reported from Buluguyi, Bulesa, and Kapayanga sub-counties. Vibrio cholerae Inaba was isolated from the stool specimens. The source is presumed to have been a contaminated stream in Muwayo Trading Centre. Cholera Butaleja May 2010 25 1 4 All the cases were from Nabiganda sub-county and epidemiologically linked to the cholera outbreak in Kirewa sub- county, . Vibrio Cholerae was isolated from the samples. The spread was attributed to unsupervised burials.

Cholera Manafwa Jan 10 – Mar 10 88 8 9.1 The initial cases were reported from Lwakaka Town Council. A total of 8 sub-counties and Lwakaka TC were affected. The source of the outbreak is believed to have been contaminated water from river Lwakaka along the Kenya-Uganda border. Most of the cases were reported from Bumbo sub-county. Vibrio Cholerae Inaba was isolated from stool specimens. Cholera Moroto April 10 – Jul 10 664 11 1.6 The initial cases were reported from Kanakomol village in Nadunget sub-county where there was no single latrine or protected water source. All the cases were reported along Nadunget river. A total of 9 sub-counties/ divisions were affected i.e. Nadunget; South division; Rupa; Lokopo; Lotome; Lopei; Lorengechora; Irriri; North division; Matany and Katikekile. Vibrio Cholerae 01 El tor Ogawa was isolated from the stool specimens. Cholera Pallisa Jun 10 – Jul 10 41 2 4.9 The initial cases were reported from Kapyani Parish, Buseta sub- county and were associated with unsupervised burial of the index case. The most affected villages included: Kapyani II , Kapyani III Kasasira, Katiryo and Nalumbembe. Vibrio Cholerae was isolated from the stool samples. Cholera Tororo May 10 – Jun 10 47 11 25 The initial cases were reported from Kirewa sub-county. Further cases were reported from Paya (most affected), Mulanda, , and Kisoko. Vibrio Cholerae was isolated from the stool samples. Cholera Wakiso Oct 09 – Nov 09 7 0 The cases were reported from , , , Namusera, and Mabumbwe. The cases were managed in the CTC at Mulago hospital. Cholera Busia Jul 09 – Aug 09 95 7 7.4 Most cases were reported from Mugungu and Arubaine in Busia TC. Additional cases were reported from Marach and Mawero in Busia TC and in Buteba sub-county. The latrine coverage in the affected areas is low. Vibrio Cholerae 01 El Tor Ogawa was isolated from stool samples.

40 Annual Health Sector Performance Report Cholera Luwero May 10 – Jun 10 24 2 8.3 The index patient originated from in division Kampala. He died at a traditional healer’s shrine in Misanje village, Wankanya Parish, Kikyusa sub-county in Luwero district. Vibrio Cholerae was isolated. Cholera Nakaseke May 10 – Jun 10 1 0 An imported case from Nakulabye in , Kampala and was admitted in Nakaseke hospital. Stool samples tested negative for cholera. Cholera Total 3,046 105 3.5 Nodding Syndrome Nodding Kitgum 1997 to date At At least The syndrome is characterized by head nodding attacks that are Syndrome district least 4 precipitated by the sight of food and cold weather. The head nodding may be associated with epileptic fits. EEG tests revealed 194 the nodding syndrome attacks are atonic seizures. The cases in cases addition present with progressive mental retardation, growth retardation and variable deformities of the chest and limbs. Up to 194 cases were identified starting 2000, reaching a peak of 33 cases in 2006 and cases sustained at (20-27) cases per year between (2007 -2009). Cases were more likely to be 11-15 yrs old (MOR: 13.50 (95%CI: 4.58-39.79); were males (53.3%); fits (60%); and stunted growth (53.3%). Hepatitis E Hepatitis E Kaabong Aug 09 – to date 495 13 2.6 The initial cases were linked to the consumption of Kwete in Kaaboong Town Council. Additional cases were reported from Sidok, Karenga and Kaabong sub-counties. Latrine coverage is low (1%). Hepatitis E Kitgum Oct 07 – to date 10,609 168 1.58 The epidemic that started in October 2007 is on the decline. The current interventions include: house to house sensitizations by a team of environmental staff on basic personal hygiene, ensuring safe faecal disposal and usage of safe water; chlorination is going on in s/counties while others have shortage of supply; radio sensitization is ongoing on the local FM radios; and repair and maintenance of water sources activities are ongoing. Hepatitis E, Moroto Dec 09 to Mar 10 21 1 4.8 The cases were identified from Nadunget sub-county, Moroto Moroto (confirmed) Town Council, Rupa, Matanyi, Iriri and Katikekele sub-counties. Samples were sent to UVRI and Hepatitis E Virus infection was confirmed. Hepatitis E Pader May 08 – to date 256 8 3.1 The initial cases were imported from Orom s-county in Kitgum; subsequent cases were then reported in Pader TC, Atanga s/c, Acholibur s/c, Kilak s/c, Pajule, Paimol, and Laguti. Most cases are reported in sub-counties of Pader TC, Acholi-bur s/c, Pajule s/c & Paimol s/c most of which are either bordering Kitgum district or have many IDP camps. Hepatitis E Abim May 10 – Jun 10 6 0 Initial cases were reported from Morulem boarding Primary School and Morulem mission. The rapid response team conducted the initial verification that led to the lab confirmation for one of the cases. Hepatitis E Kotido Sep 09 to Mar 10 18 1 5.6 Initial cases were reported from Kotido sub-county, Panyangara sub-county, and Kotido Town Council. The affected areas have very low latrine coverage of up to 2%. Four cases were confirmed by UVRI. Hepatitis E Total 11,405 191 1.67 Malaria Malaria Mubende Jan 10 – April 10 59,328 115 0.19 The outbreak affected a total of six (6) sub-counties including Bagezza, Nabingoola, Kasambya, Kigando and having exceed the epidemic threshold. Children were most affected, & majority died of severe anaemia. Meningitis, meningococcal Meningitis, Arua Jan 10 – Mar 10 8 1 12.5 The initial cases originated from Emvoba village, Oreku Parish meningococcal in Manibe sub-county and had head ache, fever, diarrhea and vomiting. Two of the cases from Manibe sub-county tested positive for Neisseria meningitidis type A by rapid test. Meningitis, Koboko Jan 10 – Mar 10 16 0 The cases were initially reported from Mugujai village, Nyambiri meningococcal Parish, Kuluba sub-county; one from Kerejei village. Cases were last reported from Kuluba and Koboko TC and rapid testing isolated NM type A and W135. Meningitis, Maracha- Jan 10 – Mar 10 121 7 5.8 The initial cases were identified from Abiriyo village, Kijomoro meningococcal Terego sub-county. The most affected sub-counties, that even exceeded the epidemic threshold were (attack rate in cases per 100,000); were Oluffe (109.1); Oluvu (188.2); Kijomoro (33); and Nyadri (14). Rapid field testing confirmed Neisseria meningitidis in 5 cases and 4 of them were positive for Neisseria Meningitidis type A. Vaccination in Oluvu, Oluffe, Kijomoro and Nyadri was

Annual Health Sector Performance Report 41 Meningitis, Moyo Jan 10 – Mar 10 6 1 The cases were detected from Itula, Dufile and Moyo sub- meningococcal counties. Meningitis Total 151 9 5.96 Methanol poisoning Methanol Kasese Aug 09 – Sep 09 13 10 77 The cases were reported from Ibuga, Mobuku, Nyakirango poisoning village in Nyakiyumbu sub-county. Analysis of autopsy specimens and alcohol samples revealed high levels of methanol. Methanol Kamwenge Apr 10 – May 10 42 20 47.6 The cases were reported from Nganiko Parish, Nyabani sub- poisoning county and from Kaberebere Parish, Nkoma sub-county. Methanol Gulu Oct 09 – Dec 09 65 11 17 The cases were reported from Layibi and Bardege divisions, in poisoning Gulu municipality; aged (36 - 70) years and became ill after drinking liquor from Kabedo-Pong. Samples of the alcohol revealed a methanol content of 3.32% yet the normal levels shouldn’t exceed 0.05%. Methanol Kabale Apr 10 – May 10 179 8 40 The most affected areas were Kabale municipality, Kitumba, poisoning Kaharo, and Bubaro sub-counties. Alcohol samples analyzed by the government chemist indicated methanol levels of 300 times higher than the normal range. Methanol Kalangala Sep 09 – Oct 09 22 12 55 The cases were mainly from Bufumbira, Gyana and Nkese poisoning landing sites. Methanol Kampala Aug 09 – Jan 10 24 12 50 The cases were first detected from Central zone, poisoning Kyanja Parish, division and eventually from Banda zone 5. Analysis of autopsy specimens and alcohol samples revealed high levels of methanol. Methanol Mpigi Aug 09 – Sep 10 12 7 58 The cases were reported from Musa parish, Kamengo sub- poisoning county. Samples of Viva gin from Kamengo had higher than acceptable levels of methanol .

Methanol Wakiso Sep 10 – Oct 10 14 14 100 The cases were detected from Busambaga LCI, Katabi, poisoning Municipality. Samples of Rio Vodka alcohol from in revealed higher than acceptable levels of methanol (50g/100litres). Methanol Total 371 94 25.33 Pandemic Influenza A, H1N1 Pandemic Bushenyi Jul 09 – Jan 10 37 0 Initial cases were confirmed starting July 2009 among Influenza A, Jinja Jul 09 – Jan 10 1 0 international travellers followed by a phase of local transmission in Schools. The majority (82%)of the confirmed cases were aged H1N1 Kabarole Jul 09 – Jan 10 9 0 (5 – 29) years. No cases have confirmed in Northern and Kampala Jul 09 – Jan 10 96 0 Karamoja regions. 67% of confirmed cases are from schools Koboko Jul 09 – Jan 10 1 0 while 28% are from the community. Cases had a mild to Luwero Jul 09 – Jan 10 27 0 moderate presentation and responded well to Tamiflu. Mbarara Jul 09 – Jan 10 11 0 Mukono Jul 09 – Jan 10 29 0 Wakiso Jul 09 – Jan 10 51 0 Total 264 0 Acute hemorrhagic conjunctivitis (‘Red Eyes’) Acute Bundibugyo Mar 10 – Jul 10 261 0 A total of 26 districts are affected countywide. The outbreaks hemorrhagic Hoima Mar 10 – Jul 10 454 0 were initially reported from the Central division of Kampala. Specimens analyzed at CDC Atlanta: 13 (45%) were identified as conjunctivitis Kampala Mar 10 – Jul 10 1,024 0 Coxsackievirus A24 variant and one (3%) as enterovirus 99. (‘Red Eyes’) Lira Mar 10 – Jul 10 47 0 Luwero Mar 10 – Jul 10 30 0 Mpigi Mar 10 – Jul 10 153 0 Nebbi Mar 10 – Jul 10 72 0 Wakiso Mar 10 – Jul 10 778 0 Yumbe Mar 10 – Jul 10 73 0 Total 2,892 0

42 Annual Health Sector Performance Report Typhoid Typhoid Kibaale Aug 09 – Dec 09 24 6 25 The initial cases originated from Bwikara and Mpeefu sub- counties in the Western part of . Initial samples from the affected patients were negative for S. typhi. Typhoid Masaka Mar 10 – Apr 10 29 6 21 The cases were all notified by Kitovu hospital and they all presented with perforation of the small intestines. The cases have been reported from Kyazenga, Kyamukama, Lwamagwa, and Kitamba villages. Typhoid Bukwo Jul 09 – Oct 09 850 17 2 The most affected areas being Bukwo s/county, Bukwo TC, & Kabei s/county. Salmonella species was isolated from specimens The affected areas were all located along Bukwo River. Latrine coverage is low in affected sub-counties (54%). Typhoid Kasese Jul 09 – Apr 10 71 0 22 sub-counties affected (Kitswamba, Bwera TC and Kyabarungira most affected). Salmonella typhi isolated. Most of the fatalities had ileal perforations. Typhoid Total 974292.98 Viral Hemorrhagic Fever (VHF) VHF Bundibugyo Feb 10 9 3 33 The cluster of suspect VHF patients was reported from Busendwa village, Butholya Parish, Ngamba sub-county, Bughendera HSD. Blood specimens taken from cases were negative for Ebola/ Marburg IgM & Ig G at UVRI. VHF Gulu Oct 09 1 1 100 The suspect case was referred to Lacor hospital from Lira. Lab test in UVRI were negative for Ebola & Marburg by PCR and serology. VHF Kabale Jun 09 1 1 100 A 20 year old female was admitted in Kabale hospital with a presentation suggestive of VHF. Blood samples were negative for VHF. VHF Mbale Aug 09 1 0 The suspect case was detected in Mbale hospital. Specimens tested negative for Ebola and Marburg by PCR. ELISA for Ebola & Marburg antigens was negative as well. VHF Mityana Nov 09 1 0 The patient was admitted in . Serology for Ebola/ Marburg IgM & IgG was negative. Suspect VHF Total 13 5 38

Cholera Kampala Sept 09 - Feb 10 82 4 5 The cases were reported from all the five divisions of KCC i.e. , Kawempe, Nakawa, Rubaga and Central divisions with being the most affected. The outbreak started when National Water and Sewerage Cooperation turned off 12 out of the 29 communal water taps in . The residents hence resorted to using water from ponds and contaminated water sources. Cholera Kampala Mar 10 – Apr 10 12 0 0 The cases were reported from Rubaga and Makindye divisions. Affected areas in Rubaga were slummy & located in a wetland that became flooded following the onset of the rains in March. Cholera Kamwenge Sep 09 - Dec 09 252 8 3.2 The cases were reported from Bukulungu, Masyolo sub-county on the shores of Lake George. Vibrio cholera Ogawa was isolated from stool samples. The fishing villages in Bukulungu have the lowest latrine coverage (57%) in the district with a high water table and hence the area gets water logged during the rain season. The fishing village has no access to safe water. Cholera Kasese Mar 09 – Apr 09 652 13 2 The outbreak was imported from the DRC and cases were initially reported from Nyakiyumbu and Karambi sub-counties in Bwera HSD. The most affected sub-counties were Munkunyu, Karambi and Bwera sub-counties. Vibrio Cholerae 01 El tor Inaba was isolated from the stool specimens Cholera Kayunga Jun 10 – Jul 10 113 9 8% The cases were initially reported from Kawungu Parish in Galilaya sub-county on the shores with Lake Kyoga and eventually from Kayunga Town council. Vibrio Cholerae was isolated from the stool specimens. The affected fishing villages use Lake water for domestic use and the latrine coverage is very low (10%). A total of 36 cases including one death were registered in Kayunga Town council and the rest (68%) were from Galilaya sub-county. Cholera Kotido May 10 – Aug 10 557 11 1.97 The cases were reported from 5-sub-counties i.e. Nakapelemoru; Panyangara; Kotido; Kotido TC; and Regen. The majority of the cases originated from Nakaperemoru and Panyangara sub- counties. Vibrio Cholerae isolated from stool specimens sensitive to tetracycline and Ciprofloxacin. The continuous use of water from ponds (Ataparas) as well as open defecation were responsible for outbreak activity in the district.

IDSR among the health workers through training is yet to be done in some of the new districts hence the indicator (86%) is below target. Similarly the utilization of surveillance data is at health facility level is still billow target as evidenced by having trend analyses. The proportion of epidemics with laboratory confirmation has steadily improved reaching the target of 100%. Provision of laboratory reagents to health facilities and designation of District laboratory focal persons helped in improving the situation.

Annual Health Sector Performance Report 43 Challenges

i) Understaffing: Has there been any change in the human resources required to follow up on community interventions especially during epidemics and disasters? What was done to address the capacity of health workers and communities to respond to epidemics and health related ii) Constrained budget: under-funding for the NDC programs by GoU iii) Delayed release of funds iv) Inadequate means of transport

Recommendations

1) There is need to revise the budget for IDSR to cater for response to emergencies and other vital surveillance functions. The key areas that need financial support include: i) The publication of the weekly epidemiological data in the newspapers as it contributes to improved reporting of surveillance data from districts and health facilities ii) The establishment of Community based disease surveillance to improve on the sensitivity of the early warning systems for detecting outbreaks iii) Adequate logistical support to the Epidemiology and Surveillance Division to facilitate epidemic investigation and response through availing appropriate transport, and epidemic investigations kits. iv) Support the use of ICT (mobile phone SMS, internet) to improve the timely transmission of data to the next level for timely decision making to save lives and prevent morbidity. 2) There is also need to improve the capacity of the labs at all levels to confirm disease outbreaks by availing the appropriate human resources, equipment and reagents.

3.1.6 Occupational health and safety programme

The Occupational Health and Safety programme was established to contribute towards the first of all to the reduction of occupational illnesses and disabilities prevalence through prevention of work related accidents, diseases and injuries in health facilities and other workplaces. Secondly it was to ensure that awareness of occupational safety and health issues among workers and employers is at its maximum. The core activities during the HSSP II included the development and dissemination of appropriate policies and guidelines on OH&S developed and disseminated in order that health workers and trade unions are made aware of existing services and how to access them;

44 Annual Health Sector Performance Report Table 3.7: Achievements of the Occupational Health and safety Programme Indicator 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 HSSP II target

% of all health No data No data No data No data No data 5% 50% workers in the formal sector accessing occupational health services % of all health No data No data No data No data No data 1% 30% workers in the informal health sector accessing Occupational health services % of health No data No data No data No data No data 1% 100% facilities with established Occupational health & Safety programmes, % of Trade No data No data No data No data No data 0% 100% Unions made aware and educated on Occupational Health and Safety

Progress i) Technical support supervision visits conducted in FY 2009/10 reveal that all; districts in the country make use of the of policies by :- a) Availing protective clothing and equipment for the health workers; b) The Number of Technical support supervision visits conducted to lower Health facility level to support implementation of occupational health regulations; c) The Level of awareness and knowledgeable about OH&S, prevention and control among the Health workers; d) Level of personal hygiene & personal protection practices; ii) The occupational Health Policy and Occupational Health Guidelines have been developed, printed and launched by the Minister of health and disseminated in 100% of the then 80 . iii) The districts of Oyam, Amolatar and Kabarole have piloted OH and Safety policy. iv) Training of HU in charges, DHTs in the pilot districts in OH&S has been carried out. v) OH&S committees have been formed in the pilot districts up to HC II level. vi) Inspection of Workplaces- vii) Implementation strategy is still in draft form.

Annual Health Sector Performance Report 45 viii) A survey to identify the, number, names and location of Trade Unions is ongoing. This is intended to quantify these unions in order to effectively make a plan of action for awareness creation and education about Occupational health services Challenges i) Understaffing ii) Limited funding iii) Lack of coordination, information sharing and support from line ministries and other stakeholders. Recommendations i) Increased funding. ii) Identify key line ministries; map out their roles and responsibilities for better iii) Involvement of private sector as they are large employment sector. iv) Use of media for advocacy and sensitisation of the public on OH and safety issues v) Training/orientation and retention of health workers in current OH&S is

Environmental Legislation Environmental law is concerned with balancing environmental concerns of the public generally, with the rights of property owners (individual, business and governmental) to develop and use their property. It is reflected both in explicit environmental laws and other statutes and regulations, such as local building codes, zoning ordinances, condemnation policies and land use restrictions. State and local environmental laws reflect local policy and priorities, which vary from place to place, resulting in conflicts between localities on environmental laws’ enforcement and compliance. Environmental Health legislation is a broad category of laws that include laws that specifically address environmental Health issues and more general laws that have a direct impact on environmental health issues. Environmental health law/legislation can be generally defined as the body of laws that contains elements to control the human impact on the Earth and on public health

The Public Health Act, (P.H.A) has provisions for the prevention and control of environmental pollution. In addition, the P.H.A CAP (281) PART XVI—miscellaneous provisions.Sec 138 (General power of Minister to make rules; empowers the Minister to make rules related to the P.H.A “The Minister may make rules generally for carrying out the purposes of this Act”.

The Local Government Act (LGA) Chapter 243 Section 38(1) empowers Districts to enact laws which are referred to as Ordinances which are consistent with the Constitution or any other law enacted by Parliament or laws enacted by the District and Lower Local Governments. Section 40 empower Districts to create offences and penalties

46 Annual Health Sector Performance Report Progress i) The National Environmental Health Policy was developed and disseminated. ii) 50% of the districts in Uganda have formulated and implement Environmental Legislation. iii) Guidelines for developing environmental health ordinances; bye laws for districts and lower local governments have been developed and disseminated a few districts. iv) The districts of Busia, Tororo, Butaleja, Kitgum Iganga are some of the districts who have developed and implemented Environmental Health by-laws. Challenges i) Lack of awareness about Environmental Health Legislation at all levels. ii) Environmental Legislation enforcement agents are conversant with the law themselves. iii) The law books are expensively priced and environmental health staff cannot afford to buy them. iv) The district political and civic leadership are neither exemplary, no supportive in implementing environmental health legislation. v) Paucity of funds for enforcing the law. Recommendations i) There is need for developing and disseminating a communication strategy to create awareness at all levels about environmental legislation. ii) Specific training for the law enforcement arm will improve law enforcement in the country as the enforcers will be in the know of the legislation they are dealing with. iii) Environmental health legislation book should mass printed and distributed free to all environmental health staff, enforcement, and all local government offices at all levels iv) Advocacy meetings should be regularly held to enhance exemplary leadership and to solicit for commitment and support of all district and civic leadership. v) Increased funding.

Food Safety and Hygiene

Food safety and Hygiene, nutrition and food security are national priority health determinants because they directly translate in the health outcomes of individuals and the community. The prevalence of food safety related illnesses and problems of its control and management in Uganda is similar to what occurs in other countries globally, in particular the developing world. Food borne illness is recognized to be a significant public health problem in Uganda. Problems of food safety in Uganda are compounded by low levels of sanitation and hygiene, low sanitation and water supply coverage. In towns most foods are supplied to the community through unhygienic transport, storage, preparation and vending systems. Uganda does not at the moment have a single agency responsible for food safety. There is instead a multi-agency system for ensuring food safety. As a result of this arrangement, the food safety, quality and infrastructure are rather fragmented being share between several Ministries, departments and agencies. Examples of these are, Ministry of Health that acts as a

Annual Health Sector Performance Report 47 lead agency, Ministry of agriculture with three semi-independent departments of Animal Production and Animal health, Department of Crop Production and Protection and the Department of Fisheries Resources, the Ministry of Tourism Trade and Industry with the Uganda National Bureau of Standards (UNBS) and the Ministry of Water and Environment with the Directorate of Water Development (DWD) and the National Water and Sewerage Corporation (NW&SC). All the above ministries and departments share responsibility for food safety based on their respective institutional mandates. Due to this fragmented organization, linkages and coordination are not smooth. Together, with limited resources, Uganda has at present limited capacity to implement and integrated and effective national food safety control system. Despite all the above constraints, some progress was recorded in the area of inspection at retail outlets for food fortification. Progress i) The National Food Safety Strategic Plan (NFSSP) 2007-2016 was developed and disseminated. ii) All the 80 old districts of Uganda were visited for advocacy and sensitization of Avian and Human Influenza and zoonoses. iii) A total of 40 districts were reached while monitoring for food fortification at retail outlets iv) A total of 601 samples were collected and tested for Vitamin A, Iodine and intrinsic iron. The food vehicles sampled included: • 282 samples salt- for iodine. • 295 samples of cooking oil for Vitamin A • 124 samples of wheat flour for intrinsic iron. v) Ten advocacy &Support supervision visits on food safety and hygiene; covering 40 districts were carried out. Challenges

i) Interference by influential people during inspections for compliance enhanced non compliance. ii) Inadequate funds and human resource at all levels in the food safety and hygiene inspection system. iii)Inadequate coordination and collaboration by all players in the sub-sector iv)Absence of sanitation and hygiene codes for food processing establishments. v) Poor transportation methods of food items vi)Consumption by the public of uninspected meat/meat products; poultry and poultry products; agricultural produce

48 Annual Health Sector Performance Report Recommendations

i) Consumer education and information to create awareness ii) Develop a communication strategy of food safety and hygiene iii) Increased staffing at all levels. iv) Training of food inspectors to reach households v) Increased funding for all food safety and hygiene activities vi) Improved collaboration and coordination of all players to avoid duplication.

Annual Health Sector Performance Report 49 3.2 Maternal and child health

Through multi-pronged approaches, there have been some improvements in maternal and child health outcomes in Uganda. However at the beginning of the HSSP II in 2005/6, the maternal mortality ratio at 435 deaths/ 100,000 live births was still unacceptably high20. Also infant and child health had stagnated 76/1000 and 137/1000 respectively [ref]. ]. In order to effectively respond to the challenges of reducing maternal and child morbidity and mortality, a number of interventions have been implemented in the areas of sexual and reproductive health and rights, newborn health and survival, common childhood illnesses, immunization and nutrition.

3.2.1 Sexual and Reproductive Health and Rights A number of core interventions were identified to tackle the unacceptably high maternal mortality rate. Key among these was the operationalization of Emergency Obstetric Care (EmOC) Services at HC III, IV and hospitals. This would include the establishment of maternal death reviews, scaling up goal oriented antenatal care (ANC) including the provision of Intermittent Preventive Therapy in pregnancy (IPTp); family planning services with special emphasis on improving logistics and increasing availability to adolescents. Additionally, the community outreaches were conducted by health facilities. Other stakeholders were to be mobilized through relevant advocacy and IEC to ensure the SRH remained high on the agenda. The progress on the targets that were set for the HSSP II period is summarized in table 3.8

Progress

i) Like in the other years of the HSSP II period, in order to tackle the unacceptably high Maternal Mortality Ratio, core interventions identified in the Roadmap to reduce maternal and neonatal mortality and morbidity were rolled out to more districts. At the end of 2009/10 63% of districts were implementing strategies outlined in the Roadmap which is an improvement of the previous FY 2008/09 where only 45% were doing so. ii) The JRM in 2008/09 emphasized the need to focus on EmOC and reducing the unmet need for FP. Subsequently, the Ministerial Policy Statement of 2009/10 committed resources to scale up EmOC in 50 district hospitals. An additional 8.8% of districts were sensitized on the roadmap. iii) An example of improved availability of services is demonstrated in the SHSSPP- supported districts where all HC IIIs, HC IVs and hospitals provide Basic EmOC. However, only 15 (2 HC IVs and 13 hospitals) out of 49 health facilities (30.6%) in these districts have capacity for the provision of Comprehensive EmOC (Caesarean sections and blood transfusion).

20 Uganda Demographic and Health Survey, 2005/06

50 Annual Health Sector Performance Report Table 3.8: Sexual reproductive health and rights key outputs

Indicator 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 HSSP II target Proportion of 38 29 32 40 34 33 50 deliveries in GoU and PNFP facilities (%)

Unmet need for 86 No data 65 50 40 No data 40 Emergency Obstetric Care (%) Percentage of 20 No data 4521 No data No data No data 60 health facilities providing EmOC (%) Proportion of 42 47 47 56 58 No data 50 pregnant women attending four FANC visits (%)

Contraceptive 234,259 309,757 357,021 361,080 549,594 460,825 494,908 Prevalence Rate (Couple Year of Protection)

Contraceptive 23 24 23.6 23.6 23.6 40 prevalence rate (%)

Teenage 37 No data 25 25 25 25 23 pregnancy rates (%)

iv) At health facility level, SRH activity implementation to support attainment of the set targets, continued, with emphasis on scaling up Focused Antenatal Care (FANC) including the provision of Intermittent Preventive Treatment in pregnancy (IPTp); improving Reproductive Health logistics management, counseling and managing survivors of sexual gender based violence, screening for and managing cervical and breast cancer. Misoprostol use in the prevention of post-partum hemorrhage was introduced in 10 districts; service providers in HC IIIs, HC IVs and hospitals were trained on its use. This served to reduce the need for blood transfusion. At the community level, VHT kits were procured for 927 / 3150 (29%). A key intervention was the revitalization of maternal death audits which was done by setting up and training 7 MPDR health facility committees consisting of 97 health workers in 7 hospitals.

21 Information from UNFPA supported districts

Annual Health Sector Performance Report 51 v) Service provision to youth in selected tertiary institutions was done by carrying out HIV Counseling and testing, counseling and provision of Family Planning services. For adolescents, community-based activities done included ASRH out reaches during which young people were reached with ASRH information; peer education and information provision on adolescent health issues in schools. vi) Reducing the unmet need for FP was addressed by scaling up provision of services through outreach camps, and integration of FP services in other RH services at health unit level. Development Partners also provided contraceptives that they had procured under their system for distribution to health units. In addition, the Reproductive Health Commodity Security strategy development was finalized and printed. Another strategy to scale up FP use was the integration of HIV with RH service provision by finalization of the strategy, technical support supervision and development of data management tools (Integrated FP registers). This integration was supported by Development partners and developed by the RH division in collaboration with the AIDS Control Program (ACP). vii) In a bid to improve the knowledge and skills of service providers, training on various areas of Reproductive Health covered:

a) Short term methods of Family Planning (65 service providers), b) Long Term & Permanent Methods of Family Planning (100 service providers in 18 districts), c) Emergency Obstetrical Care (63 service providers), d) Adolescent Health (60 service providers in 2 districts), Malaria in Pregnancy (30 service providers in 1 district), e) Focused Antenatal Care ( service providers) VHT (12152 in 10 districts), f) SGBV (70 service providers in 3 districts), g) Active Management of third Stage of Labour (12 service providers in 1 district), h) Prevention and management of Obstetrical Fistulae (in 2 hospitals in 2 districts), i) Peer education (30 peer educators). viii) Other efforts to operationalize Emergency Obstetric Care (EmOC) services at HC III, IV and hospitals were carried out through:

a) Hands-on skills building using national trainers, Association of Obstetricians and Gynaecologists b) Identifying health facilities with gaps, especially in the SHSSPP districts, on equipment, procurement and distribution of basic EmOC equipment, medicines and related health supplies to those facilities.

ix) On the advocacy side, Parliamentarians were supported to hold an International Conference for Parliamentarians from other countries on the Reduction of Maternal and Newborn Morbidity and Mortality. A Campaign for Accelerated Reduction of Maternal Mortality in Uganda (CARMMU) was launched. This campaign had the purpose of renewing the intensity by all stakeholders to scale up implementation of cost effective interventions aimed at speeding up the attainment of MDG5 by the year 2015.

52 Annual Health Sector Performance Report x) In the area of BCC, materials that were developed included Adolescent Health Job aide, Adolescent Health IEC materials, and IEC materials on Focused ANC. Public awareness was also raised during the preparatory period and the actual commemoration of national health days like Safe Motherhood Day, Africa Malaria Day, National Youth Day, and World Population Day. xi) Support supervision was provided to districts on at least one of the following – PMTCT, EmOC, ASRH and FP. In addition to the above areas logistics management was added onto the list during supervision of the 10 SHSSPP II supported districts. xii) Development of guidelines and other RH tools to improve service provision (Standards for Adolescent-friendly services, Documentary film on youth voices) was accomplished.

Major challenges

i) Funding constraints were in form of delayed release of funds coupled with unpredicted budget cuts. ii) Logistic challenges faced were those on delays in procurement of contraceptives using government funds. iii) Referral of emergencies within the districts was mainly due to insufficient allocated to maintenance and running of ambulances. iv) There are still gaps in midwives, doctors and anaesthetists within the districts; this compromises the much needed EmOC service provision.

Recommendations i) Emphasis should be placed on ensuring timely release of funds and streamlining procurement to prevent compromising services at all levels. ii) There is still a need to improve on the human resources available at districts if EmOC service provision is to be improved.

3.2.2 Integrated child survival

During latter part of HSSP I, concerns about the stagnation of the reduction of child mortality in the country prompted a refocusing on child survival in the HSSP II. The overall goal of integrated child survival is the attainment of a good standard of health by all the children through scaling up and sustains high coverage of cost effective interventions and ensure their integrated delivery at family/community and institutional level. A number of interventions to improve child survival were prioritized including revitalization of EPI, Newborn Survival, Child Days Plus (CDP), Integrated Management of Newborn and Child Illness (IMNCI), Home Based Management of Fever, which has evolved into the Integrated Community Case Management (ICCM) and Nutrition especially Infant and Young Child Feeding and HIV/AIDS.

Annual Health Sector Performance Report 53 Progress Introduced in May 2004 the Child Days Plus strategy, involving vitamin A supplementation, de-worming, immunization and promotion of key family care practices have been implemented in the months of April and October. i) Launched the Integrated Community Case Management (ICCM) strategy, including ii) Adaptation of WHO/UNICEF training materials for ICCM for community health workers iii) Newborn health was also integrated into the ICCM strategy and training guidelines iv) Conducted baseline surveys and training VHTs on ICCM v) Finalize the development of the newborn implementation framework, service standards and job aids for health workers vi) Started assessing quality improvement assessment in eight districts vii)Children without Worms shipped 9 Million doses of Mebendazole to support Child Days viii) The 1st line treatment policy for pneumonia was reviewed from cotrimoxazole to amoxycillin ix) All districts in Uganda implement two rounds of child health days but with varying degrees of performance. Performance in child health days however deteriorated and actions to strengthen CDP were initiated x) Commemorated the African child & breast feeding week xi) The division staff participated in the African Summit conference held in Uganda, which there was infant, & maternal mortality. Progress in child days plus during HSSP II period is summarized in table 3.9.

Table 3.9 Bi-annual Child Days performance HSSP II Target outputs 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 Target

HSSP II Indicators

Children 6-59 months received two 37% 68.5% 61% 56.5% 69.5% 46% 80% Vitamin A doses

Children 1-5 years de-wormed twice 60% 68.7% 61% 62% 37% 100%

Central level program performance indicators

Central district supervision/monitoring bi 2 2 2 1 1 1 during CDP annually

Audit CDP data and performance Y - - Y - - Annually indicators + re-planning

Communication & mobilization for Y Y Y - - - Biannually CDPs

District level (service delivery level) indicators

Children 6 - 14 years de-wormed twice 65% 61% 54% 66.2% 53% 40% 80%

Districts with micro plans for CDP 15% 21% 30% 30% 46% 48% 100%

Districts with adequate drugs for CDP 30% 40% 45% 50% 50% 55% 100%

54 Annual Health Sector Performance Report Major challenges i) District capacity to pan and manage child days including mobilizing resources ii) Weak leadership, coordination and management of CDP at national level iii) Inadequate advocacy, communication and community mobilization iv) Inadequate supplies of de-worming drugs v) Inadequate preparation and sensitization for new interventions e.g. HIV testing vi) Poor monitoring and lack of clarity on performance indicators vii)Political support and engagement of partners at all levels viii) Weak routine outreaches and lack of post child days interventions ix) Lack common understanding of CDP among national programs, districts and communities x) Inadequate long-term planning for CDP and strategy for capacity building

Recommendations i) Strengthen planning, implementation and monitoring especially quality of data ii) Finalize the communication plan, develop and disseminate relevant IEC materials iii) Develop a five year implementation plan and capacity building for CDP iv) Integrated CDP in national budgets and all district plans v) Expand partnerships for CDP including other sectors and private sector vi) Implementation research for CDP vii)Develop standard operation tools for CDP and build capacity at all levels

3.2.2.1 Newborn Health and Survival

The high contribution of neonatal deaths to national infant mortality prompted a special section dealing with Newborn Health and Survival in the HSSP II. The core interventions identified to improve newborn survival included emphasis of those already in use such as the provision of essential pregnancy and postnatal care; safe and clean deliveries. Some of the new areas included: counseling and education on newborn practices; sensitization and education on danger signs for the newborn; promotion of appropriate care seeking and homecare practices for the newborn. Figure below shows the progress in newborn survival performance indicators in HSSP II, national & district level: Progress in this area during the HSSP II period is summarized in table 3.10.

Annual Health Sector Performance Report 55 Table 3.10: Performance against Newborn health and survival indicators over the HSSP II period Target outputs 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 HSSP II target

HSSP II indicators Proportion of children with low birth 12% 10% 8% No data 10% 8.9% 30% reduction (8.4% weight <2500g level) Proportion of neonates seen in 70% 70% 55% 51% 50% 50% 30% reduction (49% health facility with level) septicemia/severe disease Central level program performance indicators Quarterly performance reports 1 2 4 4 4 4 Four Technical newborn steering 10 12 12 10 Twelve committee meetings Technical support planning and 11% 19% 25% 33% 100% supervision visit to districts

District level (service delivery level) indicators District work-plans with core 6% 15% 16% 70% interventions for child survival Proportion of newborns who 23% 25% 34% 28% No data 26% 40% receive postnatal visit in the first week of life

Progress In the FY 2009/10, some slight improvement was realized in some indicators for newborn although rather suboptimal. This years target for HSSP II was not attained. Efforts were stepped up to address this poor performance. According to the supervision report of the last quarter, at least fifteen districts had initiated some activities to strengthen newborn health. The following program activities were undertaken to improve the performance i) The national multi-disciplinary advisory committee continued to advocate for and coordinate different efforts to improve newborn health including: participation in the MCH cluster meetings, developed/reviewed policies and guidelines, including planning and evaluation ii) Integrated in-service health worker training package covering newborn examination, resuscitation, recognition and management of a low birth weight baby and sick newborn, death auditing, routine newborn care and how to organize the health facility to make it newborn friendly, including tools for evaluating trainings has been developed as part of the helping babies breathe (HBB) strategy. Some members of the newborn steering committee attended a TOT workshop for HBB conducted during the International Pediatric Association Conference held in South Africa. Two districts have started implementing HBB guidelines as part of the broader newborn health strategy iii) Standards based facility assessment/evaluation and improvement of the quality of newborn care has been initiated in 8 districts and 2 of these have gone ahead to give feedback and start undertaking specific quality improvement action. Seven district level newborn champions have been trained to support the roll out of newborn activities in the regions iv) Efforts to support Kamwenge, Bushenyi, and Mityana hospital to improve newborn health through systematic quality improvement approaches has been initiated, including plans for setting up nurseries through centrally coordinated but

56 Annual Health Sector Performance Report participatory assessment of capacity, action plans for revitalization, resource mobilization, supervision and monitoring. v) Peri-natal death auditing has been initiated in 15 districts as a way of finding and reducing avoidable deaths at the facility, and strengthening quality of care for maternal and newborn services. a national level death audit review team has also been set up. vi) In order to support capacity building for newborn care and survival, guidelines for the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) were adapted from WHO generic material and subsequent training will use revised guidelines. vii)In an effort to increase demand for services, a formative study was conducted and currently a private firm is developing a behavior change strategy to address not only cultural home care practices but also advocacy for newborn rights, social marketing and interpersonal communication skills to improve provider client interaction.

Major challenges i) Limited number of national and regional mentors and supervisors for newborn health ii) Most activities for newborn health are supported by partners and newborn activities are not well integrated in district plans and other quality improvement activities iii) Need for a comprehensive costed newborn health roll out plan and mobilization of resources iv) Peri-natal death audit activities are not implemented widely – only 15 districts have initiated this and national review teams are not very functional v) Newborn data is not well integrated in routine sources of health information – HMIS, surveillance, supervision and monitoring at all levels vi) Lack of equipment and supplies for newborn health service

Recommendations i) Establish district clinical audit teams consisting of hospital clinical specialists, district health teams, financial administrators and NGOs to champion and support lower level health facilities and communities in the catchment area to assess newborn health standard, introduce and maintain quality improvement approaches in these units. ii) Conduct rapid assessment of the level of implementation of newborn standards at facility and community level, and use this as a basis for selecting priority areas for initial implementation to improve coverage and quality of services. A criterion based tool and guide for conducting the assessment will be developed based on the Yellow star program and other quality improvement activities e.g. collaborative etc iii) Build capacity for implementation and monitoring of newborn activities through training needs assessment, training health workers and VHTs, supply of job aids, registers and other tools, procurement and distribution of medicines, supplies and equipment for newborn care; and regular supervision. iv) Strengthen postnatal care services including health worker capacity building, disseminating information and tracking children who miss postnatal services v) Mobilize existing resources, including a number of "hidden resources" (local organizations, traditional structures, groups) to integrate or build on newborn activities such as reproductive health, child's health, immunization, HIV, malaria and others. A

Annual Health Sector Performance Report 57 number of actions could help to develop partnerships, such as undertaking an inventory and determining the kinds of support needed to enable them to be more effective in the promotion of newborn health.

3.2.2.2 Management of Common Childhood Illnesses

The IMCI strategy Ministry of Health was one of the priority programs under the UNMHCP for improving child survival, development and growth. IMCI is a key strategy whose aim is to contribute to the reduction in under-five mortality through improvement of health worker skills in regard to assessment and management of common childhood illness and preventive measures like immunization, counseling on infant and young child feeding, vitamin A supplementation and de-worming all provided in an integrated manner. The 2nd and 3rd component of IMCI are related to strengthening health systems needed for child health and family and community health care practices respectively.

Table 3.11: IMCI programme performance over the HSSP II period

Target outputs 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 HSSP II target

HSSP II indicators

Proportion of sick under-fives seen by a health worker 60% 45% 62% No data 52% 48% 60% using IMCI guidelines.

Proportion of under fives with fever, diarrhea and 27% 34% 37% 42% 42% 50% 70% pneumonia seeking care within 24 hours

Proportion of under-fives with acute diarrhea receiving 27% - 37% 40% 44% 45% 70% ORT.

Proportion of under-fives with pneumonia receiving 18% 30% 27% 42% 42% - 70% appropriate antibiotic treatment

Percentage reduction of missed opportunities for 50% 45% - 55% 40% 62% 80% immunization among sick under-fives.

Central level program performance indicators

Bi-annual technical IMCI supervision 1 2 1 2 2 2 2

Health facilities accredited as implementing IMCI 42% 55% 55% 57% 60% 60% 80%

Training institutions integrating IMCI in their curricula - - 6% 19% 25% 33% 50%

District level (service delivery level) indicators

District implementing community IMCI - - - 6% 15% 16% 100%

Health facilities with no stock out of IMCI supports and 23% 25% 34% 28% No data 26% 40% drugs

Source: Service Provision SPA 2007, Supervision reports, IMCI zonal team reports In 2000 the implementation of IMCI was largely decentralized and although this was meant to register more resources for implementation, in most districts IMCI training seemingly stalled. During HSSP II the main focus was on strengthening pre-service training, alternative training methods and linkages and continuum of care through development of guidelines for

58 Annual Health Sector Performance Report community case management and newborn care, second referral level quality of care services including newborn care and reviewing treatment policies for pneumonia and diarrhea. The following were some of the main achievements and IMCI performance against the HSSP targets in table 3.11. Progress In the FY 2009/10, some slight improvement was realized in terms of processes to institutionalize IMCI and more innovative ways of implementation. Efforts were stepped up to address the low number of sick children managed using IMCI guidelines by bringing services closer to the community through ICCM and more and more emphasis is being put on improving quality of care through standards development and facility accreditation methods. According to the supervision report of the last quarter, many districts are beginning to revitalize IMCI. The following program activities were undertaken to improve the performance during period of HSSP II: i) Initiated process for reviewing and scaling policy for community pneumonia treatment through: a study towards improving presumptive diagnosis of childhood malaria and pneumonia, change pneumonia and diarrhea first line drug treatment policies from Cotromixazole to Amoxicillin for pneumonia, and Zinc and low osmolar ORS for diarrhea and a pilot for ICCM was evaluated; and a national ICCM technical committee was established to oversee the process with the MoH. ICCM was eventually launched in July and VHT training has started slowly in eight districts ii) Training of tutors in medical, paramedical and nursing institutions was intensified and schools in the eastern, western and northern region were covered. iii) To support scaling of IMCI, ICCM and other related training, the concept of zonal teams as a support arm to the centre has been revitalized. New TOR and letters of appointment to zonal teams have been issued. Efforts are ongoing to mobilize resources to support the zonal teams to assist districts in their geographical regions iv) The complementary IMCI/HIV training for health workers has continued and during this period trainings were introduced in 6 new districts v) Plans have been initiated to introduce emergency patient triage and management of referred patients

Major challenges i) High turnover of staff in districts and health units which affected the attainment of a critical mass of trained staff in the units. ii) Lack of resources for training, production of training and other implementation materials further limited district training, supervision and monitoring activities iii) Few numbers of trainers and supervisors for IMCI to support implementation especially new districts iv) Irregular technical supervision and monitoring activities affecting institutionalization of IMCI and continued improvement of IMCI

Annual Health Sector Performance Report 59 v) Low implementation of community IMCI affecting family care practices including timely and correct care seeking vi) Shortages or irregular supply of drugs especially 1st line anti-malarial, de-worming drugs and antibiotics vii)Low levels of post natal attendance and poor administrative data to support decision making and feedback, and therefore continued improvement in quality of care

Recommendations i) Review the IMCI implementation framework to reflect new development and build district management capacity for child health programming in general and implementing IMCI in particular ii) Revitalize and strengthen the implementation of the IMCI referral care package including ETAT iii) Scale up ICCM and community IMCI through mobilization of resources, capacity building, production of implementation guidelines and materials and effective monitoring and supervision iv) Advocacy for early and effective management of newborn and childhood illnesses including integration of preventive services v) Evaluate the program and disseminate information as way of advocating for IMCI and other related interventions vi) Develop centers of excellence and demonstration sites for continued learning in the regions, including introduction of computerized and long distance training (ICAT)

3.2.2.3 Expanded Programme for Immunization

Immunization is a nationwide programme targeting mainly infants and women of childbearing age. The mission of UNEPI is to contribute to the reduction of morbidity and mortality due to childhood disease to levels where they are no longer of public health importance. The programme goal and objective in HSSP II was to ensure that all children are fully immunized against the vaccine preventable diseases before their first birthday and all babies are born protected against neonatal tetanus. Progress 1. Ensuring an efficient cold chain system

i) Procured cold chain equipment for the Karamoja district through UNICEF support. The equipment included 35 vaccine storage fridges and 20 cold boxes ii) Conducted cold chain maintenance and support supervision in 39 districts of Masaka,Mpigi,Sironko,Mbale,KaseseBundibugyo,Bushenyi,Ibanda,Lyantonde,Kiruhu ra,Rakai,Sembabule,Kaberamaido,Soroti,Mukono,Kayunga,Amuria,Katakwi, Kabarole,Hoima,Kiboga,Luwero,Kisoro,Kabale,Kalangala,Namutumba,Nakaseke,Neb

60 Annual Health Sector Performance Report bi,Nakasongola,Budaka,Nakapiripirit,Moroto,Kabong,Abim,Kampala,Wakiso, Kibale, Kyenjojo,and Kotido for routine activities. iii) Production and printing of 3,000 posters on vaccine management with support from UNICEF and WHO. iv) Carried out inventory of cold chain equipment in all the districts. A report will be made available. 2. Forecasting, procurement and distribution of adequate vaccines and supplies within the Vaccine Independency Initiative framework

i) The GOU has continued to contribute 100% towards the procurement of the routine immunization vaccines (BCG, OPV, TT and measles) and their related injection safety materials. GOU contributed US$909090.91 (5.4 %) for procurement of DPT-HepB + Hib vaccine. The rest of the vaccines were procured by GAVI. ii) UNEPI has continued to deliver the vaccines, injection safety materials, gas and other EPI logistics to the districts on a monthly basis. The districts and HSDs distribute the logistics to the health facilities that carry out immunization at static and outreach sessions. 3. Social mobilization for immunization including campaigns

The Ministry of Health took the leadership in advocacy and sensitization of the public to create awareness on the threat to importation of the wild polio virus from neighboring countries, about the possible spread of the virus. 4. Injection safety promotion

UNEPI has continued to use syringes with re-use prevention features (RPF) for both reconstitution and injecting. The generated waste is disposed off by burning and burying, and incineration where the incinerators exist. 5. Surveillance of measles and polio cases

EPI disease surveillance is implemented in the context of Integrated Disease Surveillance and Response-IDSR). Several strategies were implemented in 2009/2010 to ensure that WHO quality EPI surveillance performance indicators are attained. These included: i) Regional surveillance review meetings (involving the District Surveillance Focal Person, HMIS Focal Person and HSD Surveillance Focal Person) to assess the progress of quality surveillance performance indicators, the status of implementation of IDSR activities in the district, and sharing new concepts of disease surveillance. ii) All districts conducting quarterly surveillance review meetings involving the District Health Officers (DHOs), District Surveillance Focal Persons (DSFP), HMIS Focal Persons, District Laboratory Coordinators (DLC), Health Sub District Surveillance Focal Persons (HSDSFP) and in charges of the HSD. In 2009/2010, 77 (96%) districts investigated at least 1 AFP case for laboratory confirmation. At the national level, a non AFP rate of 2.9/100,000 children below 15 years o age was attained with district variation between 0.0 and 14.0 AFP rate. Sixty five percent (52

Annual Health Sector Performance Report 61 districts) attained a non polio AFP rate of at least 2/100,000 children below 15 years of age as a recommendation of minimum standard of WHO A total of 588 suspected measles cases were reported in the monthly HMIS and 1083 measles cases had a case –based form filled meaning 184% of the cases had blood specimen taken off for investigation than those cases reported through the HMIS. Of the 1083 measles cases, 1.3% (14 cases) tested positive for measles IgM and 10% (104 cases) tested positive for Rubella IgM. Of the conformed measles cases 86% (12 cases) had received at least one dose of measles vaccine 6. Control of Wild Polio Virus

In FY 2009/10, 2 rounds of polio campaigns were carried out in August and November 2009 targeting 12 high risk districts of Kaabong, Moyo, Moroto, Adjumani, Pader, Gulu, Amuru, Kotido, Masindi, Nakapiripirit, Abim and Kitgum. The overall coverage was 102% and 101% in round 1 and 2 respectively. There were no cases of confirmed Wild Polio Virus. 7. Implementation of the Reach Every District (RED) strategy Using district monthly HMIS reports, 22 districts that were poorly performing (with the highest number of un-immunized children) or not submitting complete reports were identified. The following activities Micro-planning, Verification of data, and Supervision by the district team and delivering of supplies, social mobilization including radio talk shows were carried out in the districts of Arua, Yumbe, Masindi, Iganga, Kamuli, Luwero with support by WHO while UNICEF supported Nakapiripirit, Kibaale, Adjuman, Amuria, Kabarole, Bugiri, Mayuge, Kanungu, Bulisa, Kaliro, Moroto, Kabong, Kapchorwa, Nakaseke Kaberamaido, and Soroti in Micro-planning and social mobilization. 8. In order to build capacity for service providers so that they are able to deliver quality immunization services, the programme trained; i) 169 Mid Level Managers were trained to build their capacity for EPI management and supervision with support from Africa Field Epidemiology Network (AFENET) through regional workshop in Hoima (Hoima, Kiboga, Masindi, Buliisa and Kibaale districts), Mbarara (Mbarara, Bushenyi, Ibanda, Kiruhura Isingiro districts), Jinja (Jinja, Kamuli, Iganga, Kaliro, Mayuge, Bugiri and Namutumba districts), Kabale (Kabale, Kisoro, Rukungiri, Ntungamo and Kanungu districts) and Masaka (Masaka, Rakai, Sembabule, Lyantonde and Kalangala districts) ii) Conducted OPL training courses in 9 districts of Bundibugyo, Kabarole, Kamwenge, Kasese, Kyenjojo, Apac, Pader, Amolatar, Kitgum iii) Conducted training of tutors from 28 Nurses and Clinical officers training schools on EPI. 9. Two rounds of Human Papilloma Virus (HPV) vaccination targeting girls aged 10 years in the demonstration project districts of Ibanda and Nakasongola were carried out, with dose three coverage of 88% and 106% respectively. After successful completion of demonstration project the bridging phase for HPV vaccination was introduced that delivers the vaccine using the hybrid strategy which targets girls in P4 during Child Days Plus in the same districts of Nakasongola and Ibanda and the coverage achieved for the two doses

62 Annual Health Sector Performance Report so far received is 96% and 92% respectively. A third dose is yet to be given during the month of October. 10. Strengthening Tetanus Toxoid Immunization in schools was carried in 13 districts of Isingiro, Ibanda, Kiruhura, Mbarara, Masindi, Buliisa, Manafwa, Mbale, Rakai, Lyantonde, Bugiri, Bundibugyo, and Bududa Mubende, Mityana, Busia, Kibaale, Kiboga and Masaka districts were covered with one round of tetanus campaigns in July – Sept 2009, with overall coverage was 45% which was below the target of 80%.

Table 3.12: Uganda National Expanded Programme on Immunization key outputs HSSPII 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 HSSP II target/Indicators target

Fully immunized 41% 46% - - - 80% children

DPT-HepB+Hib3 89% 89% 90% 82% 85% 76% 95% coverage

DPT-HepB+Hib 16% 11% 10% 12% 11.0% 10% 1-3 dropout rate

Measles coverage 91% 88% 82% 77% 72% 97%

Identified cases 0 0 0 0 8 0 0 of Wild Polio Virus

HMIS, Case based AFP surveillance

Major Challenges

1. There was a decline in the DPT-HepB+Hib3 coverage from 82% in FY 2008/09 to 76% in FY 2009/10. This can be attributed to;

i) Delay in payment to Shell (U) Ltd in qrt1 of FY 2009/10 and they halted the supply gas until payment was made. During this period the districts were not supplied with vaccines, since most of the fridges use gas supplied by Shell (U) Ltd for running. This caused a disruption in implementation immunization services at health facility level. ii) Lack of Child Health Cards and tally sheets for recording child immunization which may be causing under reporting by the health facilities carrying out immunization. iii) Inadequate transport at district level for delivery of supplies to the lower levels. iv) Irregularity of outreaches in almost all districts causing dropouts.

Annual Health Sector Performance Report 63

v) Shortage of gas cylinders at the district level causing irregular supply of gas for the cold chain. vi) Inadequate IEC materials on EPI for Health workers and the communities. 2. The threat of importation of the wild poliovirus from neighboring countries where it is still circulating 3. Late release of funds which is affecting delivery of logistics to districts, servicing of vehicles and surveillance activities. 4. Inadequate funding from the GOU for replenishment of spare parts for cold chain equipment, vehicle maintenance/repairs and generator maintenance (fuel and servicing) and training of operational level health workers. 5. Two new cold rooms were installed last year but the other three cold rooms are more than ten years old and have occasional breakdowns. Recommendations i) UNEPI has scheduled an extensive programme review to be carried out in October 2010 to identify factors that are affecting the immunization coverage. ii) There is need to increase the funding for the programme at all levels to fill the existing operational gaps. iii) Provision of basic tools for service delivery such as child health cards and tally sheets should be given priority iv) Districts should earmark funds for integrated outreaches which will ensure continuity of the immunization services and hence give assurance to the parents of the regular availability of immunization services. v) The threat for wild polio virus importation from neighboring still exists and there is need to strengthen routine immunization activity at all levels. Mass polio vaccination may have to be carried out in districts that are high risk whenever recommended.

3.2.5 Nutrition

Adequate nutrition is an essential prerequisite for maintaining health status. Malnutrition remains a major public health concern in Uganda and affects almost all regions. According to the 2006 UDHS, 16% of children under five in Uganda are underweight, 38% are stunted and 6.1% wasted. Micronutrient deficiencies have been and continue to be a silent emergency in the country. Vitamin A, Iron and Zinc deficiencies continue to take a heavy death toll among children. The National Health policy and HSSP recognized the important role of nutrition and hence include it as one of the components of the National Minimum Health Care Package. The Nutrition section has various strategies to reduce the problems of malnutrition in Uganda.

The overall objective of the nutrition programme was to improve the nutrition status of the population with emphasis on the vulnerable groups of the children and mothers. Various strategies were put in place to achieve this. Data from the previous three Uganda Demographic Health survey (UDHS) show that the nutrition indicators have not improved

64 Annual Health Sector Performance Report much over the past 15 years and some indicators have even shown a worsening trend. Also, malnutrition remains one of the single direct causes of child morbidity and mortality and the prevalence (under fives) remains unacceptably high at 60% (Lancet Series February 2008). Micronutrients and the double burden of disease are also on the rise. Progress towards the attainment of HSSP II indicators is shown in table 3.13.

Table 3.13: Nutrition programme key outputs

Annual Health Sector Performance Report 65

Figure 3.7: Hon. Minster of Health officiating at the World Breast-Feeding week

Vitamin A supplementation

Child Days were the main activity for scaling up vitamin A supplementation. Support supervision was conducted in 80 districts country wide. Yet still it was not possible to attain the 80% Child days intervention coverage, and this was mainly due to many district not owning CDP and therefore lack micro-plans for this, poor reporting on CDP performance from the districts to the centre with many districts populations not stable and may not tally with the figures available at the centre, and subsequently there is delayed feedback to most districts. The majority are not able to implement CDP fully due to challenges like lack of transport within the districts and at health facilities to conduct outreaches, PHC funding to the districts are limited and are received late, while many districts do not allocate funds for CDP. There is also low partner involvement in support of CDP activities at national and district levels, especially the non-health sector and private sector partners. Addressing malnutrition in under-fives This is one of the indicators where the set target was attained at the end of the HSSP II. Various activities as outlined below took place to address under nutrition among children aged less than five years: 1. Development of the Operational Framework for Nutrition in the Child Survival Strategy and the Maternal, Infant and Young Child Nutrition (MYICN) Action plan 2. Handbook on population nutrition developed and produced 3. Quarterly Coaching Visits to 52 sites implementing providing ART services supported by NUlife project.

66 Annual Health Sector Performance Report Box 3.5: Lessons learnt from the NUlife Project • Nutrition assessment, counselling and support can be integrated in routine services however the staffing norms are still very low • Provision of Ready to Use Therapeutic Feeds (RUFT) especially to the malnourished persons on ARVS quickens adherence to drugs and maintains nutritional status, but there is a missing link at the community level whereby the weaned clients many times regress and become malnourished again • The community health workers if motivated can do a tremendous job where there is

active case finding for the malnourished in the communities • Multi-sectoral involvement in the implementation of the program is key to the success of any project or program

4. Harmonized and Finalized the Integrated Management of Acute Malnutrition (IMAM) Guidelines, Reviewed the IMAM training Manual, Pretested and Conducted training of trainers course in the harmonized content. 5. Harmonized the Integrated Infant and Young Child Feeding (IYCF) Counseling Course, Conduct training of trainers course in the harmonized content and Scaled IYCF in all two Regions through capacity buildingHeld Coordination meetings which were attended by Nutritionists, DHOs, and Nutrition focal points from the different districts with other Nutrition Stakeholders 6. Recently the CHT training guide was revised. The VHT training manual (2010) now includes a nutrition component including screening for malnutrition at the community using mid-upper arm circumference, counselling and referral for management. However, integration of community growth monitoring and promotion by the VHT was not implemented as planned. Also, at facility level, children’s anthropometric measurements are taken but in most cases are not plotted on the growth chart.

Major challenges 1. Inadequate funding for nutrition activities especially by the Government budget. 2. Most district plans still do not include nutrition activities during planning and this has retarded the implementation of activities at the district 3. There is a huge gap in human resource at the national, regional and district levels to implement the nutrition interventions, while most health workers still have inadequate skills to implement nutrition interventions 4. Low involvement of communities in nutrition interventions mainly because the Ministry has been focusing more on treatment as an approach rather than preventive. 5. Progress data has been a challenge as most of the indicators to be reported on are mainly collected by the UDHS which is conducted once in every five years.

Annual Health Sector Performance Report 67 6. While it is important to have zinc supplementation it is not available and there have been frequent stock outs of iron and folic acid in health facilities. The lack of Zinc is related to limited sources internationally, with only one company supplying, this is not able to satisfy the demand.

Recommendations 1. There is need for continuous advocacy for Nutrition interventions to be mainstreamed in all health services 2. Increasing the number of health facilities that are designated as baby friendly 3. Community Growth monitoring and Promotion be revitalized and integrated into the VHT program as a way to reduce malnutrition at early stages 4. Coordination of all nutrition interventions should be by the Ministry of Health and give direction to the different implementing partners 5. Most Districts still need to be encouraged to recruit at least a nutritionist who can spearhead the nutrition activities at the hospital and district level. 6. The funding for nutrition activities also needs to re-visited and more funds allocated for the smooth running and implementation 7. There is need to strengthen monitoring and evaluation strategies that can provide short term data sources such as sentinel sites, thus providing routine nutrition information on a regular basis. The HMIS should also include more nutrition related indicators that can be collected routinely. Furthermore, there is need to set targets and strategies within the HSSP III that will ensure an improvement in the nutrition status of the population.

68 Annual Health Sector Performance Report 3.3 Prevention and control of communicable diseases

3.3.1 Prevention and control of STI/HIV/AIDS

FY 2009/10 was a period of re thinking, re-planning and revitalization of the HIV response in the Health Sector as both HSSP2 and HSHASP1 (Health Sector HIV Strategic Plan (2005/10)) ended. This year also marked the end of PEPFAR 1 supported HIV programmes most of which were transitioned to PEPFAR 2 under the new administration in Washington under President Obama. This is important for us because 90% of HIV funding is US supported. The ACP therefore had to heavily coordinate this tough period. The HIV prevalence from the ANC surveillance in 2009 was estimated to be 7%.Antenatal HIV prevalence was higher in urban than in rural sites. In sites located in the major urban areas (cities and municipalities), median HIV prevalence was 8.4 percent. In the sites located outside the major urban areas, median HIV prevalence was 5.7 percent. Approximately 1 million people are infected with HIV over 140,000 of them being children below 15 years of age (table 3.14). Of the 100,000 new infections, 20,000 of them were in children from Mother to Child Transmission.

Table 3. 14: The HIV/AIDS Epidemiology in 2009

Magnitude of HIV/AIDS In Uganda in 2009

1. No. of HIV Infected Individuals Total 1,192,372 100%

Sex

Males 512,070 43%

Females 680,301 57%

Age Group

Adults (15 years +) 1,042,711 87%

Children 0-14 years) 149,661 13%

2. Number of new HIV infections in 2009 Total 124,261 100%

Males 56,079 45%

Females 68,182 55%

3. Number of AIDS Related Deaths in 2009 Total 64,016 100%

Males 28,812 45%

Females 35,205 55%

The epidemic has shifted from the single younger-aged individuals to older individuals aged 30–35 years, who are married or in long-term relationships. Multiple concurrent partnerships,

Annual Health Sector Performance Report 69 extra-marital relationships, discordance and non-disclosure are among the key factors driving the spread of HIV in Uganda. Progress ACP consolidated most of the achievements under HSSP2 and HSHASP1. Most of the Policies for comprehensive HIV prevention, care and treatment were in place and were updated to match and meet the ever changing global changes and challenges especially ART and PMTCT policies. A new National Prevention Policy (NPC) was also developed in the context of the multisectoral approach under Uganda Aids Commission. The Home Based Care policy was finally completed with support from WHO. HIV services were scaled up to many health facilitues both in the public and private. For example HIV care PMTCT and ART services were provided in 66% and 83% of the health facilities respectively. One hundred (100) of the ART sites were in the private health facilities supported by HIPS (Health Initatives in the Private Sector), USAID funded. This is a great achievement enhanced by the MoH – PPP Policy. By June 2010, the numbers of active clients enrolled onto antiretroviral therapy were 237,070. Of these, 89 percent were adults aged 15 years+, and, eight percent were children 0-14 years. Based on new Ministry of Health guidelines i.e. adults with < 350 CD-4 T-cells/ul., data from modeling indicates that 540,094 adults and children were in need of ART by December 2009. Based on these estimates, and the number of people enrolled on ART, 47 percent of adults and 26 percent of children in need of ART were already enrolled as of June 2010. If the previous national ART eligibility criteria of < 250 CD-4 T-cells / ul were considered, modeling data indicated total ART need of 442,103 adults and children indicating that 54 percent adults and children were enrolled on ART by June 2010. Over 800,000 pregnant women accessed PMTCT through ANC. A lot of success was made in integrating HIV services with others especially TB, RH and MCH. For example HIV Early Infant Diagnosis (EID) was integrated into Child Days Plus. This increased the Number of HIV exposed children that accessed HIV testing (EID) from about 17,000 to 43,000. While 63% of TB patients in Uganda are co-infected with HIV and TB remains the commonest cause of death among PLHIV. There was success in the implementation of regional HIV programs like GLIA (Great Lakes There was success in the implementation of regional HIV programs like GLIA (Great Lakes Initiative on HIV/AIDS) funded by the WB. IOM conducted hotspots study along northern corridor from Kampala to Juba and the report is available. There were also some IGGAD supported activities that were implemented during this FY. Most of the ACP activities were supported under the CDC/MoH Coag Project. The Global Fund resumed operations in 2009/10 and $ 24m was disbursed out of the year budget of about $30m for emergency procurement of ARVs. UNICEF mainly supported PMTCT and EID services. WHO supported the HSR for HIV, HBC policy and capacity building for ART. UNFPA supported MARPS related HIV activities. Overall 90% of the Health Sector HIV activities were supported by PEPFAR through USAID and CDC. Six new – 5 year projects were funded USAID; the SUSTAIN project replaced TREAT which was under JCRC while the latter got the THALAS project; MJAP got a new HCT project for 22 districts; EGPAF, got STAR-SW while STAR –E and STAR EC were awarded to MSH and former UPHOLD projects. A new supply chain project - SURE commenced this year. Those supported through CDC will start in 2010/11. GoU funded ARVs procured from CQIs and supported internal travel and operational costs for the ACP. 70 Annual Health Sector Performance Report Several research studies were conducted or completed. Examples include; i) Planning for the 2010 AIDS Indicator Survey was in final stages ii) Sex and Reproductive Health Choices supported by UNFPA iii) Commercial Sex Workers HIV/RH study iv) Condom Mapping v) HIV EWI survey 2009 vi) Fishing Community HIV prevalence Survey vii)The HIV Health Sector Review (HS HSR) was conducted for the first time in Uganda. viii) The Refugees HIV study ix) 2009 ANC surveillance samples were collected from 24 sentinel sites.

Table 3.15: Achievements of the ACP over the HSSP II period Indicator 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 HSSP II target Proportion of population with Comprehensive 90% 36% (UDHS AIDS 95% knowledge (proportion of population who cite 2 correct (HSSP II 2006) information methods of HIV prevention and reject the 3 common estimate) survey due misconceptions of HIV/AIDS transmission) 32% (UHSBS 2004/05) Prevalence of HIV among women attending ANC 6.20% 6.20% 9.70% 7.00%5-10% 3% ANC surveillance data (2008) Prevalence of HIV among the general population 6.2% (HSSP II 6..3 [5.9-6.8] 6..3 [5.9-6.7] 6..2 [5.8-6.7] 6..2 [5.8-6.7] AIDS 3% estimate) information survey due Proportion of HC III offering VCT services 0.1 - - 0.46 0.5 90%[1] 1

Proportion of HC III offering PMTCT services No data 0.2 0.29 0.45 0.68 0.38 0.5

Proportion of HC IV offering comprehensive HIV/AIDS No data No data 0.65 0.83 0.9 0.83 0.75 care with ART

Challenges Inadequate health systems hindering the expansion of PMTCT service points at HCIII levels Recommendations

1. Develop HIV Health Sector HIV Strategic Plan 2 (HSHASP2) taking into considerations the findings from the Health Sector HIV Review.

Annual Health Sector Performance Report 71 2. Strengthen ACP management and leadership for more effective cordination of Partners and Programmes. 3. Increase numbers of people on ART by 50,000 in 2010/11 4. Begin the implementation of Virtual Elimination (VE) of mother to child transmission of HIV 5. Develop a better R10 – GFATM proposal

3.3.2 Tuberculosis

Tuberculosis remains a major public health problem in Uganda. According to the 2009 WHO Global TB Report, Uganda is ranked 16th among the 22 high burden countries. In addition, the country has an emerging multi drug resistant TB (MDRTB) problem; and a high HIV prevalence (6.4% among the general population and over 50% among TB patients) fuelling TB epidemic. Moreover, TB is the leading cause of death among people living with HIV/AIDS. At National level, TB and Leprosy Control are coordinated by the National TB Leprosy Programme (NTLP) under the Communicable Disease Division of Ministry of Health. To fulfill this mandate, NTLP formulates policies, sets standards, builds capacity, and mobilizes resources for TB and Leprosy Control in the country. At district level, TB control is integrated into Primary Health Care Services and is coordinated by District Health Teams. Tuberculosis is one of the priority diseases included in the national minimum health care package and addressed by Health Sector Strategic Plan II (HSSP II). HSSP II was aimed at reducing the morbidity and mortality due to TB, and set out to attain the following targets: DOTS targets: 70% case detection rate (CDR) and 85% cure/treatment success rate (TSR) TB/HIV targets: 80% of TB patients tested for HIV, 100% of the HIV + TB patients started on cotrimozaxole preventive therapy (CPT) and 20% on anti retroviral therapy (ART) EQA target: 80% concordance. CBDOTS target: 100% geographical coverage sustained Progress This section highlights the DOTS targets, CBDOTS coverage, TB/HIV targets and laboratory related targets NTLP, partners (including GLRA, GFATM, USAID, Italian Corporation and WHO) and districts achieved over the HSSP II period. These are summarized in table XX below. DOTS (CDR and TSR) targets: There was a slight increase in the case detection rate (CDR) and a fluctuation in TSR. CDR that had stagnated around 50% over the first three years increased to over 55% in the last 2 years of HSSP II. Despite the increase, the country has not attained the CDR target of 70%. The overall national TSR performance also remained low, the maximum attained being 75% in 2007/08 and the lowest being 69.6% in 2006/07. However, it is encouraging to note that 15 districts had attained the CDR target in 2009 and the number of districts attaining the TSR target steadily increased from 8 in 2005 to 26 in

72 Annual Health Sector Performance Report 2009. The case fatality rate among smear positive cases has steadily declined to 4.6% short of the targeted 3.1%. CB-DOTS coverage: The country has sustained the 100% CBDOTS geographical coverage attained in April 2005 (when training of Sub-County Health Workers and general health workers and the initial group of community volunteers/treatment supporters in all Sub- Counties in the country was completed). However, due to lack of funding the proportion of patients on Directly Observed Therapy (DOT) remains low. TB/HIV targets: Uganda adapted WHO generic TB/HIV collaborative policy in 2005/06 to guide TB/HIV interventions in the country and trained health workers in a bid to standardize implementation. All districts are now implementing & reporting on TB/HIV collaborative activities. As a result, the proportion of TB patients tested for HIV increased from 28% in 2006/07 to 77% in 2009/10, close to the target of 80%. The proportion of HIV positive TB patients started on CPT rapidly rose from 4% in 2006/07 to 86% in 2009/10; this was short of the set target of 100%. In addition, 22% of TB/HIV patients were started on ART. This surpassed the set target but remains a challenge since the recent WHO recommendation is to start all HIV positive TB patients on ART as soon as it can be tolerated.

Table 3.16: Achievements of the TB control programme

Target outputs 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 HSSP II target Case detection Rate (%) 50.3 50.2 49.6 50.3 57.4 56 70 TB cure rate (%)* 73.2 71.3 69.6 75.1 70 85 Proportion of deaths among 6.9 5.5 5.7 4.7 4.6 3.1 newly registered smear positives per year (%)* Coverage for CB DOTS (%) 100 100 100 100 100 100 100 Proportion of TB cases 27.6 39.1 59.1 77 80 notified who are tested for HIV among all TB cases per year (%) Proportion of TB/HIV co- 52.5 66.6 77.2 86 100 infected patients offered Cotrimoxazole Prophylaxis Therapy (CPT) among all TB cases notified per year (%) Proportion of TB/HIV co- 13.1 15.8 21.6 22 20 infected patients receiving Anti-Retroviral Therapy (ART) among all TB cases notified per year (%)

Source: NTLP Quarterly and Annual Disease Surveillance Reports. * Treatment outcomes (cure and death rates) are obtained after a year

Annual Health Sector Performance Report 73 Laboratory related outputs: The National TB Reference Laboratory (NTRL) instituted external quality assurance (EQA) for Sputum smear microscopy in 2008/09 using blinded rechecking with first controller at district level and second controller at NTRL and feedback provided to DTUs quarterly. EQA now covers 97% of microscopy centers; and has improved their proficiency increasing concordance to 87% above the target. EQA also reduced the level of high false negatives (HFN) from 22% in 2008 to 10% and high false positives (HFP) from 12% in 2008 to 2.5% (target HFN and HFP less than 5%). However, the proportion of labs involved in EQA keeps fluctuating and declined to 70% in the third quarter and 35.4% in fourth quarter of 2009/10.

Progress in implementing other activities Establishment of programmatic management of drug resistant TB (PMDT): During the HSSP II, NTLP and partners set out to establish a Programmatic management of MDR-TB these included: appointing an MDRTB Focal Person; developing PMDT guidelines; carrying out a drug resistance survey initiated in 2009/10 to establish the magnitude of MDRTB in the country; collaborating with Green Light Committee and securing an approval for 200 MDRTB cases for initiating treatment in the country and with GF R 6 for funding for procuring 300 courses of SLDs. In addition, Ward 5 of Mulago is planned to be used for MDR-TB management, 34 Regional Trainers and 24 health workers trained on PMDT; and a routine surveillance of drug resistant TB system22 was set up and a total of 124 (cumulative from march 2008-October 2010) MDRTB cases identified awaiting enrolment. Laboratory: The country has a network of 851 TB diagnostics facilities (DTUs), 12 Regional Laboratories and one National TB Reference Laboratory (NTRL). During the HSSP II NTLP and partners strengthened the laboratory network at all levels by renovating and equipping the NTRL and training 931 laboratory personnel (including 31 Lab technicians, 175 lab technicians, 394 Lab Assistants and 122 microscopists). Drug and Logistics Management: The TB medicines have been fully supplied up to the health unit level with no noticeable stock outs countrywide. There were LMIS trainings conducted in the districts of Pallisa, Budaka, Mbale and Manfwa. A total of 120 health workers were trained in the month of March 2010 with the support of the STAR E Project. In April 30 health workers were trained in the districts of Mbale and Manafwa with the support of the TB CAP Project; There were also training in Logistics management at Buluba Hospital for 33 health workers and new district TB and Leprosy supervisors conducted during the month of May 2010. Timeliness, completeness and accuracy of recording and reporting (quality of LMIS) is still a challenge, the new districts formed and their health centers have created a challenge in capacity at the new districts to manage TB logistics, some districts and facilities submit their bi-monthly reports and request for drugs late. The country’s reliance on donor support for procuring all anti-TB medicines has occasionally led to delays in shipment of medicines to the country; which has led to constraints in full supplies at central level. At facility level management of TB logistics system faces a challenge due to the high rate of staff attrition which leaves a massive capacity gap. 22 This involves referring sputum samples from DRTB suspects (all retreatment cases, failures of cat I and contacts of MDRTB) to NTRL for DST

74 Annual Health Sector Performance Report Partnerships: The country continued to run the Uganda Stop TB partnership introduced in 2004 to harness and coordinate partner efforts towards NTLP TB control targets. During HSSP II, USTP continued to work through its working groups, and to organize World TB Day Commemorations; the 2009/10 of which was commemorated at Uganda Prisons Luzira. USTP became a legal entity in 2009/10 TB/HIV: During the year, TB/HIV modular training guidelines were update to incorporate components on TB Infection Control, R&R. In addition, Intensified Case Finding Tools and suspect TB registers were developed and disseminated M&E: Under M&E, R&R tools were modified to capture TB/HIV indicators; quarterly reports were received from all districts; quarterly review and planning meetings were held in all zones as well as at the National level. These facilitated standardization of implementation all over the country, sharing of experiences, and cleaning of data Operational Research: • TB/HAART • Research on barriers on implementing TB/HIV collaborative activities • Situation analysis on TB/HIV in 26 districts • Situation analysis on PPM Private sector collaboration and compliance with standard treatment guidelines; Very few Private Health Providers (PHPs) are fully engaged in TB control, only three facilities in Kampala engaged fully. Data from districts quarterly reports does not capture the contribution or the level of involving the PHPs in TB control.

Challenges The major challenges that led to the non attainment of the set DOTS, TB/HIV and EQA targets can be broken down into health system, health provider and health user challenges. These included: Health System Challenges: The health system challenges can be summed as a weak health system, included: i) Inadequate national funding as evidenced by lack of a dedicated budget line for TB drugs, difficulty implementing such critical activities as support supervision ii) a weak procurement supply management system leading to repeated stock outs of test kits and drugs iii) a weak recording and reporting leading to inadequate capture of data, non evaluated cases iv) Poor access especially to ARVs both in terms of distance (there are fewer ART sites than DTUs) and old policy of using CD4 levels for determining eligibility to ARVs23.

23 As opposed to the current WHO recommendation that all HIV + TB patients irrespective of CD4 status are eligible for ARVs

Annual Health Sector Performance Report 75 v) Inadequate support supervision and therefore inadequate guidance to peripheral health workers implementing TB and TB/HIV activities vi) Policy: use of CD4 to determine eligibility for ART (note this was before the country adopted the WHO recommendation that all HIV + TB patients irrespective of CD4 level are eligible for ARVs vii)Lastly, the true magnitude of TB in the country is not known; CDR is based on estimates

Health Provider Challenges: i) Inappropriate implementation of DOTS strategy: non adherence to sputum smear to diagnose and monitor treatment leading to low sputum conversion rates and to extremely low cure rates; non adherence to DOT - only 38% of the 2008/09 cohort treated under direct observation; poor R&R; evaluation rates (91% among 2008 cohort), ii) Poor interpersonal communication skills leading to inappropriate education of patients iii) “Staff attitude”

Health user Challenges: i) Weak community support system - VHTs trained and functional in less than 25% of the districts in the country. ii) Low community awareness leading to late health seeking behavior, high mortality rates, poor adherence, unfavorable treatment outcomes (defaults, transfers) etc. iii) Poor community participation

Recommendations i) Government should increase the level of funding to TB control including establish a dedicated TB drug budget line ii) MOH/NTLP/NACP should ensure a strong referral system to increase coverage of ART and work towards integrating TB and HIV services in the same units. iii) NTLP should as first priority prevent the production and transmission of MDR-TB, through continued strengthening of the general TB program to reduce risk factors for MDR-TB to an acceptable level, such as adequate DOT, regular drug supply and infection control; then establish and sustain PMDT iv) The monitoring visits by SCHWs would support communities implement CB-DOTS thus enhance treatment completion and monitoring. v) Increased awareness would also lead to reduced stigma associated with TB and TB/HIV.

76 Annual Health Sector Performance Report 3.3.3 Prevention and control of malaria

The control of Malaria was critical in HSSP II as one of the leading causes of morbidity and mortality in Uganda. At the outset, Malaria accounted for 25-40% of outpatient visits, 20% of inpatient admissions and 9-14% of inpatient deaths in public and private-not-for-profit health facilities. Malaria and malaria-related illnesses contribute 20-23% of deaths among children aged less than five years. Some of the reasons for this poor state included: limited access to adequate treatment of malaria/fever; increasing resistance of malaria parasites to medicines; and incorrect and/or inadequate malaria treatment at home or within communities. Due to improved reporting, many cases are now being reported which may account for the increased number of cases in this FY 2009/10.

Figure 3.8: Malaria cases seen in OPD from 2000/01 to 2009/10

Source: HMIS/Resource Centre, Ministry of Health

The mainstay of intervention strategies for malaria included prompt and effective case management at facility and community levels using Artemisinin-Based Combination Therapy (ACTs); use of insecticide treated mosquito nets; indoor residual spraying with efficacious insecticides; intermittent preventive treatment in pregnant women; epidemic preparedness and response; and IEC/BCC, Monitoring & Evaluation & Research and Health Systems Strengthening which cut across all the interventions.

Annual Health Sector Performance Report 77 Table 3.17: The performance of the Malaria specific HSSP II indicators over the past five years Target outputs 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 HSSP II Baseline target Proportion of pregnant women who 34 37 42 42 44 39.6 (HMIS) 80 have completed IPT2 (%) (HMIS) (HMIS) (HMIS) (HMIS) (HMIS) 31.7UMIS) Proportion of households having at 15 16 16 42 46.7 54 70 least one insecticide treated net (%) (NMCP) (UMIS) (UDHS) (UDHS) (NMCP) Proportion of households in 6 0 0 95 95 97 99 80 targeted District sprayed with IRS (NMCP) sprayed (%) (NMCP) (NMCP) (NMCP) Proportion of children under five 25 60 71 71 No data 13.7 80 getting correct treatment within 24 (NMCP) hours of onset of symptoms (%) (NMCP) (UMIS) Percentage of uncomplicated fever/ 55 60 71 71 No data 13.7 85 malaria cases (all ages) correctly (NMCP) managed at health facility (%) (NMCP) (UMIS) Case fatality Rate (%) 4 4 No data 3 (HMIS) 2 1.4 2 (HMIS) (HMIS) Percentage of health facilities 50 50 35 35 50 No nationally 80 without any stock-outs of first line (NMCP) (NMCP) (NMCP) representative anti-malaria medicines (%) (NMCP) data

Progress on targeted outputs for 2010: 1. Proportion of pregnant women who have completed IPT2 (%) In order to reduce maternal morbidity and mortality as well as improve the newborn’s chances of survival malaria in pregnancy remained an essential part of the malaria control strategy in Uganda with the three elements of i) Intermittent preventive treatment (IPT) using the Directly Observed Treatment (DOT) strategy ii) Prevention with ITNs distributed through ANC services iii) Prompt treatment of clinical malaria episodes with drugs or drug combinations appropriate for the stage of pregnancy. Achievements to date include: i) Scaling up of IPT to all antenatal clinics in Uganda ii) Introduction of the pre-ruled integrated antenatal register which enabled facility recording and monitoring of IPTp uptake at health facilities. iii) New Policy and Guidelines: In order to minimize missed opportunities, the IPTp policy was revised to widen the period when an expectant mother can take SP for IPTp. It was recommended that SP could be taken between 16 weeks of gestation and term (when woman delivers: 40-42 weeks). The guidelines also removed the old contraindication of the concomitant use of SP and folic acid. Furthermore, guidelines offered flexibility in methods of ensuring the directly observed therapy (DOT) of SP- IPTp where a client can now use any safe drink (e.g. milk, soft drinks, sachet water,

78 Annual Health Sector Performance Report

tea etc) to uptake the drug. Because of these changes, more women are now taking SP-IPTp under supervision in the country. iv) Some of the Partners working in this area and making contributions to the national achievements include the Uganda Health Partnerships communities’ partnership (UMCP) which provided advocacy and communication package in the West Nile region; NUMAT which distributed a total of 150,000 LLINs and achieved an IPT 2 coverage of 48% in the Acholi and Lango regions; AMREF in and the Stop Malaria Project in 15 of the Central Uganda Region, Mid Western and Teso region Districts. The Proportion of pregnant women who completed IPT2 increased slightly and stayed at 42% between 2007/8 and 2008/9 and later dropped slightly to 39.6. IPT2 coverage was found to be at 31.7 countrywide by the Uganda Malaria Indicator Survey (UMIS) of 2009/10.

2. Proportion of households having at least one insecticide treated net (%) The proportion of households having at least one insecticide treated net (%) increased steadily over the years, from 16% in 2006/7 to 46.7% by the end of 2009 (UMIS) and achieving an operational coverage of 53.1% for the proportion of House Holds having at least one net by the time of reporting in 2010. This compares well with the Operational achievement for Universal coverage at 51% (8.24M nets distributed over the past three years divided by the current population). Also from the UMIS, the proportion of under fives who slept under an ITN the previous night was 33% while that of pregnant women was 44%.

Table3.18: The implementing partners and funding sources for nets. Implementing Partner No. LLINs Funding source Method of Districts served No. of S/C distributed distribution covered AFFORD July-October 282,236 PMI Campaign 35,137 LLINs were 2009 targeting sleeping distributed Kaberamaido, rooms 15,350 in Kumi, 116,610 4 in Manafwa and 8,319 in 1 Soroti and 175,416 in Mbale. 8 1 8 Malaria Consortium 66,342 PMI Campaign Moyo (Moyo 14,948; 2 Uganda(UMCP), July targeting one per Itula 8,018 total 22,976) sleeping space Yumbe Lomogi SC 20,400 Nets 1 Malaria Consortium 17,525 PMI campaign as the last Only Panyimur Uganda(UMCP) targeting one net district in the project area sub county in per sleeping place Nebbi received LLINs in October 2009 12,000 Adjumani Cipholo S/C Malaria Consortium Hoima- Comic Relief Campaign 3 districts, All sub- counties Uganda Hoima(November 2009), in the two (311,065) Of UK Bullisa (December 2009) districts attaining Hoima (one net and Kiboga (March 2010) universal per sleeping place coverage

Annual Health Sector Performance Report 79

Implementing Partner No. LLINs Funding source Method of Districts served No. of S/C distributed distribution covered Bullisa- and one net per two persons in (92,0000) 87,986 Bulisa & Kiboga)

Kiboga- (201,290) Global Fund Sub 1,481,050 GFATM/PMI Targeted 13 Central region districts GAFTM nets Recipient CSOs/Stop campaigns to PW (less Kiboga, Kampala distributed to all Malaria Project/PACE & U5s and Wakiso) sub counties using the PMI funding Commercial sales 12,540 Nets Central and Eastern Uganda Global Fund Sub 2,844,950; GFATM Western 1,854,850 Recipient CSOs/Stop Kampala, Wakiso Malaria Project/PACE Kampala 492,750 (ADRA) 497,350 Wakiso (CHS)

TOTAL 2009/10 5,316,983 Total per Capita The current National Operational Coverage of House Holds with at increase 7.3% least one ITN (LLIN) stands at 54% (NMCP).

3. Proportion of targeted households with IRS sprayed (%) Objectives & targets: i) To attain at least 85% coverage of the targeted households with IRS. ii) To develop capacity at national and district levels to implement effective IRS. Implementation strategies/approaches: i) IRS has been applied in both endemic and epidemic prone areas in a systematically phased manner using WHOPES approved insecticides and involved: ii) Macro-planning, budgeting and procurement of IRS logistics at national level iii) Micro-planning and resource allocation for IRS implementation at district level iv) Advocacy, Social Mobilization and Community mobilization and sensitization at various levels (IEC/BCC activities) v) Baseline entomological, epidemiological and environmental studies vi) Training of spray personnel vii)Implementation of spraying including supervision and monitoring quality of spraying viii) Post-IRS activities including post-IRS evaluation activities, report writing and feedback to local district leaders Achievements: i) High community compliance and acceptance of IRS ii) High spray coverage rates of >85% of targeted houses in all 10 districts so far sprayed iii) >3.1 million people protected in past 1 year (July 2009-June 2010).

80 Annual Health Sector Performance Report

iv) A rapid decline of malaria cases (OPD Attendance); parasitaemia, and health facility admissions v) Trained and re-trained 5,792 spray personnel in 2009/2010 FY (DHT members, Subcounty supervisors, Team leaders, spray operators, storekeepers and wash persons) Table 3.19: Performance of IRS 2009-2010 Indicator Kitgum Pader Apac Oyam Amuru Gulu Kumi TOTAL Round 4 Round 4 Round 2 Round 2 Round 2 Round 2 Round 1 (Nov-Dec (Nov-Dec (Mar-Apr (Feb-Mar (Mar-Apr (Apr-May (Jul-Sep 2009) 2009) 2010) 2010) 2010) 2010 2009) Houses 162,799 173,653 151,182 111,548 107,894 115,279 106,073 928,428 Found Houses fully 157,982 172,681 151,179 110,985 107,719 111,976 105,012 917,534 & partially sprayed % House 97.04 99.44 99.9 99.5 98.8 Coverage 99.8 97.1 99 Targeted 593,666 667,999 439,707 316,088 360,301 389,158 354,900 3,121,819 Total Population Population 593,666? 664,787 439,702 314,554 359,874 379,873 356,670 3,109,126 Protected % Population 97.5 99.5 100 99.5 100 97.6 99.5 99.1 Protected

NB: Original Government plan targeting 24 epidemic, border/post conflict districts and peri- urban centres in 5 major towns with funds from Government, PMI and Global fund round 9 did not materialize. This was because the Global Fund application for funding did not succeed, and yet there were no immediate mechanisms for Government to pick up the whole bill. Table 3.20: IRS Personnel Trained in 2009/10 Type Kitgum Pader Amuru Gulu Oyam Apac (Jan Kumi Total (Feb 2010) 2010) (Oct 2009) (Oct 2009) (Feb 2010) (Jan 2010 Jul-Sep ) 2009 Supervisors 21 26 19 28 14 36 22 166 Team Leaders 101 114 58 86 61 108 51 579 Wash Persons 71 80 36 54 58 68 33 400 Spray Operators 711 796 481 692 722 713 307 4,422 Storekeepers 24 28 32 18 41 16 11 170 DHT 9 10 8 8 4 6 10 55 Total 937 1,054 634 886 900 947 434 5,792

In addition to the above districts, boarding institutions, Army and Police Barracks were also sprayed using Lambdacyhalothrin 10% WP. The numbers of Police Barracks sprayed in 2009 were 30 as indicated here-below.

Annual Health Sector Performance Report 81

Table 3.21: Uganda Police Barracks Sprayed from June to August 2009 No. Region No of Barracks Barracks Name 1 Central 03 Nakasongola, Mityana, Mubende 2 South eastern 02 Jinja, Iganga 3 Eastern 01 Mbale 4 Mid Eastern 01 Soroti 5 North Western 01 Arua 6 Western 02 Kabarole, Kasese 7 South Western 01 Mbarara 8 Mid western 03 Kabalye PTS, Masindi PTS, Masindi barracks 9 Southern 01 Masaka 10 Kampala 15 Naguru, , Kireka, , , Old Kampala, Kira Metropolitan Road, , Jinja Road, PTS , , Mukono, Entebbe, Bombo, Luwero Total 30

African Field Epidemiology Network (AFENET) under the auspices of the Avian Influenza and other Zoonotic Infections Project (AIZIP) worked together with MOH and Districts DHT members to conduct IRS in order to prevent and avert Plague outbreak as well as control malaria in Arua and Nebbi districts in NW Uganda. IRS was carried out in 25 worst hit and susceptible villages to plague outbreaks in the last back to back outbreaks in the five sub counties in Nebbi and Arua districts. The sub counties so selected were: Kango, Jangokoro and Zeu in Okoro County, Nebbi district; Logiri and Sub counties in Vurra County, . Results: A total of 625 homesteads in Arua and 549 in Nebbi district were sprayed by the team giving a total of 1174 households sprayed. All the five sub counties in the two districts benefited from this exercise. 22 or 88% of the 25 villages were sprayed between 23rd September and 20th October 2009

4. Proportion of children under five getting correct treatment within 24 hours of onset of symptoms (%) Performance on this indicator which was doing well at 71% using HOMAPAK, a combination of Chloroquine and Fansidar (SP) suffered after the change of policy to ACTs, in 2006. But the effects were most pronounced in 2007/9, when, because of suspension of the major source of funding (Global Fund Round 4 Phase II) the planned roll out of ACTs to the community level to replace HOMAPAK did not happen as planned. However, pockets of partner funding continued to sustain these efforts in the Districts of Kiboga (Malaria Consortium) and the Acholi region (UNICEF). The numbers of children involved were so minimal compared to the previous performance. The projects finally wound down in 2008 because of late release of the GF Round 4 Phase II grant which had been envisaged to sustain these efforts towards the end of the projects. Following the recent release of this grant, the roll out of ACTs to community level will finally occur early in the FY 2010/11.

82 Annual Health Sector Performance Report The proportion of children under five getting correct treatment within 24 hours of onset of symptoms (%) leaped from 25% to 60% in first year and then increased and stayed at 71% for the next two years (2006/7 and 2007/8). In 2008/9 there was no data as the planned ACT roll out to the communities did not happen. In a related event the recently concluded UMIS found that 36% of children aged less than five years took antimalarials on the same day they developed symptoms while only 13.7% accessed ACTs the same day.

5. Case fatality Rate (%) The Case Fatality rate is an impact indicator whose performance is not completely within the control of the NMCP but can be largely influenced by an interaction of all Malaria Control and Prevention interventions in scope and scale. This includes the health systems response to uncomplicated and severe malaria cases as well as availability, access, equity of services. On the other hand community awareness and use of these services also have a lot to do with the case fatality rate. The HMIS has consistently shown achievements toward the target of 2, and by mid 2010 the case fatality rate is 1.4. However, this data should be taken with caution as only 44% of the population seeks care from the Public and Private not for profit health facilities from which HMIS is compiled. The rest of the deaths occur in the community and are not captured. In addition, the accuracy and validity of figures reported has been weakened over the years by challenges of poor in-patient and incomplete reporting from hospitals and Districts respectively.

6. Percentage of health facilities without any stock-outs of first line anti-malaria medicines The proportion of health facilities without any stock-out of first line anti-malarials (ACTs) has been unstable, first showing a decline from 50% to 35% in the first two years, then back to the baseline value in 2008/9. This financial year there has been no nationally representative data on this indicator. In the absence of routine funding for nationwide supervision, data on this indicator has been largely dependent on PMI partner efforts, especially the Stop Malaria Project in Central Uganda as well as NUMAT in the Acholi and Lango regions. There is therefore no nationally representative data on this indicator.

7. Additional Efforts Case Management i) SMP conducted training of health workers in the case management of severe malaria in four districts in the Teso region, namely Kumi, Amuria, Kaberamaido and Soroti. A final report including the final numbers trained will soon be available. The training utilised trainers based in that region. Job aides on severe malaria were distributed during the trainings. ii) District health team meetings were conducted in the same districts in the Teso region, where policy changes in the management of complicated and uncomplicated malaria cases both in adults and children were discussed. iii) Pre-referral training for severe malaria case management in Nakasongola, Mukono, Kiboga and Wakiso districts were conducted. Health workers targeted were from HCIIs and HCIIIs, with the cadres trained including clinical officers, registered nurses and midwives. A final report will soon be available.

Annual Health Sector Performance Report 83 iv) Twelve central level trainers were trained in the management and clinical audit of severe malaria, who then trained district trainers in five districts trained in the management and clinical audit of severe malaria. Clinical audits on the management of severe malaria for the health workers at hospitals and health centre IVs in 4 project districts (Mukono, Wakiso, , and Nakaseke) were conducted. v) Severe malaria clinical audits conducted at 29 referral level (hospitals and HCIVs) in 5 districts. vi) In total, 320 severe malaria management posters were produced and disseminated in 4 districts. vii)Technical support was provided in order to review the HMIS in line with NMCP monitoring needs. Weekly malaria monitoring indicator tools were developed and incorporated into the HMIS. The reviewed HMIS final documents are expected to be out in the next quarter.

Malaria Diagnostics (i) Malaria Microscopy Training: The Ministry of Health, Malaria Control Program with support from PMI and SMP/Jump is strengthening capacity for malaria microcopy in 14 districts of Soroti, Bukedea, Kayunga, Mukono,Wakiso,Rakai, Sembabule, Mityana, Mpigi, Luwero, Nakasongola, Nakaseke, Kiboga, Kibaale, Buliisa and Masindi districts. The training approach used includes building capacity at district level developing a pool of district trainers who are full time Government employees. These are charged with responsibilities of training laboratory workers in lower level health units.

(ii) Microscopy External Quality Assurance Program: The Ministry of Health, Malaria Control Program worked with the Central Public Health Laboratories with funding from Malaria Consortium to pilot malaria slide re-checking scheme in 5 districts of Hoima, Masindi, Buliisa, Kibaale and Kiboga. The Estimated population in this region is 2.2m and Malaria accounts for > 40% of outpatient cases. A total of 5 Labs (4 Hosp, 9 HCIV, 37 HCIII) was enrolled to participate in this program.

(iii) WHO supported Regional Quality Assurance Scheme (RE-QAS): The World health Organisation through ARMREF supports Malaria Microscopy Quality Assurance through panel testing program. Under this scheme, standard known malaria slides prepared centrally are distributed to participating laboratories for reading. Results are processed, analyzed and feed back sent, sometimes with a call for corrective action. Selected Laboratories from all the five East African Countries including Zanzibar participate in this program.

(iv) Global fund Round 4 RDT implementation: The Ministry of health received Funding from the GFATM of about 2 million USD to fund the procurement of 1.4 million RDT tests and train 5000 health workers in 17 districts across the country. Significant progress has been made towards the implementation of this grant with the major activities accomplished being Training of National RDT TOT team, as well as Printing of RDT manuals, guidelines and job aids. There are still challenges with procurements of tests which is a major source of delay in implementation.

84 Annual Health Sector Performance Report IEC/BCC activities i) Successfully held World Malaria Day events which included a Prayer breakfast with parliamentarians, and Grand rounds in , Mbarara, Kampala International and Gulu Medical Schools. Among the other activities was the scientific symposium which attracted a wide range of papers presented and discussed among research, public health and Clinical specialists and practitioners for the first time in the history on NMCP. The other was the World Malaria day event, attended by many dignitaries and at which Round 7 Phase 1 Net distribution was officially flagged off by the Minister of Health who stood in for the Vice President of the Republic of Uganda. ii) Completed, printed and distributed Leaflets on ACTs (250 pieces in English and Local languages each), one communication strategy for Malaria Control 2006-2010, one Social Mobilization guide for HBMF, 20 posters on Malaria treatment using ACTs (for health facilities), 20 flow chart for Malaria in pregnancy, 20 World Malaria day Posters, 30 Community Health Promotion handbooks and 30 Posters on malaria in pregnancy in the local language in 60 of the Districts in Uganda this year. iii) Supported advocacy, communication and social mobilization including 30 Radio spots and radio talk shows per district for LLIN distribution in Central, Western Regions as well as Kampala and Wakiso Districts. In the same way supported IRS activities in Abt districts of Western Uganda. Some of this work was done in conjunction with MACIS, UHCP and other partners.

M&E & Health Systems Strengthening The NMCP is in the final stages of releasing the report for the first Uganda Malaria Indicator Survey which has provided authentic statistics to use as baselines and future benchmarking of Malaria Control and Prevention performance in Uganda. National and District M&E efforts have also been boosted through the works of the CLOVER project at the Resource Centre, NMCP M&E Unit and in the districts of the South Western/Hoima and Teso regions. Amongst other activities they supported training of staff, computerization, communication with lower health facilities and installation of data management soft ware.

NMCP Programme Management i) Convened three out of four Quarterly Roll Back Malaria Partnership meetings inclusive of a Five day re-treat in an attempt to forge a new strategic direction for Malaria Control and Prevention in Uganda. An Aide Memoir was reviewed, agreed upon and is in the process of being signed by all partners and officially endorsed by the Ministry of Health authorities. ii) Successfully hosted a five day Eastern and Southern African Regional Network for Roll Back Malaria meeting in Imperial Resort Hotel, Entebbe. iii) There is a new Programme Manager in the names of Dr. Seraphine Adibaku who started work in May 2010. Dr. Peter Okui is the new National Coordinator for Case Management within NMCP and beyond.

Annual Health Sector Performance Report 85 Major challenges (i) Human resources a. There was only skeleton staff in most of the health facilities where severe malaria and pre-referral training was planned thus fewer health workers were trained than initially hoped. b. Several staffing gaps exist at all levels; health facility, district and zonal/regional office therefore there is limited human resource capacity at the district and regional levels for direct services delivery and overall coordination of NMCP strategic work plan c. The weak capacity to deliver the services at the facility level and the clinicians’ malaria diagnosis and treatment approaches that largely hinge on clinical presentation, as a basis for diagnosis & treatment (presumptive case management). d. Changes in NMCP top staff have at times delayed decisions and activities to be implemented. There are also significant human resource constraints in terms of staff numbers at many of the facilities (ii) Medicines and diagnostic supplies a. There remains a lack of ACTs, SP and other supplies in many health facilities. Chronic shortage of malaria medicines, especially the approved 1st line medicines - arteminisine based combination therapies (ACT). Available supplies have not been able to adequately meet the health facility level needs. The HBMF services have remained stagnant, as a result. Selected village health team members (VHT) volunteers, two per village, have been trained as community medicine distributors. However, not much has been accomplished beyond the trainings. b. Limited access to adequate treatment of malaria/fever; increasing resistance of malaria parasites to medicines; and incorrect and/or inadequate malaria treatment at home or within communities. (iii) Diagnosis of malaria a. Malaria diagnostics is currently only funded by Partners which may not be sustainable b. Low quality slide reading were observed in some districts due to poor quality microscopes and lack of effective laboratory external quality assurance system. c. The major challenge now is the delay in procurement of the 1.4 Million RDT tests for implementation in 22 districts. d. Delayed release of funds for Round 4 Phase II implementation of roll out activities for HBMF and training of RDT implementation in the targeted Districts. This is putting the grant which is already in class C at risk of being cancelled. Procurement of vital commodities for implementation of this grant have also been delayed by internal bureaucracy and slow procession of requisition within the Ministry of Health.

(iv) LLIN Distribution a) Preventing data corruption in served areas (village registers often miss out/over register residents); stepping up BCC could be of help but usually not

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given sufficient resources (funds &time). Focus should be towards promoting universal coverage distributions to minimize data inflation. b) Sustaining a vibrant commercial market as the main stay of LLINs program for sustainability; support in form of commercial subsidies extended to major importers and distributor helped to strengthen this sector but this stopped with the closure of NetMark and AFFORD. There is need for partner support towards the commercial sector as the main stay of LLINs beyond free distributions. c) Increasing correct use of LLINs proportionally with the apparent increasing ownership; the UMIS conducted November 2009 still shows almost 50% gap from the targeted 80% usage. There should be deliberate effort to narrow this gap in order to realize the full net gains. (v) Indoor Residual Spraying a. Sustainability of IRS: Currently, IRS is largely donor dependent b. Development and spread of insecticide resistance to public health insecticides in Uganda c. Wide distribution of LLINs without knowledge of Pyrethroid resistance patterns in the country because of absence of sustainable M & E due to inadequate funds d. Implementing IRS in diverse cultures, political orientation and social beliefs e. High cost of transportation of spray operators (SOs) (vi) Finances a. Lack of funding for support supervision country wide which has also contributed to the non-functionality of Zonal Malaria Coordinators (vii) Reporting a. Late and incomplete services data submission through HMIS system. b. The delays in the release of HSSP III and HMIS reviewed documents have led implementation of HMIS strengthening activities to be postponed. Recommendations i) Human Resource: The Ministry of Health should work closely with the Ministry of Public service to accelerate release of the revised staffing norms so that adequate staff can be recruited. There is also need to review working conditions within districts so that staff can be attracted to stay and work within the Districts. The staffing levels within the NMCP also need to be reviewed in line with the current workload and importance of the burden of Malaria ii) Medicines and diagnostic supplies: There is need to improve effectiveness of NMS and NMCP in communicating and coordinating procurement and distribution of ACTs and other supplies to districts and health facilities as well as improve the strength of the linkages between the two organizations to improve systems for ensuring a reliable supply of ACTs to the health facilities country wide. 5 Regular supply of drugs (Fansidar) will improve the uptake of IPT1 and IPT2 since since more pregnant women will be able to access the drugs.

Annual Health Sector Performance Report 87 iii) Global Fund Round 7 LLIN distribution through CSOs a) More time should be allocated to training the CSOs on logistics and finance management (a full day in the training should be dedicated to this) b) To address the variances often seen between UBOS population estimates and actual population data, where funds and time allow, the registration exercise should take place several weeks ahead of the distribution in order for micro-planning activities to be based on actual population numbers. There should be ample time allowed from the end of the registration exercise to the onset of the actual distribution to allow for actual planning and preparation based on reliable information. c) Ample time should given be given (not less than 3 weeks) to have all materials procured, packed and labelled before distribution. d) The training should be split into two phases; one to focus on the registration just before the registration exercise and the second on distribution process. e) The hang up form should be simplified to be better understood by the VHTs. The purpose of the exercise also needs to be clarified in the Training Manual. f) An evaluation of the social and mobilization activities, pre, during the post distribution, is recommended. g) During the CSO training, the different parts of the report and the information required in each should receive additional emphasis in order to have timely and completion of reports.

iv) For Round 4 Phase 2 implementation to improve to a level that can redeem the grant, there is need to improve on the bureaucratic procedures within the Ministry of Health and those concerning procurement of the necessary supplies and services. v) Regular provision funding for country wide support supervision as well as analysis, dissemination, feedback and use of data collected from this exercise will go a long way in proving delivery of Malaria Control and Prevention services. vi) GOU and partners should increase funding for IRS in order to expand IRS coverage in the country especially in the highly malaria endemic areas in order to drastically cut down malaria transmission thereby contributing to its elimination the country. vii)The country should consider Implementing Integrated Vector Management (IVM) approach (i.e. use of IRS, LLINs, Larviciding, Environmental Management Control Measures). viii) There is need for efforts to strengthen systems for reporting through dissemination of the revised HMIS, and cascade countrywide training on supervision, monitoring and evaluation while taking into account the mechanisms to address weaknesses afflicting the reporting systems currently.

88 Annual Health Sector Performance Report 3.3.4 Veterinary Public Health

The mission of the Veterinary Public Health (VPH) unit is to reduce the burden of zoonotic diseases and animal related food borne infections to a level where they are no longer of significant public health importance in the country. A number of diseases that have emerged and/or re-emerged globally in the last 15 years have been zoonotic (i.e. of animal origin ); for example; Avian influenza/ Bird flu, Rift Valley fever, Severe Acute Respiratory Syndrome (SARS), Mad Cow Disease /Bovine Spongiform Encephalopathy), Viral heamorrhagic fevers, (Ebola and Marburg fever). The country is also burdened by new pandemic threats such as Influenza HINI as well as long established zoonotic diseases like rabies, bovine tuberculosis, plague, brucellosis, anthrax, meat borne parasitic diseases (cysticercosis and hydatidosis). All these zoonotic and emerging diseases cause significant morbidity and mortality and are therefore of major public health concern in Uganda. The VPH Unit contributes to the overall mission of the health sector through prevention and mitigation of the impact of these zoonotic diseases thereby improving the health and well being of the Ugandan population. 2. Progress on implementation of interventions Planned in HSSP II

• In FY 2009/10 Ug.shs. 175 million were secured for procurement of human rabies vaccine through the National Medical Stores for post-exposure prophylaxis to rabies suspects in the country. • Reduction of the burden of emerging and zoonotic diseases was undertaken through a number of strategies, such as developing guidelines, training, public awareness and implementation of prevention and control for a number of zoonotic diseases such as: Rabies: This was achieved through the Urban Rabies Control Initiatives (URCI) conducted in two Kampala City Council divisions and organizing activities for the World Rabies Day globally commemorated on 28th September annually. Pandemic influenza type A H1N1: Public awareness campaigns were coordinated and implemented throughout the outbreak of the disease in the country (July 2009 to January 2010). Brucellosis: The VPH unit in collaboration with Central Public Health laboratory (CPHL) conducted assessment of laboratory diagnostic protocols for brucellosis in Masaka Regional Referral Hospital, Kitovu Hospital and in .

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Table 3.22: Veterinary Public Health key outputs –FY 2009/10 HSSP 11 target/ 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 Data Source indicators

Number of human 11,846 13,000 9,600 1,500 4,048 8,750 VPH reports rabies vaccine vials procured

Number of suspected 2,962 3,750 2,820 1,012 1,325 Rabies post- cases given rabies exposure post-exposure 420 treatment treatment reports

Reporting of cases of 44 56 70 75 Weekly zoonotic diseases IDSR 64 73 reporting.

Quarterly 4 4 4 4 4 4 VPH Unit performance reports

Technical Support 9 7 6 6 12 14 VPH reports supervision to districts

j Major challenges There is gross understaffing within the department and there is urgent need to recruit of more professionals. There is a twofold under funding for the purchase of human rabies vaccine. Recommendations Increase staffing of the VPH Unit during the process of restructuring the Ministry. The National Medical Store should allocate more funds for human rabies vaccine.

3.3.5 Diseases targeted for elimination

3.3.5.1 Uganda Guinea worm eradication programme

Dracunculiasis is one of the diseases targeted for eradication nationally and globally. Uganda achieved this goal and the country was certified free of dracunculiasis in 2009 by the World Health Organization. However, the country still faces a challenge of cross-border importation of guinea worm cases from Southern Sudan, the only neighboring country still endemic for the disease.

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Achievements The following were the main achievements of the programme during the FY 2009/10. i) No cases of guinea worm (indigenous or imported) reported during the financial year. ii) Guinea worm surveillance was fully integrated into HMIS and IDSR. Active surveillance conducted in 74 at risk villages in the 15 districts bordering Sudan iii) Technical support supervision conducted in all formerly endemic districts. iv) NCC had all scheduled meetings and field visits to the formerly endemic districts. v) All reported rumors of suspected cases were investigated and all proved to be false cases. vi) Inter-district coordination meeting held in Lira. vii)Mapping of populations at risk of importation of the disease from S.Sudan achieved. viii) Printing of reward posters and post cards to assist in advocacy and social mobilization of communities about the disease. The specific indicators set during the HSSP II were all achieved as shown in the table below.

Table 3.23 : Achievements of the Guinea worm eradication programme Indicator 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 baseline

No transmission Achieved Achieved Achieved Achieved Achieved Achieved

100% containment of Achieved Achieved Achieved Achieved Achieved Achieved imported cases

Challenges The following challenges have continued to affect the operations of the programme:- (i) Threat of cross-border importation from the Southern Sudan (ii) Dwindling resources to UGWEP at this stage of post certification. (iii) Lack of maintenance of boreholes in some of the formerly endemic villages. Way forward. During the FY 2010/11, the programme will consolidate post certification interventions to check potential threat of imported cases from Southern Sudan. The main focus will be on the cross- border collaboration with S.Sudan; rumour registry and investigation; strengthen the capacity of village health teams for community based surveillance and case search for any rumours in all formerly endemic districts; support supervision & monitoring at all levels; advocacy & community mobilization; maintain cash reward system to ensure vigilance and lobbying for more safe sources of drinking water supply. Conclusion The programme will continue to submit the monthly data on guinea worm to the World Health Organization as required until global eradication of the disease has been achieved.

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3.3.5.2 Leprosy control programme

The objective of the programme during the HSSP II was to further reduce the leprosy elimination status to less than 1 case for every 10,000 population and to reduce the rate of grade 2 disability among the newly diagnosed cases to less than five (5%). During the HSSP II period, prevalence rate was further reduced from 0.16 in 2006/07 to 0.13/10,000 populations in 2009/10. It would have been even lower if all patients who completed the treatment schedules had been released from treatment and removed from treatment registers. The proportion of new cases with grade 2 disabilities has almost doubled when compared to 2005/06, which is reflection of a delay in case detection. This may be attributed to lack of awareness among the population and lack of knowledge as well as appropriate skills among health workers to recognize and manage leprosy cases.

Figure 3.9:The distribution of new Leprosy cases and highlighting the “Leprosy hot spots” in red

Sudan NTLP UGANDA New leprosy cases detected during Moyo Yumbe 8 Kitgum 2009 17 21 Total number = 346

Kotido Adjumani 4 Arua 4 35 Pader Gulu 10 n = number of new leprosy cases 26 Moroto 12 Nebbi 2 Lira 40 Democratic Apac Katakwi 34 0 Masindi Republic of 11 Kaberamaido Nakapiripirit 2 Congo Lake Albert 0 Soroti Kumi Hoima Nakasongola 5 20 Kapchorwa 6 4 0 Kamuli Sironko Kiboga 2 Pallisa 4 No new cases Bundibugyo Kibaale 0 2 Mbale 4 Luwero Iganga 1 to 9 0 Kayunga Tororo 1 2 0 2 02 10 to 19 Kabarole Kyenjojo Jinja Mubende Bugiri 1 0 Wakiso 0 20 and above 1 Mukono Mayuge 1 0 Busia Kenya Kamwenge 0 37 Kampala 0 Kasese 0 5 Mpigi 11 Sembabule 2 0 Lake Edward

Bushenyi Masaka Kalangala 0 0 Mbarara 2 1 Rukungiri Lake Victoria 2 Rakai Kanungu Ntungamo 1 1 0 Kisoro Kabale Tanzania Some districts have cases attributed to new (smaller) 0 districts curved out of them Rwanda Source: NTLP/GLRA Ministry of Health May 2010

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Table 3.24: Progress of Leprosy case notification over the HSSP II period Case Pauci Bacillary Multi Bacillary detection YEAR (PB) (MB) ALL New Cases Rate 2004/05 208 455 663 2.5 2005/06 173 379 552 2.1 2006/07 140 283 423 1.5 2007/08 78 311 389 1.4 2008/09 70 275 345 1.2 2009/10 71 275 346 1.2 Source: NTLP Quarterly Leprosy Surveillance reports 2004 /05- 2009/10. The absolute numbers of newly notified leprosy cases decreased from 552 in 2005/06 to 346 in 2009/10. Case detection rate was reduced to almost a half, from 2.1 to 1.15/100,000 population over the same period. Given the concurrent upward trend of disabilities among new cases, this may be more a reflection of actual failure to detect cases than an indicator of diminishing leprosy incidence. This is reflection of a delay in case detection which may be attributed to lack of awareness among the population and lack of knowledge as well as appropriate skills among health workers to recognize leprosy cases. Progress Following attainment of the Leprosy Elimination target in 2004, there was no more need to conduct leprosy elimination campaigns. Instead World Leprosy Day was commemorated at 4 different sites in the country for purposes of sensitizing the general population on the continuing existence of yet untreated leprosy cases and the availability of free effective anti-leprosy treatment. The occasions also served to lobby civic leaders to allocate resources to leprosy control. Activities for intensified case finding were planned for 6 but implemented in only 2 districts. The yield of new cases was extremely low but during the exercise the health facility staff in the selected sites was re-trained in suspecting, diagnosis and management of leprosy cases. Greater emphasis was shifted to Contact surveillance over the HSSP II period. The emphasis on contact tracing has been sustained, by issuing guidelines and modified reporting forms to emphasize the importance of this activity. Implementation has been done mostly by requesting patients and those accompanying them to screen their own families and to encourage those with suspect symptoms to attend the nearest health facility for screening. Between 2007/08 to 2009/10, about 2% of contacts screened turned out to be leprosy cases, representing about 9% of all new cases notified in the same period. Contact tracing is only next to examination of general suspects as an approach for case finding. Systematic examination of school children is no longer recommended as a case finding strategy except in a relatively high burden situation. However, leprosy should remain an integral part of school health services.

Annual Health Sector Performance Report 93 In 2009/10, School surveys were conducted in the seven districts of Sironko, Kaabong, Kotido, Adjumani, Amuru, Kitgum and Oyam covering a total of 4778 children. There were seven(7) leprosy cases were identified, 6 of them from Kitgum and Oyam. A higher number of cases (18) were identified when the surveys covered more children in 2008/09 (11, 417). Overall less than 1% of screened children had leprosy. In the final year of HSSP II, training of health workers in diagnosis, referral and treatment of leprosy cases was as follows: 1 Zonal Supervisor attended an international leprosy course in Addis Ababa, Ethiopia. 23 newly designated District Supervisors attended the basic 4 weeks’ course for District TB/Leprosy Supervisors (DTLSs). 118 general health workers attended in- service training programmes on different aspects of leprosy control. 837 pre-service trainees (528 nursing students) attended short orientation courses in leprosy. The coverage was higher than planned for the year. The referral system used for leprosy control currently is not yet well integrated into the general health services referral system. Case finding activities are integrated into the PHC system, supported with dedicated focal persons at District and Zonal levels. Leprosy suspects from most health units are referred to the District Supervisor (DTLS) to ascertain the diagnosis and start treatment. Difficult cases are referred to the Zonal Supervisor or to one of the leprosy referral facilities. All Leprosy referral facilities are Faith Based NGO except Lira Regional Referral Hospital. Monitoring is done through data collection using Health Unit Leprosy Registers, and District Registers as well as Quarterly Reports on Leprosy Control compiled by all districts and used at NTLP Central Unit to compile national data. Treatment (MDT) was provided to 775 patients (346 of whom were diagnosed during 2009/10). There are reports of 392 admissions for management of leprosy related complications (18% for leprosy reactions, and 36% for management of ulcers) About 1,400 pairs of protective footwear were manufactured and distributed to people living with insensitive feet due to leprosy; this covered about 50% of the estimated needs. A format for collecting information about people with rehabilitation needs after leprosy treatment has been further disseminated to cover all districts in the country. Ministry of Gender Labour and Social Development has already developed and is implementing Community Based Rehabilitation (CBR) programmes at Sub-County level for Persons with Disabilities (PWDs). The NTLP Rehabilitation Advisory Committee (RAC) is developing a strategy for linking the people with disabilities due to leprosy to the existing and functional CBR programmes in the various districts. Major challenges i) There is evidence pointing to an increase in the proportion of newly detected leprosy cases found with already established visible (grade 2) disabilities at the time of detection. This is related to late detection as a consequence of lack of awareness in the general population and of knowledge and relevant skills among health workers. ii) Anecdotal evidence suggests that there is a large number of leprosy patients that develop new grade 2 disabilities in the course of treatment; this is a reflection of poor quality care in terms of identifying and providing appropriate management for high risk sub-groups of known leprosy patients e.g. Only 50% of the needs for protective footwear for people

94 Annual Health Sector Performance Report with insensitive feet were addressed during the final year of this period. Such patients have a high risk of developing foot ulcers. iii) Inadequate funding for advocacy, communication and social mobilization activities as well as other of interventions for prevention and management of leprosy related disabilities. iv) Diminishing skills and capacity for leprosy case management among general health workers v) A special referral system for leprosy seems to operate alongside the normal health services referral system in the country. Such a parallel system is bound to have limited coverage and is not sustainable. vi) Very few Sub-Counties have functional CBR programmes that have integrated persons with disability due to leprosy.

Recommendations

i) Mobilization for more resources to operationalise the proposed and planned activities detailed below. ii) Provide for measures for advocacy and social mobilization to improve public awareness of the signs and symptoms of leprosy iii) Provide for measures to improve the knowledge and skills of staff in the general health facilities as well as those providing referral services iv) All districts should include contact surveillance as a core case finding activity. This is particularly important in more low prevalence situations where other methods are less likely to lead to early detection of new cases.

3.3.5.3 Onchocerchiasis

Onchocerciasis is endemic in 37 districts where an estimated 3 million people are at risk of contracting it and over 2 million people are on treatment with ivermectin. The disease which is transmitted from one person to the next through the bite of a female black fly, causes chronic skin lesions, troublesome itching and sometimes blindness. . Onchocerciasis Control Programme is mandated to reduce the burden of onchocerciasis in the country to levels where it is no longer a disease of public health importance. The major strategy of reducing the burden of onchocerciasis is annual or biannual mass administration of ivermectin and vector elimination in isolated foci. In some districts the programme aims at eradicating the disease. In these districts ivermectin is given twice a year. Vector elimination interventions are also implemented in foci where the transmitting vectors breed. The specific targets as set in HSSP 11 (2006/2006) – (2009/2010) were therapeutic coverage (over 70%), geographic coverage (100%) and integrated work plan in 90% of the districts endemic with onchocerciasis

Annual Health Sector Performance Report 95 Table 3.25: Achievements of the Onchocerciasis control programme from 2005 to 2010 Indicator 2005 2006 2007 2008 2009 2010

Geographic coverage 100% 100% 100% 100% 100% *

Therapeutic coverage 78% 80% 79% 81% 78% *

Integrated plans 10% 30% 60% 80% 90% *

NB * Treatment for this year is ongoing in some districts and the data provided for therapeutic coverage and integrated plans is an estimation since no comprehensive study has been done. The data on integrated is based on the old districts such as Bushenyi or Yumbe and excludes Kitgum and Pader. The decline in coverage is attributed to the low coverage in Koboko and Yumbe districts which registered 56% and 55% respectively which skewed the national coverage. Challenges

i) Lack of district/government financial contribution. The programme is whole dependent on donors which makes sustainability difficult ii) Limited experienced manpower especially in the area of vector elimination. The few experienced staff are overworked. iii) Health workers are few and already burdened by clinical work which makes their participation in the community health interventions difficult iv) Gross understaffing at Onchocerciasis Control secretariat. Only two officers are on government payroll. All support staff and drivers are dependent on donors. Way forward

The Ministry should expedite the process of recruiting staff for the secretariat

3.3.5.4 Neglected Tropical Diseases Division

The main role of the Division of Neglected Tropical Diseases (NTDs) during the period under review continued to be the prevention, control and /or elimination of the diseases which belong to the category of neglected tropical diseases. To ensure this, the Division deployed two major strategies, using the integrated approach, namely: i) Implementation of mass medicine administration (MMA) for the elimination of Lymphatic filariasis, control of schistosomiasis or bilharzia and soil – transmitted helminths or Intestinal parasites. ii) Implementation of Intensified disease management for the control of sleeping sickness and Kala-azar. Generally, these diseases are parasitic and bacterial ancient infections that have been endemic in the country for centuries with hardly any attention paid to them as far as control is concerned.

96 Annual Health Sector Performance Report The leading neglected tropical diseases in the country include: i) Lymphatic filariasis or elephantiasis which puts up to 15 million Ugandans at risk of infection. ii) Schistosomiasis (Bilharzia) which puts up to 16.7 million Ugandans at risk of infection. iii) Soil- transmitted helminths or intestinal parasites which put up to 22 million Ugandans at risk of infection. iv) Onchocerciasis or river blindness which puts up to 2.6 million Ugandans at risk of infection. v) Sleeping sickness or Human African Trypanosomiasis (HAT) which puts up to 10 million Ugandans at risk of Infection. vi) Trachoma which puts up to 7 million Ugandans at risk of infection vii) Leishmaniasis or Kala-azar which puts up to 0.5 million Ugandans at risk of infection. viii) Plague which puts up to 1 million Ugandans at risk of infection. ix) Buruli ulcer for which only one district, so far, is known to be endemic. However, this report covers only Lymphatic filariasis, Schistosomiasis and soil –transmitted helminths and sleeping sickness. Onchocerciasis is covered under the Department of National Disease Control while trachoma is covered under the Disability and Rehabilitation section. On the other hand, this report does not cover plague, Leishmaniasis or Kala – azar and Buruli ulcer because not much is being done about these diseases under the Ministry of Health currently. What is happening in the field of plague is mainly research based at the Uganda Virus Research Institute (UVRI). The same applies to Buruli ulcer whose research is based in the Pathology Department of the Makerere school of Medicine. Similarly, the main thing going on in the field of Kala-azar is research based at Amudat hospital under the funding of the Drugs for Neglected Disease Initiative (DNDi). However, the patients who are not included in the research studies receive routine treatment using drugs provided by DNDi. The drive to prevent, control and/or eliminate these diseases is a new realization arising from the far-reaching consequences that some of these diseases cause, e.g. i) Trachoma & river blindness are known for causing blindness. ii) Leprosy, Kala-azar, River blindness & Buruli ulcer are known for causing considerable disfigurement. iii) Lymphatic filariasis is known for causing a high degree of disability. iv) Sleeping sickness is known for causing a high degree of debilitation and eventual death if untreated. Furthermore, these diseases are associated with extreme poverty and illiteracy and the heat and humidity of our tropical setting. They affect, almost exclusively, poor and powerless people living in rural communities and are given little attention; hence, the term “Neglected”. The price of neglect, however, is very high because these diseases contribute, substantially, to disabilities, stigmatization and malnutrition in many communities.

Annual Health Sector Performance Report 97 In addition, they affect the physical and intellectual development and educational outcomes of children, fix intergenerational cycles of poverty, challenge food security and, above all, limit national economic growth. Fortunately, for five (Lymphatic filariasis, Schistosomiasis, Soil-transmitted helminths, trachoma and river blindness) of these diseases, there are now simple, effective and low- cost interventions available for their control and /or elimination. These interventions are largely based on what is referred to as preventive chemotherapy (PCT) using medicines which are donated, free of charge, through various initiatives and partnerships. Thus, this group of NTDs is said to be “tool – ready” diseases as opposed to the “tool – deficient” diseases which consist of sleeping sickness, buruli ulcer, Kala – azar and plague. For this group of diseases, there is great need to improve the existing interventions and strategies and /or to develop new ones for their control. This report covers mainly the “tool – ready” diseases whose interventions are provided as free donations through international initiatives and partnerships as already alluded to. Interventions against neglected tropical diseases are based on the following key principles: i) The right to health by everyone. ii) Existing health system as a setting for them. iii) A coordinated response by the health system. iv) Integration and equity v) Intensified control of diseases alongside pro-poor policies.

Disease specific Progress Report Disease specific Progress Reports: Lymphatic filariasis, (LF) Lymphatic filariasis, also known as Elephantiasis, is transmitted by mosquitoes that bite infected humans and pick up the microfilarial that develop, inside the mosquito, into the infective stage in a process that usually takes 7-21 days. In its most obvious manifestations, the disease causes enlargement of the entire leg or arm, the genitals, vulva and breasts. The psychological and social stigma associated with these aspects of the disease are immense. The disease is associated with extreme poverty. According to the mapping that has been carried out, so far, the disease is endemic in 44 districts where a population of more than 15 million people are at risk of infection. During the period under review, two core interventions were supposed to be deployed, namely: i) Mass medicine administration using ivertmectin and albendazole for interruption of transmission of the disease. ii) Management morbidity and disability associated with the disease, namely hydrocoeles and lymphoedema or elephantiasis.

98 Annual Health Sector Performance Report Progress Specific targets as stipulated in HSSPII: i) To achieve 90% therapeutic coverage of the affected people with single annual dose of ivermectin and albendazole. ii) Reduce morbidity and disability associated with the disease by 25%. Table 3.26: Therapeutic coverage for people affected by lymphatic filariasis HSSP II 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 Data Comments target/indicators Source

No of IUs 5 10 2 25 31 52

Therapeutic 0.838 88.60% 105.00% 92.40% 93.40% 92.86% PELF Coverage coverage data calculated Bank using the eligible population as the denominator Management of No comprehensive programme has been initiated yet morbidity and disability associated with LF

Progress Core interventions i) Mass medicine administration in all the endemic areas ii) Intensive public education and social mobilization Table 3.27: Performance according to set targets for elimination of lymphatic filariasis Indicator HSSP II 2005/06 2006/07 2007/08 2008/9 2009/10 Data Comments baseline Source FY 2004/05 A: Coverage’s 1. Target IUs 5 10 2 25 31 52 PELF Data 2. Total population 21514266 491448 371075 689230 895953 Bank 19 2 4 3. Eligible 1721141 393185 296860 551384 716762 population 5 2 7 4. Treated 1158892 348338 311593 511688 669686 population 4 8 3 5. 53.9% &0.9% 84.0% 74.2% 74.75 Chemotherapeutic coverage (Total) 6. 67.3% 88.6% 105.05% 92.8% 93.4% 92.86 Chemotherapeutic

Annual Health Sector Performance Report 99 Indicator HSSP II 2005/06 2006/07 2007/08 2008/9 2009/10 Data Comments baseline Source FY 2004/05 coverage (Eligible)

B: Adverse events Not Assessed: No results therefore C: Microfilaremia level 1. Obalanga 22.4% - 0.4% PELF Data 2. Akumangor 1.7% 0.6% - Bank 3. 25.5% - 0.6% 4. Barr D: Chronic manifestation rate (a) Hydrocele 1. Obalanga 17.3% - 6.3% PELF Hydrocelectom Data y support 2. Akumangor 8.2% 2.1% - Bank receive from DANIDA 3. Alebtongor 28.7% - 4.7% 4. Barr - - - (b) Limb Elephantiasis 1. Obalanga 3.7% - 0.3% 2. Akumangor 3.2% 0.2% - OHHRCA active 3. Alebtong 9.7% - 6.1% 4. Barr 1.7% 0.4% - E: Transmission No follow up Rate

OHHRCA: Obalanga Health and Human rights Care Association, a voluntary group of people who have suffered from the disease before. Challenges: i) Operations of the programme are entirely dependent on donor – funding. ii) Morbidity and disability management are yet to commence.

Recommendation: The Government of Uganda in general and the Ministry of Health in particular should demonstrate ownership of this programme by making financial contribution towards it.

Sleeping sickness: Sleeping sickness is caused by protozoan parasites, trypanosomes, which are transmitted by tsetse flies. The disease occurs in two forms: a chronic form caused by T.b gambiense which occurs in the North and North Western Uganda; and an acute form caused by T.b. rhodesiense

100 Annual Health Sector Performance Report which occurs in south Eastern Uganda. The chronic infection lasts for years, whilst the acute disease may last for only week before deaths occurs if not treated. Currently, there are strong fears about a geographical overlap of these two forms of the diseases in the Teso/Lango regions. If this occurs, it is likely to cause problems of diagnosis, treatment and control of the disease. Under HSSPII the core interventions planned for implementation were as follows: i) Social mobilisation ii) Case detection and management including regular screening of communities iii) Drug distribution iv) Integrated vector management(IVM) v) Sleeping sickness surveillance and monitoring All these interventions were implemented except IVM. Specific targets i) Improving access to quality diagnostic facilities by 80%. ii) Improving access to quality treatment facilities by 80% iii) Community empowerment for sleeping sickness control increased to 100% of the communities in endemic districts. Improving access to quality diagnostic and treatment facilities has been met up to 80% and community empowerment for ownership of sleeping sickness control currently stands at 60%.

Table 3.28: Performance to set targets for elimination of sleeping sickness HSSP II 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 Comments Target/Indicators Proportion of 33% 28% 39% 35% 45% This HAT patients proportion is detected in the slightly lower early stage of in the T,B infection. gambiense Not done focus Proportion of HAT patients developing treatment related Not done Not Not Not Not Not available complications available available available available Proportion of HAT patients This was relapsing after assessed for treatment Not done %0 4.3% 4.5% 1.5% 1.4% patients who received DFMO Proportion of Follow up HAT patients was assessed Not done 42% 38% 40% 48% 52% followed – up at least once after treatment Data source: Treatment centers

Annual Health Sector Performance Report 101 Major challenges i) Lack of ownership of the programme by the district local governments where the disease is endemic. ii) The likely overlap of the chronic and acute forms of the disease at some geographical point in the Lango/Teso regions. iii) Very high drug (melarsoprol) failure rates, particularly in the Omugo area, Arua district. iv) Human border (SouthernSudan, DRC Congo & Kenya) traffic v) Cattle movement & market promoting disease transmission vi) Inadequate operational funds vii)Shortage of appropriately skilled manpower Recommendations i) Districts should be supported to own the programme ii) Efforts should be made to halt the overlap of the two forms of the disease. iii) More resources (Human and Financial) should be committed towards the programme.

Schistosomiasis and soil- transmitted helminths control

During HSSP II, the focus was on scaling up the interventions to reach the new populations at risk in addition to the re-treatment of previously treated populations both in the communities and schools. Targets: i) Expand preventive chemotherapy in all the endemic districts up to 100%. ii) Get all endemic districts to integrate the prevention and control of schistosomiasis and soil transmitted helminths within their district work plans. Mechanisms for scaling up; i) Develop district capacity and provide technical support for the management of the programme. ii) Ensure the availability of medicines and improve the efficiency of their distribution. iii) Promote the integrated approach for the distribution of medicines. iv) Involve the private sector. Core Interventions i) Social mobilization ii) Mass Medicine distribution both community and school based. iii) Advocacy for improved water supply and sanitation. iv) Empower communities and schools for the control of Schistosomiasis and soil transmitted helminths.

102 Annual Health Sector Performance Report Progress i) 11.5 million School children and 3.5 million adults treated. ii) Reduced prevalence of schistosomiasis to less than 20% in 80 % of the endemic districts.

Table 3.29: Performance according to selected indicators for Schisto/STH Control Indicators 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 Comments District 18 26 24 26 37 43 targeted for chemotherapy (schisto/STH) Percentage of 21.4 23.7 23.9 24.20% 29.4 Schisto is only in schools in the a few sub programme counties in endemic districts

Drug coverage FY 07/08 has after incomplete data 88.00% 87.60% 84.80% Missing 74 93.75 chemotherapy set data Proportion of Treatment for FY high prevalence 2008/09 is still 100% 43% 17% 12% Not yet of schisto/ STH under way computed infections

Proportion of Baseline surveys visible for mapping S. N/A N/A N/A N/A N/A haematuria in haematobium the case of S. have not yet been haematobium done

Overall Evaluation for proportion of FY 2008/09 has Not yet children with not yet been done computed any of the soil 78% 44.20% 21.70% 19.30% transmitted helminthes

Schisto/STH, Prog/NTD records Challenges: i) Improvement of water supply and sanitation ii) Incentives for community medicine distributors iii) local funding Recommendations i) The Ministry of Health should liaise with the relevant sectors to improve water supply and sanitation in addition to Mass Medicine Administration (MMA). ii) Vector (snail) control should be deployed alongside MMA. iii) The Government of Uganda should start contributing funds towards the programme.

Annual Health Sector Performance Report 103 3.4 Non-communicable diseases/conditions cluster

Uganda is experiencing dual epidemics of communicable and non communicable epidemics. Non communicable diseases such as diabetes mellitus, cardiovascular diseases, cancer and chronic respiratory diseases are on the increase in the developing countries and Uganda is no exception. This cluster includes challenges and achievements in following: Injuries, Disabilities and Rehabilitative health; Gender based Violence; Mental Health and Control of Substance Abuse; Integrated Essential Clinical Care; Oral Health and Palliative Care.

3.4.1 Prevention and control of non-communicable diseases

Non communicable diseases (NCDs) particularly; cardiovascular diseases, diabetes, cancers, as well as chronic obstructive pulmonary diseases are becoming increasingly important as causes of morbidity and mortality in the Ugandan population. The records have demonstrated a 500% increase in outpatient attendance due to heart related conditions over the past 7 years (2002-2009). The Uganda Cancer Institute has also reported an upward trend in cancer incidence over the past four years (2005-2009), particularly among HIV infection related cancers. Regional referral hospitals have reported an increasing number of diabetes and chronic obstructive pulmonary disease patients either admitted in their medical wards or seen at their out- patients clinics. The increase in the incidence of chronic non communicable diseases is predicted to continue over the years fueled by the increasing exposure of our population to unhealthy lifestyles associated with urbanization. The WHO predicts that NCDs will reach epidemic proportions by the year 2025 if NCD preventive, control and surveillance measures are not undertaken immediately. The Non communicable disease programme was established during the 2006/07 Financial Year to the plan, implement and coordinate actions aimed at prevention and control of NCDs in Uganda. The mandate of the NCD prevention and control programme is to reduce the morbidity and mortality attributable to non-communicable diseases through appropriate health interventions targeting the entire population of Uganda. Achievements of the NCD programme over the HSSP II period are summarized in table 3.30. Major Challenges i) There is no baseline data and information on NCDs and their risk factors in Uganda. This data and information is critical to the formulation of an evidence based National NCD policy and the development of comprehensive and integrated NCD interventions. The delay in completing the NCD survey due to insufficient funds is consequently delaying the formulation of an NCD policy and development of other NCD prevention and control interventions.

104 Annual Health Sector Performance Report Table 3.30: Progress on implementation of interventions planned in HSSP II HSSP II Target Indicator HSSP II Baseline 2006/07 2008/09 2009/10 FY 2004/5 Comments Obtain national baseline data No NCD Programme NCD Programme NCD Survey plan Listing of Enumeration Survey pre-test and data collection on NCD risk factors in the established completed Areas completed delayed by lack of funds Uganda population

No baseline Planning for NCD NCD Stakeholders’ Plan for pretesting of Data collection planned for FY Survey started meetings held Survey tools and 2010/11 subject to release of funds. Equipment completed

Resource mobilization Survey tools produced. started

National NCD Policy, No baseline Technical team to NCD Survey results to guide policy standards and Guidelines formulate NCD policy formulation produced identified

National Programme for NCD No baseline Draft 0 produced Programme interventions to be prevention and control in guided by survey results place

Percentage of HC IVs with No baseline Health facility audit plan Audit to be carried out as part of the functional integrated NCD completed NCD survey clinics increased by 30%

ii) Existing efforts against NCDs are facility based, poorly coordinated and supported iii) Insufficient drugs and high cost of medicines for NCD conditions at health facilities, particularly those at lower health care levels iv) Understaffed and under resourced NCD Prevention and Control Programme Recommendations i) Facilitate the NCD Programme to complete the planned National NCD Survey. ii) Conduct a rapid assessment of Health facilities at HC IV and above to establish the actual capacity to prevent and control NCDs. That will be the benchmark for setting realistic targets in improving the quality of NCD care. iii) Facilitate the completion of the Ministry of Health restructuring and support the NCD programme with adequate human and financial resources to enable it to carry out its mandate

Annual Health Sector Performance Report 105 3.4.2 Injuries disabilities and rehabilitative health

Prevention of injuries, disabilities and rehabilitative health encompasses conditions that result in an individual’s deprivation or loss of the needed competency The HSSP II period focused on integrating injury and disability prevention interventions with other programmes. The programme is coordinated by a section at the Ministry of Health in conjunction with an Injury control Unit in Mulago National Referral Hospital. The strategic objectives were to: i) strengthen and increase accessibility to rehabilitative health care services of PWDs in the districts for a better quality of life and ii) provide standards and guidelines to the districts for development and provision of quality rehabilitative services The progress towards attainment of the specific HSSP II targets is shown in table 3.24.

Table 3.31: Progress on implementation of intervention planned in HSSP II Indicator 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 HSSP II Target

Mass Distribution of * * * 7 (28%) 11 (44%) 12 100% Azithromycin and (48%) Tetracyclin to all Trachoma endemic districts (25 districts).

Integration of trachoma * * * * * * 25 prevention and control measures in work-plans of endemic districts

Increase by 30% access * * * * * * 30% to and provision of surgical services to patients with trichiasis

In order to chart progress toward the control and elimination of trachoma, prevalence studies were carried out in all 25 endemic districts. Data has been compiled and disseminated to the relevant districts and Development Partners who support Prevention of Blindness programme in the country.

The Lions Club International supported a rehabilitative project of lid rotation in region that has one of the highest prevalence of trachoma.

Reduction of visual and hearing impairment: i) ENT and Eye care Units were established in the districts of Kabale, Mbarara, Moroto, Soroti, Kitgum, Arua, Nebbi, Gulu and Lira so as to scale up the early detection and proper treatment of disorders of sight and hearing in order to minimize complications. This was in collaboration with LAN and SSI. ii) A communication strategy on hearing impairment has been developed and is in final stages. iii) Guidelines on prevention and management of Low Vision have been developed and are ready for dissemination.

106 Annual Health Sector Performance Report Table 3.32: Summarizes the progress of other important milestones. Indicator 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 HSSP II Target To reduce prevalence of hearing - 10% 9.80% 9% 9% 8% 8% impairment

To reduce prevalence of visual - 1% 0.90% 0.90% 0.80% 0.80% 0.80% impairment Provision of assistive devices to - - 2% 2% 3% 5% PWDs who need them. ICRC rehabilitation and Mbale orthopaedic workshops.

To reach 80% of the population - - - 29.60% 31% 51% NTDs promotes with messages on disability and disability prevention in 57 rehabilitation. districts. Conduct prevalence Trachoma -28% 44% 64% 80% 20 districts surveyed. 199% prevalence studies in all endemic 7 districts 11 districts 16 districts all 25 districts have been districts (25 districts). surveyed. surveyed. surveyed.

surveyed.

Strengthening of Regional - - 2 out of 6 2 out of 6 3 out of 6 (ICRC 4 out of 6 (ICRC orthopaedic workshop for (Arua, (Arua, Gulu) rehabilitated Fort Portal in rehabilitation Mbale production of assistive devices ( Gulu) addition workshop in addition)

Early detection and proper 81% 81% treatment of disorders of sight and Nine Regional Referral hearing in order to prevent Hospital have functional complication in all Regional Eye and ENT Units. Referral Hospitals (11)

Data collection on injuries and disabilities i) In collaboration with UBOS suggestions to have more specific items in the U.D.H.S field tools focusing on disability have been made. ii) The Section has developed a data collection/surveillance tool on Landmine survivors. iii) The Cataract Prevalence Survey conducted in Masaka district in 2008, provides highlights on the burden of the condition.

Prevention of accidents and access to assistive devices i) In 2006, sensitization of the general population and school children about road traffic accidents was undertaken. This was during the United Nations Global Road Safety Campaign whose theme was ‘’Young Road Users’’. Black spots on some major highways were identified and marked.

Annual Health Sector Performance Report 107 ii) Four regional orthopaedic workshops were strengthened for production of assistive devices. Six orthopaedic technicians were trained in wheelchair technology at TATCOT in Tanzania and have been deployed in regional Referral Hospitals. A wheelchair provision project supported by MOTIVATION was inaugurated. In collaboration with UNDP Land Mine survivors in Oyam, Amuru, Pader and Lira districts have been provided with assistive devices. In partnership with ICRC orthopaedic workshops at Fort Portal and Mbale Regional Hospitals have been renovated and are in full production capacity. iii) Enhanced collaboration with the Social development Sector in respect to the Community Based rehabilitation (CBR) initiative mainly in support of Land Mine Survivors was carried out. iv) Dissemination of guidelines of handling of trauma, disabilities and rehabilitative care. In collaboration with WHO injury prevention and control policy has been developed and is in final stage. Rehabilitation and health care policy on disability was cleared by MOH top management meeting and is ready for forwarding to Cabinet.

Challenges Provide the main challenges specifically related to why the set targets were not attained or the lack of progress during the HSSP II period. i) Understaffing at all levels. For example 3 of the Regional Referral Hospitals (Masaka, Lira and Fort Portal) cannot provide specialist eye care services because they don’t have ophthalmologists. ii) Inadequate support to orthopaedic workshops. Although technicians are available at all the 6 orthopaedic workshops, raw materials for production of assistive devices are visually inadequate or not available at all. iii) Low priority accorded to disability at all levels. For example disability programmes are usually allocated the smallest budget support. iv) The challenge of coordinating many different stakeholders with varying interests still exists. Recommendations Increase budget allocation to activities targeting prevention of disabilities and rehabilitation services, e.g. if possible create a sub-programme for orthopedic workshop so that they have a separate budget from that of the hospitals where they are located.

3.4.3. Gender mainstreaming

Gender mainstreaming in health is aimed at advocating against all forms of discriminations, such as sex, age, race etc. This includes physical, psychological injuries due to domestic violence, assault, rape, defilement, conflict situations as well as cultural practices including Female genital mutilation (FGM) Progress i) Sensitization of all regional Hospital and general district hospitals in GM ii) Manuals on GM where distributed in all Regional and general Hospitals

108 Annual Health Sector Performance Report iii) Built up sectoral corroborations ( WHO, DANIDA, Law societies, Police ) e.t.c iv) Process for planning together is on-going. Challenges i) Gender is still considered to be all about sex, in terms of empowering women. ii) The few trained hospital staff can not cause the desired change in attitude and practice. iii) Weak GM Monitoring & Evaluation systems iv) The concept of gender was not universally understood and conceivable by health managers Recommendations i) Scale up GMs in all PNFPs and PFP health facilities ii) Sensitize CDOs on Health Gender Mainstreaming in all Hospitals iii) Setup a Database on GMS in all District iv) Plan to engender all National Health Indicators and vital documents v) HMIS to be reviewed to address Gender vi) Need to sensitize Parliamentarians on GM for advocacy vii)CPDs on GMS to be conducted in all Hospitals viii) Most managers wish to have gender as a health indicator.

3.4.4 Mental Health, Management of Neurological Disorders and Control of Substance Abuse

The programme has the mandate to implement interventions to address the high burden of mental health problems which contribute about 13% of the burden of disease. Uganda is experiencing a major challenge in addressing the high prevalence of epilepsy and other neurological disorders. Supervision reports indicate that about 75% of attendances at Mental health clinics have some form of neurological problem commonly Epilepsy, with cases of dementia on the increase especially among persons living with HIV/AIDS. The programme is scaling up interventions to prevent and manage substance abuse problems which have increased in all age groups resulting not only in addiction and increased crime but also deaths due consumption of unsafe and adulterated alcohol. Progress i) The Six Regional Mental Health units constructed in Masaka, Mbale, Lira, Mubende, Jinja and Moroto are now functional, although only one has resident Psychiatrist. ii) The Draft Mental Health Bill is ready for presentation to parliament. iii) The National Alcohol policy is ready for presentation to cabinet. iv) The draft Mental Health policy has been presented to the senior management committee of the MOH and is being reviewed. v) Drafting of Tobacco control policy, Tobacco Control Bill, Drug control master plan is on going. vi) Several Media programmes were held for educating the public on Mental Health, Epilepsy and substance abuse control. IEC materials were developed and disseminated on World Mental Health Day, World No Tobacco Day, National Epilepsy Advocacy Day and the UN Day against substance abuse and illicit trafficking.

Annual Health Sector Performance Report 109 vii)To build capacity for management of mental health, neurological and substance abuse problems, sensitization of District political leaders, District Health Management Teams and other relevant sectors was conducted and PHC workers trained in community Mental Health to cover all Districts in the Regional referral areas of Arua, Lira, Mubende, Mbarara, Gulu, Mbale, Masaka, Moroto, and Kampala. Training of Psychiatrists, Psychiatric Social workers and Psychiatric Clinical officers was supported by SHSSPP II. Most Districts have recruited Mental Health professionals for integration of Mental Health into PHC.

Table 3.33 Progress on implementations planned in the HSSPII Indicator 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 Comment

Functional No 50% 10% 100% 100% 100% 4 out of the Mental Health baseline 13 have units at resident regional Psychiatrists. referral There is need hospitals to provide posts for Clinical Psychologists, Social Workers and more nurses for full functionality Community No 20% 50% 60% 65% 75% Access to H Access to MH baseline services has services extended to most health center IVs and some HC III and II following in service training by the program Proportion of No 30 No data 70% 60% 75% Most HCIV HCiv with baseline recruited MH Psychiatric nurses but Nurses or some other MH staff deployed to do other duties Proportion of All HCIV HCIV with have plans MH plans but MH generally under funded Proportion of No 10% 30% 30% 50% 800% MH HCIVwith at baseline medicines are least one not adequate antipsychotic, to meet the one demand antidepressant, created by the and one program. antiepileptic NMS not medicine providing a full range of medicines on the EML

110 Annual Health Sector Performance Report Major Challenges i) Inadequate staffing at Regional Mental Health units ii) Inadequate resource allocation to address mandates of Mental Health, Neurological Disorders and Alcohol and drug abuse at central programme level and District level iii) Inadequate supply of MH medicines by NMS. iv) No budget for food for unaccompanied patients admitted at Regional referral MH units who are brought by police. v) The basic medicines kit for HCIII and HCII does not have MH and anti epilepsy medicines thus disrupting the service already established at those levels.

Recommendations i) Restructuring should address the staffing needs for MH at the central and Health facility level especially Regional MH units to provide adequate staff and multidisciplinary teams. ii) Increase funds allocated to the programme address the mandates. iii) The Ministry should put in place a mechanism for bulk purchase of MH and Anti epilepsy medicines by NMS. iv) Hospitals need to budget for food for MH patients with no attendants. v) Ensure that all regional referral hospitals have Psychiatrists. vi) Review the basic medicine kit to include the MH and anti epilepsy medicines according the EML

Annual Health Sector Performance Report 111 3.4.5 Integrated Essential Clinical Care

Hospital Services Essential clinical care is one of the key elements of the minimum package and indeed a major purpose of any health system. Hospitals remain to be the main contributors of essential clinical care. In the public eyes, hospitals provide the “face” of the health system for which a rough assessment of the health system is made. The number of hospitals providing essential clinical care in Uganda has continued to grow in the recent years. The recent growth has been mainly from the private sector and institutional hospitals. It is noteworthy that the definition of a hospital as in the Hospital Policy is not yet adhered to in accepting or classifying health units as hospitals. According to this policy, a hospital is “A registered health care facility, public or private organization for profit or not, devoted to providing curative, preventive, promotive and rehabilitative care, through outpatient, inpatient, and community health services. It should have at least 60 beds, a high level of skilled medical personnel including doctors, and be able to carry out major surgery and advanced investigative procedures including X-ray.” The table below shows the distribution of these hospitals. Table 3.34: Hospitals in Uganda 2009/2010 National Beds Regional Beds General Beds Total Beds Referral Referral Public 2 2,350 13 3,227 38 38,711 53 44,288 PNFP 51 8,013 51 8,013 PHP 15 845 15 845 Institutional 9 1,005 9 1,005 Total 2 2,350 13 3,227 113 48,574 128 54,151 The number of PHP beds worked out from the average 13 of the 15 hospitals the number of Institutional beds worked out from the average of 7 of the 9 hospitals

Hospitals continue to be major contributors to the outputs of inpatient, outpatient and preventive care. In this report we capture this contribution and analyze the performance of hospitals in that context. The specific contribution of Private Not for Profit (UCMB, UPMB, and UMMB) hospitals will also be highlighted. Reports for the year 2009/2010 have been received from 69 general hospitals, 12 regional referral hospitals and from 3 large Private Not for Profit hospitals (PNFP) that will be analyzed in the regional referral hospitals set. The information requested was what is routinely reported in the HMIS forms especially HMIS form 107 in order to reinforce proper reporting and use of HMIS information at hospital level. This is the sixth annual report where there has been effort to analyze the functioning of hospitals. This analysis largely looks at outputs of hospitals and relates to inputs and to outcomes including quality. In order to have uniform comparison of outputs of hospitals we will continue to use the

112 Annual Health Sector Performance Report Standard Unit of Output (SUO).24 The SUO is a composite measure of outputs that can allow fair comparison of volumes of output of hospitals that have varying capacities in providing the different types of patient care services. Basic efficiency indicators for resource use will be generated and tables comparing hospitals will be generated.

I). General Hospitals According to the records there are 113 General hospitals, however only 69 general hospital reports were received for this annual report exercise a number of which were incomplete. 1) Inputs a) Finance Of the 69 general hospitals whose reports were received, only 54 had financial reporting. The absence of expenditure on human resource for health for public general hospitals continues to make meaningful interpretation of these results difficult when we know that 50-70% of the total cost of running hospitals is human resource cost. The 54 hospitals received a total of Ush. 29,175,186,304 and spent 97% of that amount to provide the service. There is a very wide dispersion in expenditure about the mean of 539.6 million shillings – ranging from 12 million to 3 billion. b) Human resource A big shortage of health personnel still exists. Overall only 62% of the positions in the 42 general hospitals were filled compared to 61% in 2007/08, for medical staff positions (medical officer, dental, pharmacy, qualified nursing and allied health staff) only 55% are filled. Of all the cadres nursing staff have the largest gap in absolute numbers (-3,380) while pharmacy staff have the lowest percentage of positions filled at 44%. Too many nursing positions are filled by nursing aides especially in private hospitals as a coping mechanism to cut costs while keeping the service going. The effect of this on quality of care is not proven but is expected. c) Drugs and medical supplies Availability of medicines and supplies are a key aspect of hospital quality of care. This item is the second highest expenditure after human resource. The analysis of this is made and reported in the medicines section of this report. 2) Outputs Although hospitals are multiproduct firms, only some (considered important) of the outputs were collected and analyzed. Table 3.35 below shows selected outputs from General Hospitals.

24 SUO stands for standard unit of output an output measure converting all outputs in to outpatient equivalents. SUO total = Σ(IP*15 + OP*1 + Del.*5 + Imm.*0.2 + ANC/MCH/FP*0.5) based on earlier work of cost comparisons.

Annual Health Sector Performance Report 113 Table 3.35:. Staffing positions in general hospitals

Med. Med. Doctor Dental Pharmacy Nursing Allied Health Admin staff Support Medical Staff Total staff LG Staffing Norms 7 4 3 116 28 14 13 158 185 Total in Post 63 hospitals 261 120 86 3928 1041 603 1245 5436 7284 115. Average per hospital 4.1 1.9 1.4 62.3 16.5 9.6 19.8 86.3 6 Min 0 0 0 2 0 1 0 12 23 Maximum 12 6 6 192 40 29 123 216 272 1165 Expected total 441 252 189 7308 1764 882 819 9954 5 Staff Gap for 63 - hospitals -180 -132 -103 -3380 -723 -279 426 -4518 4371 % in post 2009/10 59% 48% 46% 54% 59% 68% 152% 55% 62% % in post 2008/09 % in post 2007/08 58% 52% 44% 59% 61% 52% 61% % in post 2006/07 83% 63% 58% 67% 86% 67% Medical staff only excludes nursing assistants, admin staff and support staff

Table 3.36: Outputs from the General Hospitals FY 2009/10

Beds In patients Inpatient days Out patients Deliveries Major operations ANC Cesarean Section Immunizat ion SUO Total 9,688 576,074 2,555,647 2,929,399 96,517 37,617 242,608 20,006 602,358 12,335,613 Average 142 8,472 38,722 42,455 1,419 561 3,568 299 8,730 178,777 2009/10 Minimum 17 189 1,600 2,267 44 0 167 0 818 15,140 Maximum 936 20,496 178,608 176,907 4,238 2,056 13,532 1,116 42,362 463,980 Average 123 7,271 32,197 1,389 555 12,197 1,063 13,009 439,848 2008/09 Average 130 3,194 33,185 1,465 617 14,329 911 13,323 453,348 2007/08 Data from 69 hospitals Source: Hospital submissions for AHSPR 2009/10. Note that figures for previous years are from Resource centre As indicated in table 3.36 hospital outputs have been measured in composite units – the SUO. With this measure we can compare the volume of output or activity basing on 5 main indicators – outpatients, inpatients, deliveries, immunizations and Antenatal/Family planning/MCH. The top ten hospitals with the highest outputs are: Iganga, , Mityana, St. Joseph Kitgum, Dr. Ambrosoli Kalongo, Kitgum Government, Kitovu, Kawolo, and Tororo government.

114 Annual Health Sector Performance Report Eight of these (underlined) have kept this group since last year 2008/09. Details can be seen in Annex II. Although the core hospital outputs like admissions, outpatients and deliveries have increased compared to last year, there has been a reduction in average Standard Units of Outputs due to a very high reduction in antenatal and immunization outputs which may be an indicator of improving utilization of these services in the lower level units. Some hospitals are still not able to major operations including cesarean section!! The clinical department should work with the relevant districts to address the causes of this. a) Efficiency of use of services Compared to last year (2008/09) there has been some improvement in hospital efficiency indicators however the dispersion is great, most of the indicators being propped up by “extra busy” hospitals. It has not been possible to analyze efficiency for use of funds because of lack complete or reliable financial reports. This year, the average hospital had the following indicators compared to the previous year in brackets: Average length of stay of 4.6 (4.9) days; bed occupancy rate of 80% (66%); one staff on average was producing 1,487 (1,260) units of output. This year the average hospital had 142 beds, 8,472 admissions and had 120 staff. We can infer that for 2009/10 there was improvement of efficiency with hospital admitting more, reducing the average length of stay getting higher bed occupancy rate and SUO per staff compared to the year before. The table 3.37 elaborates this.

Table 3.37: Selected Efficiency Parameters 2009/10 of Beds Total Number Admissions Total Of Stay Length Average Rate Occupancy Bed Total Staff SUO/Staff

Total 9,688 576,074 8,056

Average 2009/10 142 8,472 4.6 74% 120 1,487

Min 17 189 2 4 25 337

Max 936 20,496 12 155 278 2,829

Average 2008/09 123 7,271 4.9 66% 120 1,260 Source: Hospital submissions for AHSPR 2009/10. Quality and overall performance Previous analysis of quality of care has been based on still birth rate, maternal death rate, qualified staff per bed and cesarean section rate. However there was not sufficient information to make a comprehensive and comparative analysis to the previous years. It is however important to

Annual Health Sector Performance Report 115 note that a very high number of maternal death continues to occur in our hospitals, 9 maternal deaths occur in each hospital on average and 648 maternal deaths were reported by the 69 hospitals. One outlier – Bugiri hospital with 105 maternal deaths needs to be investigated.

II) Regional Referral Hospitals There are 13 regional referral hospitals in the country, but for the annual reporting exercise 4 large PNFP hospitals (Nsambya, Rubaga, Mengo, and Lacor) with the scale and scope of regional referral hospitals are included in the group. The full set should then be 17 hospitals. Reports were received from 15 out of the 17 hospitals some of them incomplete. a) Inputs i) Finance Only 8 hospitals had complete financial reports for a good analysis. From this set a total of Ush 30,302,038,665 was received and 30,656,894,055 was spent – 101% absorption capacity. The average expenditure for a regional referral hospital is 3,832,111,757. ii) Human resource The total number of staff in the 14 hospitals that provided staff information was 3,345 on average the number of staff per hospital is 239 but with a wide range from 125 to 373. Seventy two per cent of the total staff are medical staff (medical doctors, dental, pharmacy, nursing - excluding nursing aides and assistants and allied health).

Table 3.38: Staff in 14 Regional Referral and large PNFP hospitals Doctors Dental Pharmacy Nursing Allied Health Admin staff Support Medical Staff Total staff Total 184 81 53 1841 520 214 452 2399 3345 Average 2009/10 13.1 5.8 3.8 131.5 37.1 15.3 32.3 171.4 238.9 Min 2 0 1 67 14 5 15 67 125 Maximum 33 17 10 224 54 36 54 298 373 Source: Hospital submissions for AHSPR 2009/10. iii) Drugs and medical supplies This information is analyzed and reported under the medicines and supplies section of the annual report. b) Outputs The outputs of the 13 regional referral hospitals and 3 large PNFP hospitals have been analyzed here below. The hospitals attended to 349,698 inpatients, 1,761,150 outpatients and 68,024 deliveries among other outputs. On average each hospital attends to 21,856 inpatients, 117,410 outpatients. A comparison of volume of outputs based on the SUO has been made and is shown in figure 3.10 below. The average SUO per hospital is 468,752.

116 Annual Health Sector Performance Report Figure 3.10: Volume of outputs for Regional Referral and large PNFP Hospitals

Details of the rest of the outputs are shown in the table 3.39 below.

Table 3.39: Outputs of Regional Referral and Large PNFP hospitals Hospital Name Total OPD attendances Total ANC Deliveries in Unit Total Immunization Total Family Planning No. started ART Beds Admissions Patient Days Major Operations SUO Lira 121,816 6,886 3,414 16,832 3,907 813 350 15,543 116,979 903 380,794 St Raphael Nsambya 159,424 25,509 7,561 48,074 48 456 319 18,785 88,111 3,377 501,397 Mbarara 180,450 6,246 7,459 27,724 1,617 318 330 21,230 116,050 3,232 545,671 Soroti 90,915 11,134 4,368 31,491 1,868 30 294 21,955 96,902 2,567 454,879 Mubende 34,258 4,820 2,049 9,963 731 517 120 10,608 49,650 1,072 208,391 Mbale 97,947 8,858 7,036 17,343 4,547 - 460 60,152 143,436 1,678 1,045,578 Hoima 98,786 9,484 3,685 21,481 1,797 429 260 16,416 85,678 1,883 373,388 Rubaga 174,938 13,032 7,420 49,340 754 275 271 17,925 69,147 2,283 497,674

St.Mary'sLa 171,288 7,501 3,387 21,842 - 695 482 39,273 231,161 3,456 785,437 cor Gulu 125,423 6,225 3,874 9,149 1,830 223 359 18,755 84,934 843 431,975 Moroto 34,801 1,973 423 4,055 633 38 149 9,261 49,425 88 177,945 Jinja 90,707 12,847 4,986 9,912 2,439 36 406 25,046 140,473 990 500,952 Arua 82,082 11,168 4,824 20,187 6,245 1,194 362 21,172 112,978 1,454 436,526 Masaka - 330 20,141 104,850 302,115 Kabale 49,493 8,918 3,312 6,378 6,867 305 280 10,781 76,407 2,339 236,936 Fortportal 248,822 11,431 4,226 21,792 1,052 351 22,655 142,692 1,631 620,377 Total 1,761,150 146,032 68,024 315,563 34,335 5,329 5,123 349,698 1,708,873 27,796 7,500,036

Annual Health Sector Performance Report 117 Hospital Name Total OPD attendances Total ANC Deliveries in Unit Total Immunization Total Family Planning No. started ART Beds Admissions Patient Days Major Operations SUO Average for Average all Hospitals Average 2009/10 117,410 9,735 4,535 21,038 2,146 381 320 21,856 106,805 1,853 468,752 Min 34,258 1,973 423 4,055 - - 120 9,261 49,425 88 177,945 Max 248,822 25,509 7,561 49,340 6,867 1,194 482 60,152 231,161 3,456 1,045,578 Average 2008/09 96,231 12,197 4,662 27,623 346 20,574 667 439,848 Average 2007/08 136,446 14,329 4,777 336 18,559 3,015 453,348 Average 2006/07 121,038 12,772 4,496 334 16,934 697 411,804 Source: Hospital submissions for AHSPR 2009/10. And Resource Centre

Compared to the year before, there has been improvement in the following outputs: Outpatient attendance, admissions and major operations including the overall standard units of output. c) Quality assessment Previous analysis of quality of care has been based on still birth rate, maternal death rate, qualified staff per bed and cesarean section rate. However there was not sufficient information to make a comprehensive and comparative analysis to the previous years. It is important to note that a very high number of maternal deaths continue to occur in these hospitals, 37 maternal deaths occur in each hospital on average and 559 maternal deaths were reported by 15 hospitals. Hoima hospital is an outlier contributing 285 maternal deaths in the year. There is need to investigate this and address the reasons for this high death. d) Efficiency of use of services Regarding the scale of operation the mean hospital in this group is 320 beds, admits 21,856 patients and has a staff of 239. Generally the regional referral and the PNFP hospitals analyzed here have a high rate of utilization – Average bed occupancy is 91% compared to last year (2008/09) when it was 79%. In 2009/10 Staff productivity was 1,599 SUO/Staff greater than that for general hospitals (1,487). This is due to the very high utilization of regional referral hospitals. The average length of stay of 5 days is marginally higher than in the general hospitals (4.6) attributed to the case mix of patients in referral hospitals.

118 Annual Health Sector Performance Report Table 3.40: Efficiency parameters of Regional Referral Hospitals and large PNFP hospitals Hospital Name Beds Total Average Bed SUO SUO/ Admissions Length Occupancy Staff Of Stay Rate % Lira 350 15,543 7.5 91 380,794 1,360 St Raphael Nsambya 319 18,785 4.7 75 501,397 1,299 Mbarara 330 21,230 5.5 96 545,671 Soroti 294 21,955 4.4 90 454,879 2,382 Mubende 120 10,608 4.7 113 208,391 1,521 Mbale 460 60,152 2.4 85 1,045,578 Hoima 260 16,416 5.2 90 373,388 1,253 Rubaga 271 17,925 3.9 70 497,674 1,740 St.Mary's Lacor 482 39,273 5.9 131 785,437 1,528 Gulu 359 18,755 4.5 65 431,975 1,490 Moroto 149 9,261 5.3 91 177,945 1,534 Jinja 406 25,046 5.6 95 500,952 1,198 Arua 362 21,172 5.3 85 436,526 1,303 Masaka 330 20,141 5.2 87 302,115 Kabale 280 10,781 7.1 75 236,936 891 Fortportal 351 22,655 6.3 111 620,377

Total 5,123 349,698 7,500,036 2,133 Average 2009/10 320 21,856 5 91 468,752 1,599 Min 120 9,261 2 65 177,945 1,534 Max 482 60,152 8 131 1,045,578 2,034 Average 2008/09 346 20,574 439,848 Average 2007/08 336 18,559 453,348 Average 2006/07 334 16,934 411,804

Source: Hospital submissions for AHSPR 2009/10. And Resource Centre

National Referral Hospitals

Mulago Hospital The mandate of Mulago National Referral Hospital is to provide super-specialized healthcare, training and conduct research in line with the requirements of the Ministry of Health; with a vision of becoming the leading centre of healthcare delivery in Africa. In order to move towards this vision, the centre adopted the following strategic objectives:

Annual Health Sector Performance Report 119

i. To strengthen management systems and structures ii. To scale up the integrated super-specialised healthcare package iii. To formalize collaborative partnerships iv. To improve on customer care and public relations Progress Progress has been realized during 2009/10 as outlined below: 1. Strengthening of management structures and systems: i) The role of hospital administrators within the departments structure has been clarified and strengthened; ii) Staffs now have written job descriptions and there is an improvement of pay roll management; also a retention strategy for existing specialists has been developed e.g. the process of provision of housing and transport to Senior Consultants has just began with a plan to increase the number provided with housing and transport. iii) Harmonization of the procurement systems across departments as well as streamlining and strengthening of the supply chain management process. iv) Strengthening of the Hospital security system; 2. Efforts were made to scale up the integrated super-specialised healthcare package with a focus on increasing the human super-specialized resource capacity as illustrated in the examples below: i. Super specialists in various fields of specialization were recruited ii. Specialists were trained in Gastroenterology, Neurosurgery, Orthopaedics as well as the continued support given to those on MMed Programs. iii. Continuous Professional Development (CPD) is ongoing; iv. A platform to ensure exchange visits has been created with several universities. 3. In order to enhance infrastructural and space capacity that ensures that Mulago Hosptial can adequately provide super-specialised healthcare, a number of developments have taken place as outlined below: i) Architectural plans for Mulago III have been developed and an impact assessment study has been done. ii) Bills of quantities for women’s hospital have been done and those for Uganda Heart Institute are being developed. iii) The construction of Uganda Cancer Institute has begun and maintenance of existing infrastructure is ongoing. iv) The establishment of the following units: A telemedicine centre and the installation of an ICT program which is to become operational the following FY. v) Sickle cell clinic; vi) The relocation of the labour ward and theatre; vii)Construction of the PPS pharmacy;

120 Annual Health Sector Performance Report viii) Construction of staff restaurant.

4. Progress towards achieving the objective of formalizing collaborative partnerships include the development of monitoring mechanism for collaborations; development of a framework for collaboration and review of existing MoUs using accreditation criteria with a Memorandum of Understanding (MoU) template now in place.

Figure 3.11: Admissions and Outpatient visits in 2009/2010 Number of admissions and outpatients seen per quarter in the FY 2009/10

5. Admissions and Outpatient visits This FY Mulago Hospital provided services for 614,223 out patients and 120,848 in patients. The trends for both in and outpatients have been shown modest increases from 400,653 to 614,223 outpatients from 2000 to 2009. Over the past year, the numbers of patients seen in Mulago Hospital9 in and out patients) are evenly distributed over the past year (figure 3.11). Over the past 10 years, the admissions have also increased from 88,391 to 120,848 (figure 3.12).

Annual Health Sector Performance Report 121 Figure 3.12: Trends of admissions and outpatient attendances from 2000-2009

Mulago Hospital Admissions and Outpatients for the period 2000-2009

Butabika National Referral Hospital

Butabika Hospital was established in 1955, and is still the only National Referral Mental Health Institution in the country. The Hospital provides tertiary expert management for all patients with mental and psychological problems on a referral basis with a bed capacity of 550 patients. At the same time, it is a teaching hospital for all students who come for a placement in Mental Health ranging from nursing cadre to Postgraduate students. The Hospital is also mandated to provide specialized mental health care, train health workers and carry out mental health related research. In addition, Butabika Hospital provides General Outpatient services to the people from the surrounding areas of .

Performance during FY 2009/2010 i) Hospital patient care: In 2009/10, the centre provided mental health inpatient care to 4,394 first time admissions and 1,752 readmissions. Figure … shows that the number of first time admissions is much higher in 2009/10 compared to the previous two financial years. 95,106 patients were seen in the various clinics at the Outpatients unit. ii) Community Mental Health Services: A total of 1,225 patients were resettled in to their homes; 2,114 patients were seen at four of the mental health outreach clinics at Nansana, Kitetika, Nkonkonjeru and Maganjo-Nkonkojeru; also, 21 forensic clinics were conducted in Luzira prison; 959 patients were re-integrated with their families whilst another 475 were rehabilitated. iii) Funds from the Support to Health Sector Strategic Plan II (SHSSPP II) were used to train and conduct community sensitisation activities for both RH and Mental Health were carried out (see Table …).

122 Annual Health Sector Performance Report Figure 3.13: Admissions in Butabika Hospital from 2007/08 to 2009/10

First Admissions for Fy 2007/08 to 2009/10

600 July 500 Aug Sept 400 Oct Nov Dec 300 Jan Feb No ofPatients 200 Mar Apr 100 May Jun 0 2007/08 2008/09 2009/10 Financial years

i) Provision of Mental Health Training:1,812 Students from various Institutions were trained; – School of Health Science, , Kampala International University, Uganda Christian University, Aga Khan University, Paramedical Schools: School of Psychiatric Clinical Officers Butabika, Medicare Health Professional College Mengo, Health Tutors’ College and Nurses Training Schools of Masaka, Matany, Mengo, Mulago, Kalong, Rakai, Rubaga, , Kibuli, Nsambya and Butabika. ii) Technical support supervision to regional referral hospitals: Regional Hospitals of: Arua, Lira, Masaka, Gulu, Mbale, Jinja, Fortportal, Kabale, Hoima, Tororo and Soroti were supervised. iii) Research and advocacy: Research was conducted in the areas of mental health and research and 6 journal articles were published. iv) Infrastructure and development: the process of developing a master plan for the hospital has started; completed the construction of 3 semi-detached (2 in one) staff housing units; most of the hospital land was fenced off, remaining only about 500 metres which were incomplete due to inadequate funding; continuous maintenance of buildings, grounds and infrastructure. Butabika hospital benefits from the ‘Support to Health Sector Strategic Plan II (SHSSPP II) project that runs rom 2007-2012. Procurement during the financial year is summarized in Annex …

Annual Health Sector Performance Report 123 Table3.41: Summary of Reproductive and Mental Health activities in Butabika Hospital MENTAL HEALTH Activity Target Output Comments TrainingPsychiatry 12 M Med 8 M Med Psychiatry Could not raise the 4 and 3 have completed Clinical psychology 3 4

Msc Social Worker 4 3

Health tutors 3 5 4 completed

Psychiatric Clinical 5051 30 completed officers SeminarsDistrict leaders 12 regions 10 regions covered On going

Clinicians 12 regions 10 regions On going

Support to Supported development Tobacco control Workshop held and facilitated psychiatric unit MoH of policies policy Facilitated Monitoring Supervision Provided and supervision of mental vehicle health services

Reproductive Health

Trainings Logistics management 400400 Completed

Adolescent Sexual and 300300 Completed reproductive health

Family planning (basic) 100102 More need to be trained

FP Long term and 10060 On going permanent VHTs12248 12248 Some new areas for training came in. there is need for more training EmOC100 45 On going

Anesthetic officers 0 1 Still at school Support in this area is still required Support supervision By region obstetricians 4 visits2 conducted On going

By the central team 4 visits2 conducted On going

Support HC IVs for Mentoring 34 5 Lack of support services- provide surgery for Theatre, equipments, Emergency obstetrics infrastructure and personnel

Supply of training ProcuredDelivered to o MoH – completed equipments RH division

124 Annual Health Sector Performance Report v) Table 3.42 shows that the hospital received much less than was budgeted for. Also, research, advocacy and public relations were two of the outstanding underfunded priorities to the tune of six hundred and sixty million Ushs.

Table 3.42: Budget Performance for the FY 2009/2010: Details: Approved Actual Funds Percentage Budget Received Performance a) Non wage 2,798,707 2,096,874 89% b) Wage 1,569,694 1,390,990 75% c) Development 7,485,141 5,327,145 71% Total 11,853,542 8,815,009 74%

Challenges 6.1. Human Resource: Inadequate staffing levels across all cadres. Lack of adequate remuneration of staff leading to loss of morale, chronic absenteeism and a high attrition rate. 6.2. Insufficient Budget: Inadequate provision of financial resources to match with increasing number of patients, inflationary changes and high cost of medicines. 6.3. Disease Burden: Increased mental health disease burden all over the country leading to increased bed occupancy of 120%. 6.4. Supply of Drugs: Essential psychiatric medicines are not readily available in most centres. 6.5. Advocacy for Mental Health: Lack of community and social support for the discharged patients has continued to result into increasing number of relapses and re-admissions. 6.6. Delay in approval extension of contract periods by the Bank, hence leading to time loss of about one month. The bank approval of the contractors’ request for extension of completion dates was one month after the request. The contracts hence expired and no works were being done during the month. 6.7. Non availability of sound construction materials in some areas like Katunguru HCIII, Bufundi HCIII and Buhara HCIII in Lot 3 and Rukungiri sites in Lot 4. During the implementation phase (construction), material tests were carried out and many samples of especially sand failed. The materials hence had to be procured from far quarries thereby not only causing delays in progress but also increasing co0sts due to the haulm distances.

Annual Health Sector Performance Report 125 6.8. Revision of the VAT policy to exempt all Heath sector projects greatly affected the progress of works as claimed by the contractors that they continue to meet input VAT hence affecting their cash flows. This was the main reason for the extension of time given by the contractors who claim that they continue incurring input tax which is not recovered hence affecting their cash flows and profitability.

3.4.5.2 Oral Health

Oral health encompasses the positive aspects of good oral health, all conditions including dental caries, periodontal disease and derangement of the oral-facial tissues. Oral health problems are important public health problems because of their high prevalence in the in the population. According to the National Oral Health Survey of 1987, dental caries affects 51% of the children below 6 years, 60% of the children between 6-12 years, 68% of adults between 33-44 years and 82% of adults above 55 years. For Gum diseases 80% of children below 6 years have poor oral hygiene. The goal of the oral health programme, therefore is to ensure the availability of safe and appropriate oral health services for the entire population. Strategic objectives i) Develop National oral health strategies and implementation plans focusing on the nation al, districts and community levels. ii) Integrate oral health care activities into other health and related programs and institutions (e,g maternal and child health, nutrition, schools and sanitation programs). iii) Strengthen district health facilities with appropriate oral health technologies and human resources. iv) Capacity building using the locally available staff in the health sub-districts.

The goal of the oral health program is to ensure the availability of safe and appropriate oral health services for the entire population.

126 Annual Health Sector Performance Report Table 3.43: Performance against oral health programme indicators HSSP II 2004/05 2005/6 2006/7 2007/8 2008/9 2009/10 Comments target/indicators

Guidelines on Target fairly oral health care achieved developed 40% 45% 48% 60% 65% 50%

HC IVs with 10% 10% 18% 18% 18% 18% No Ministry of well equipped Health project and functional to equip HC dental units IV.s with dental units

Awareness of 10% 10% 13% 20% 50% 50% Target fairly the population of achieved the risk factors and prevention of oral disease/conditio ns increased

Access to 42% 42% 50% 50% 50% 60% There is need primary oral to extend oral health care health care services to HC III level

Develop a None None Draft Final draft Final Oral Target National Oral oral was made draft health achieved Health policy health printed launched policy

80% 90% 100%

Challenges The biggest challenge is the low prioritization and public health funding of oral health services. Subsequently, the following health system gaps are observed: i) Inadequate equipment in most government hospitals and HC IV’s ii) Lack of dental infrastructure in many districts especially the new ones. iii) Non- or under utilization of many of the oral health care workers in the district PHC programs. iv) Non recruitment of oral health staff in most districts.

Annual Health Sector Performance Report 127 Recommendations i) The health infrastructure division should incorporate in their annual budget a phased rehabilitation and construction of new infrastructure for oral health, especially in the new districts. ii) Due to limited funding oral health awareness activities should be integrated into other programs like school health, maternal and child health, nutrition, HIV/AIDS, Health education iii) There is need to increase funds for oral health care services in the country.

3.4.5.3 Nursing section

The nursing profession comprises the largest category of health professionals that provide health care within the country. These professionals carry the responsibility of bringing health services to all communities through the spectrum of health care delivery mechanisms from primary health care up to tertiary levels of health care. Any shortage experienced in this professional cadre negatively impacts on access and the quality of care that is enshrined in the country’s constitution and Ugandan National Health Policy. Therefore to achieve and maintain an adequate supply of nursing professionals who are appropriately educated distributed and deployed to meet the health needs of the Ugandan population; the nursing department is charged with the responsibility of offering technical support supervision, capacity development, deployment of nursing personnel in RRH and coordination nursing activities as indicated below.

Technical Support Supervision

The main objective was to improve standards and quality nursing care. It is also carried out to identify HRH issues affecting the provision of quality health services.

Achievements

The Nursing Department has stepped up the technical support supervision visits. This has enabled the nursing leadership to reach and address about 30% of the nurses in both in private and public health facilities on a number of issues affecting the provision of nursing care. The nurses especially in the public health facilities were addressed on issues concerning poor attitudes, communication skills and customer care. Areas of effective documentation and medical legal issues were also highlighted. The department has also participated in the Area Team support Supervision.

Challenges Although the Uganda National Minimum Health Care package (UNMHCP) is well defined under the four clusters namely: (i) Health Promotion, Disease Prevention and Community Health Initiatives; (ii) Maternal and Child Health; (iii) Prevention and Control of Communicable Diseases; and (iv) Prevention and Control of Non-Communicable Diseases

128 Annual Health Sector Performance Report (NCDs) emphasis during the implementation has remained very limited due to a number of factors. i) Severe shortage of nurses and midwives is affecting the quality of nursing care. ii) Constant stock out of essential medicines and supplies in a good number of heath facilities. iii) Guidelines such as blood transfusion and injection controlguidelines; protocols and manuals on practical standard procedures are either not available or not being utilized.. iv) Infection control committees are not functional in majority of the facilities. In addition infection control equipment and supplies were constantly in short supply and in most facilities nurses lacked protective gear/ uniforms. One could hardly tell the difference between the health care provider and the client. v) In most health centers especially health centre IVs and general hospitals, health services were being provided largely by nurses and where there were no nurses the nursing assistants seemed to be running the health facilities under no adequate supervision. vi) Although the training of Nursing Assistants has been rendered illegal, new institutions have continued to emerge vii)Although there has been improvement in infrastructure, these are not being fully utilized e.g. a number of mental health units where there is a shortage of staff. Also a good number of staff houses have not been renovated while the majority of nurses face acute shortage of accommodation. viii) Many regional and general hospitals have no fully established casualty departments and most nurses in these health facilities have not fully acquired skills in disaster preparedness. ix) While VHTs are playing an important role in health care promotion and provision their functionality has remained very limited due to lack of support from the trained health workers in many districts due to acute shortage health care providers.

Capacity building

Through collaboration with UNFPA / Midwifery project about 80 midwives from Northern and Western Region were trained in current issues in reproductive health. 20 Nurse leaders at National and Regional Referral Hospitals were also trained in leadership for change Course developed by International Council of Nurses. In response to the high burden of tuberculosis in Uganda, 50 nursing staff working at various levels of care received training on new TB treatment guidelines. In addition, a good number of research papers were also presented during the Annual Scientific Conference for Nurses and Midwives. However, there is a need to establish regular meetings of researchers and policy makers to turn research findings into policy. There is also lack of a national database for research done hence rendering it difficult to access.

Annual Health Sector Performance Report 129 Coordination and collaborations of nursing activities Through the Egyptian Technical Corporation and collaboration, eight (8) nurses were able to attend fully sponsored short courses on women’s health, reproductive health and MCH(safe motherhood). Also under the support of Capacity project the scheme of service has been developed to near completion. In addition the Nursing Strategic Plan has been finalized pending stakeholders input. Under the guidance of WHO and UNFPA terms of reference the consultants to review the training of comprehensive nursing has been developed. The final report is expected at the end of November 2010. Furthermore collaborative and coordination efforts between the Nursing Department, Ministry of Education and The Nurses Council have been strengthened. E-Learning training curricular and the training cadre to be trained under the support of AMREF have been identified and the E-learning Project is due to start shortly.

Through the WHO support a member from the Nursing Department and other 2 officer from UBTS and Mulago Hospital attended a workshop on blood transfusion. A number of challenges associated with the effective management of Blood transfusion were highlighted and an action plan towards the improvement of these services needs to be implemented.

Recommendations

i) While all the planned technical support visits were carried out there is a need to scale up to ensure good quality of care and mentoring professionals at regional and primary care levels. ii) Lack of staff accommodation – staff travel long distances to the health facilities leading to late coming , absenteeism, and leaving stations early. iii) There is a need to quantify medicine and health supplies requirements and provide enough quantities in the health facilities to enable nurses and midwives to provide services efficiently. iv) Develop strategies to strengthen and streamline district HRH planning, recruitment and management to improve staffing levels in districts and facilitate data driven budgeting and equity in health workforce distribution v) Although the Nursing Department continues to work closely with the Uganda Nurses and Midwives council there remains a major challenge for the Council in improving and maintaining the quality of nursing services delivered to individuals and communities in accordance with the national policies and priorities. These challenges include inadequate financial and human resources. vi) The issues associated with the nursing workforce are particularly complex and dynamic and involve multiple stakeholders, including governments, employers, professional associations, Nurses union, and educators. Therefore, addressing the long standing wrangles within the Uganda Nurses Union leadership would require the full involvement and cooperation of all of these organizations in order to maintain a productive and professional workforce.

130 Annual Health Sector Performance Report 3.4.5.4 Palliative care

Palliative Care (PC) is an approach that aims to improve the quality of life of patients and their families facing life threatening illnesses and those with severe pain, such as HIV/AIDS and Cancer. Understanding Palliative Care has helped to extend appropriate care to other forms of illnesses associated with severe pain such as sickle cell anemia, severe burns and in some cases of accidents. The strategic objectives of Palliative Care under the HSSP II have been defined as 1. Increasing the number of health workers trained to provide Palliative Care 2. Increasing the number of patients accessing Palliative Care. Ministry of Health has continued to partner with different organizations for the development of human resources, provision of oral morphine and other medications, and for monitoring and supervision of Palliative Care services in the health facilities. The Ministry of Health provided free oral morphine for pain and symptom management to those who needed it, and Coordinated all Palliative Care stake holders and Development Partners involved in implementing services at the districts to ensure provision of quality Palliative Care services.

Challenges i) There is still limited appreciation of Palliative Care among some health facility managers, the public and policy makers. Inadequate funding to meet the training needs for the health workers. ii) Continued stock outs of oral morphine and other required medicines, iii) There has been slow scale up of Palliative Care services to districts. iv) Lack of transport for support supervision and mentoring of trained health workers

Annual Health Sector Performance Report 131 132 Annual Health Sector Performance Report CHAPTER FOUR INTEGRATED HEALTH SECTOR SUPPORT SYSTEMS

Integrated Health Sector Support Systems This chapter describes the sector’s performance on the six interdependent building blocks that support the implementation of the UNMHCP. 4.1 Health Financing

The goal of health financing for the sector is to raise sufficient financial resources to fund the sector programs whilst ensuring equity and efficiency in resource mobilisation, allocation and utilisation. The medium term objectives include: 1 To mobilize additional resources to fund the sector strategic/investment plans 2 To ensure effectiveness, efficiency and equity in resource allocation and utilization. 3 To ensure transparency and accountability in resource utilization

Health care financing provides the resources and economic incentives for operating health systems and is a key determinant of health system performance. Equitable financing is based on: financial protection, progressive financing and cross-subsidies.

Efforts to improve health financing were guided by concepts of universal coverage and social health protection. The health sector was financed through government revenue, private sources and development assistance under the SWAP arrangement. At the start of HSSP II, the per capita expenditure for health fell far short of the amount needed to finance the UNMHCP. For instance, provision of UNMHCP in all health facilities was estimated at USD 41.2 in 2008/09 and was expected to rise to USD 47.9 in FY 2011/12 (HSLP Africa Limited, 2008).

Trends of the Health Sector funding 2006/07-2008/09

One of the HSSP II financing benchmarks was working towards having a 15% proportion of the total GoU budget. A more realistic estimate for the HSSP II was put at 13.2 %. The figure 4.1 and table 4.1 below illustrates how well the sector has performed in this respect.

Although funds allocated to the Health Sector have steadily increased from Ushs 236 Billion in Financial Year 2006/07 to Ushs 735 Billion in Financial Year 2009/10; they are still inadequate to fund the UNMHCP. An estimated Ushs 1.5 Trillion is required annually to deliver the UNMHCP25.

Annual Health Sector Performance Report 133 Figure 4.1: Graphical illustration of Government’s allocation to the Health Sector from 2005-2009

Whereas resources allocated to health have been increasing steadily, the public per capita expenditure has averaged at 8.9 USD over the last ten years. The percentage of government allocation to health as a proportion of the total GoU budget has not significantly increased. This trend has important implications for service delivery as it will imply the need for further priority setting. If Uganda’s population grows at current rates, there will be need for Government to correspondingly increase the health budget to meet the needs of the population. The government budget for health is allocated at the Central and Local Government levels. About 52 % of the health sector budget is decentralised.

Table 4.1: MTEF allocation to the Health Sector from 2000-2009 Per capita Per capita GoU allocation expenditure expenditure to health as % in Ushs in USD of total GoU Year GOU DONOR/GHI TOTAL allocation 2000/01 124.23 114.77 239 10,349 5.9 7.5 2001/02 169.79 144.07 313.86 13,128 7.5 8.9 2002/03 195.96 141.96 337.92 13,654 7.3 9.4 2003/04 207.8 175.27 383.07 14,969 7.7 9.6 2004/05 219.56 146.74 366.3 13,843 8 9.7 2005/06 229.86 268.38 498.24 26,935 14.8 8.9 2006/07 242.63 139.23 381.86 13,518 7.8 9.3 2007/08 277.36 141.12 418.48 14,275 8.4 9 2008/09 375.46 253 628.46 20,810 10.4 8.3 2009/10 435.8 301.8 737.6 24,423 11.1 9.6 Source: MoFPED approved estimates and Budget performance reports.

3. Analysis of health spending in FY 2009/10.

An analysis of health expenditure in FY 2009/10 highlights the following issues;

134 Annual Health Sector Performance Report 1. Government funding of health services is still inadequate estimated at 11.1 USD Per capita in FY 2009/10. 2. Donor support for health is a major component of the budget though largely targeted to three disease areas namely; Malaria, HIV/Aids and TB, 3. The bulk of the Donor support to the Health Sector approximately 41% is off budget 4. A significant proportion (21%) of the Government of Uganda expenditure on health is mainly on payment of salaries. 5. The government budget for health is allocated at the Central and Local Government levels. About 52 % of the health sector budget is decentralised 6. There is high fragmentation within and between health financing mechanisms, mainly due to high reliance on out-of-pocket payments and limited prepayment mechanisms. Without compulsory health insurance and with the low coverage of private health insurance, Uganda has limited pooling of resources, and hence minimal cross- subsidization.

Table 4.2 :Central government transfers FY 2009/10 budget performance billions of Ugx ITEM Approved Budget Actual performance Percentage PHC Wages 107.4 102 95% PHC Non wage 18.2 17.9 95% General Hospitals 10.2 9.7 95% PHC Nonwage-NGO 16.5 15.7 95% NGO wage Subvention 1.14 1.08 95% PHC Development 15.4 14.2 92% PRDP 23.4 22.8 97% Total 192.24 183.38 95% Source: MOH- Budget and Finance Division.

4.2 Donor support

Donor or Development Partner (DP) funding contributes a substantial amount to the health sector budget in Uganda. This support is channeled through budget support, project funding and off budget support.

The proportion of the project support in the FY 2009/10 budget was 41%. However, the Health Sector continues to receive a large share of resources (technical support, financial, medicines and equipment) through off-budget financing mechanisms. Off budget support was estimated at 59%, approximately Ushs 440 billion in FY 2009/10.

Annual Health Sector Performance Report 135 Figure 4.2: Donor support to the health sector 2007 to 2010

The major constraint is that, while these resources are targeted at health, the off budget spending priorities are not aligned to existing Government plans; there has been duplication of interventions and excessive spending on low priority areas such as administrative costs.

To implement a strategy for the alignment and harmonization of financing and implementation mechanisms, Government has developed a Long Term Institutional Arrangements (LTIA) framework for the health sector. Under this arrangement, Government seeks to promote the budget support financing model for all development assistance to the health sector, and to compel Donors to support the strengthening of the local health institutions to implement projects and programs rather than to institute stand alone project management teams.

The objective espoused in this measure is to reduce the overall financial burden of project management and to enable the aggregation of common results. While this strategy was initially proposed for programs funded by the Global Fund for TB, AIDS and Malaria, a section of budget- support Donors have agreed to a joint assessment of results by adopting a common Joint Budget Support Framework (JBSF) and the monitoring tool called the Joint Assistance Framework (JAF).

5. National Health Insurance (NHI) Scheme As part of Government’s efforts to improve and re organise health financing and related outcomes, a Health Insurance scheme is being designed and developed for Uganda. This plan comprises Social Health Insurance which will operate concurrently with Community Health Insurance and Private Commercial Health Insurance. The Health Insurance plan will be introduced in a phased approach. The plan is designed to work in harmony with other social security benefits under development in other government sectors. The Ministry of Health shall work with the Social Protection Directorate of Ministry of Gender, Labour and Social Development to develop a regulatory system to address accreditation and pricing of health care services.

136 Annual Health Sector Performance Report Progress Country wide regional sensitisation commenced in Karamoja, Busoga, Lango, West Nile, Acholi, Central, Kigezi, , Teso, Bugisu, Mbale and Bunyoro regions and is ongoing in other regions. Numerous technical studies have been finalised including stakeholder analysis, economic analysis, actuarial analysis, policy options for medicines benefit package, guidelines for private wings, and critical analysis of the proposed NHIS along health financing functions. The Ministry of Health submitted the drafting instructions Bill to govern the health insurance scheme to the 1st parliamentary counsel for drafting the law. The MOH received comments from the counsel on the Bill and has responded to them. The Bill is planned to be tabled in Parliament in 2011 and the Scheme envisaged to be launched in 2012. Major challenges 1. Absence of a legal framework Mto implement the scheme 2. Inadequate funding to roll out some country wide activities. 3. Capacity building of local institutions Recommendations There is need to strengthen capacity building of local institutions and have a continuous awareness campaign

6.0 Health Financing in Local Governments Health financing in Local Governments is mainly through Central Government PHC grants transfers. The following are some of the grants disbursed to Local Governments; PHC conditional grant for wages, PHC Non wage grant, PHC NGO facilities non wage grant, PHC development grant, NGO Wage subvention grant, General Hospitals Non wage grants, Projects funds from donors – both on and off-budget, Peace recovery development program, Northern Uganda Social Action Fund, Local Government service delivery and management program. The Central Government transfers to the health sector account for almost 98% of the funding to health services in Local Governments. Out of shs 1.3 trillion transferred to Local Governments for service delivery in all sectors, the health sector share of the total transfers to Local Governments is Shs 192 Billion which accounts for about 15% of the central Government transfers to Local Governments for service delivery. Some Local Governments co- finance up to 1% of the health services using their own locally raised resources (table 4.2). Resource Allocation In financial year 2009/10, the Government had planned finance Health services in Local Governments at a cost of Shs 192.8 Billion which represents 46% of the GOU health sector Budget, However Shs 183.3 Billion was released and spent for health service delivery in Local Governments in financial year 2009/10 representing 95% actual performance. This translate to Shs 6274/= per capita or about $3 per capita per year. There has been a growing concern that the present grants formulas are not adequately servicing the purpose of establishment of a sufficient level of equity in decentralised health service delivery. Whereas resources allocated to decentralised health services have been increasing steadily, the per capita expenditure has been

Annual Health Sector Performance Report 137 fluctuating from USD 4.4 in 2007/08 to USD 3.0 in financial year 2009/10. An issue in District resource allocation arises on how to compensate for external inflows of funds (off- budget) in Districts with lower inflow of external off budget funds to help solve equity issues. Equity in this case requires that areas with greater health needs receive relatively more financial resources than areas deemed to have less health care needs. A total of Shs 37.2 Billion (20 % of local government health expenditure) was spent on health infrastructure development and procurement of medical equipments while Shs 102 Billion was spent on health workers salaries (56 % of Local government health expenditure). There has been general increase in decentralised health service financing from financial year 2008/09 with significant improvements recorded in 2009/10 compared to financial year 2008/09. Figure 4.3 : Central government transfers performance FY 2009/10

Source: MOH- Budget and Finance Division. The performance targets in Local governments have not fully been achieved due to limited resources; greater attention should be paid to issues of equity to ensure access to the most vulnerable population. For example immunisation coverage has reduced in most Districts to an average of 76% and most targets have not been achieved in financial year 2009/10 as indicated in the District League table. The key outputs achieved by Local Governments include; construction and rehabilitation of health units, maternity wards, general wards, staff houses, OPD and theatres. Medical equipments were procured and supplied to Health facilities under the ORET project.

138 Annual Health Sector Performance Report Figure 4.4 : Central government grants percentage share of various grants FY 2009/10

Source: MOH- Budget and Finance Division Human Resources Significant disparities exist in staffing levels with staff establishment filled on average at 48%. This has affected health service delivery, further more limited resources has made it difficult to attract some health cadres especially in hard to reach and hard to stay areas. The existing staff appraisal system has been rendered redundant hence cases of absenteeism and attrition are so high in Local Governments resulting in resource wastage. According to UBOS, National panel survey report 2009, up to 37% of health workers are absent from their duties due to reason of being off duty or on night duty. The most affected category of health cadres on absenteeism rate are health assistants. Some staff seconded to support projects especially under HIV/AIDS regularly abandon their routine government responsibilities in health units and that weakened health service deliveries in public facilities and PNFPs in financial year 2009/10. On issues of Governance, the performance of councils, committees and commissions in Local governments has not been satisfactory due to capacity issues in areas of leadership, management, planning and budgeting. Most Health unit/Hospital management committees have not been able to deliver to the expectation of the Ministry; issues of functionality of statutory committees need to be addressed through institutional capacity building. Key Challenges in Decentralised Health service Delivery during financial Year 2009/10. i) Inadequate resources for delivery of the UNMHCP. ii) Rampant Drug stock outs and delays in delivery of drugs iii) Poor health infrastructure especially in general Hospitals. iv) In adequate supply of safe blood to health facilities. v) Under staffing vi) Increasing cases of drug abuse vii)Low immunisation coverage compared to 2008/09. viii) Low functionality of VHTs ix) Weak and non functional governance structures

Annual Health Sector Performance Report 139 7.0 Efficiency of service delivery Efficiency of service delivery is among the key strategies of the sector to improve access amidst resource constraints. Efficiency means obtaining maximum output possible from available resource inputs given the available technology. This analysis looks at productive efficiency, which is the efficient production of a basket of goods. In this instance, the goods refer to a set of outputs produced by service delivery levels (districts). Within productive efficiency we distinguish, technical (operational) efficiency, allocative efficiency and X- efficiency. This section will only focus on technical efficiency which looks at the comparison between the observed and optimal quantities (given inputs and outputs). In other words we measure the observed or actual level with the potential optimal level. Efficiency analysis was undertaken using the Data Envelopment Analysis technique (DEA). Data envelopment analysis also referred to as comparative analysis, analyses the relative performance of different entities performing similar functions. The provided efficiency scores are relative to the best performing entity based on peer group comparisons. The output- orientation has been used to identify districts that produce the maximum output mix from the given level of inputs. Analysis was undertaken at the district level, looking at the district as a production unit. Inputs included26: i) health expenditure per capita (PHC wage, recurrent non wage and development, NGO grant) ii) number of health units in the districts Outputs included 27 i) % children <1 received 3 doses of DPT according to schedule, ii) total Govt and NGO OPD utilization per person per year, iii) % Deliveries in Govt and NGO health facilities, iv) % Pregnant women receiving 2nd dose Fansidar for Intermittent Preventive Therapy (IPT) The NGO grant has been included because the outputs used include the PNFP sector. Regional referrals have been excluded because they serve more than one district and it was not possible to apportion their inputs and outputs to the districts they serve. These results should be interpreted bearing in mind that DEA uses comparative analysis. It compares with the most efficiency unit among the entities being studied. The comparator may therefore not be technically efficiency compared with the gold standard. Overall level of efficiency:

26 We have excluded number of health workers in post because data is not readily available 27 We have excluded availability of HIV services due to lack of data.

140 Annual Health Sector Performance Report Nineteen (19) districts had an efficiency score below 80% as shown in figure 4.3. This means that they can increase their level of output by 20%, while those below 60% can increase their output by 40% at the same level of inputs. Figure 4.5: districts with an efficiency score below 80%

This means that they can increase their level of output by 20% - 5% at the same level of inputs. There were however some districts that operated at 100% efficiency as shown in table 4.2

Table 4.2: Districts that operated at 100% efficiency ABIM KABAROLE KABALE MBALE AMOLATAR KALANGALA SIRONKO MBARARA BUDAKA KAMPALA SOROTI NAKAPIRIPIRIT BUDUDA KAMWENGE YUMBE OYAM BUKEDEA BULIISA KOTIDO RUKUNGIRI HOIMA DOKOLO KUMI KIBAALE ISINGIRO GULU LYANTONDE KIRUHURA MANAFWA KOBOKO KITGUM

Annual Health Sector Performance Report 141 Figure 4.6: Twenty nine (29) districts with an efficiency score ranging between 80% - 98%

Details of efficiency scores and returns to scale for the different districts are shown in Annex II The first attempt to undertake this analysis was for the FY 2008/09 which showed that only 30 districts had an efficiency score of 36%. Between the two years, there has been improvement in technical efficiency scores for the majority of districts. Table 4.2 shows districts with significant reductions or improvements in technical efficiency scores. Details for other districts are shown in annex IV.

Table 4.3: Districts with significant changes in efficiency scores between 2008/0 and 2009/10 change in the efficiency score Efficiency Efficiency Score between 08/09 and District Score 2008/09 2009/10 09/10 KIBAALE 100% 60% -40% NAMUTUMBA 98% 80% -18% KYENJOJO 93% 77% -16% KALIRO 89% 74% -15% RUKUNGIRI 100% 85% -15% KISORO 84% 76% -8% RAKAI 62% 92% 15% KASESE 77% 71% -6% NAKASONGOLA 93% 87% -6% BUSHENYI 81% 95% 14%

142 Annual Health Sector Performance Report

change in the efficiency score Efficiency Efficiency Score between 08/09 and District Score 2008/09 2009/10 09/10 MASAKA 85% 99% 14% BUGIRI 70% 86% 16% PADER 79% 91% 19% APAC 72% 92% 20% OYAM 100% 100% 37% BUNDIBUGYO 63% 85% 22% AMURIA 76% 100% 24% KATAKWI 74% 99% 25% IGANGA 57% 85% 28% PALLISA 74% 93% 36% MASINDI 57% 100% 43%

The highest reduction in efficiency score between 2008/09 and FY 2009/10 was registered in Kibaale which reduced by 40% while the highest improvement was registered in Masindi which increased by 43%. 8.0 Financial Contribution from the Facility Based Private Not for Profit Sector (FB-PNFP): 2009/2010 In the financial year 2009/2010 the facility-based private-not-for-profit (FB-PNFP) sub-sector mobilized financial resources amounting to 124 billion shillings compared to 113 bn reported in 2008/09 (FY). The 10% increment is attributed to a combination of capital donations and the MOH- DP Bursary funds for PNFP Health Training Institutions. Overall, user fees and government subsidies reduced in their relative contribution to the PNFP budget by 5.5% and 4% respectively.

Government contribution continues to finance PNFP services less and less in both absolute and relative terms. In 2007/08 the total (PHC CG, Drug Credit Line, and Laboratory Credit Line) all made up 19.6 bn. Shillings, financing 22% of the PNFP expenditures. In 2008/09 the total support dropped to 18.9 bn. shillings and financed only 20% while in 2009/2010 it only financed 16% in relative terms as total cost increased because of both the increased volume of work and output but mainly because of increased unit cost of services. This represents, in relative terms, a further decrease in budget support to both PNFP Hospital and Lower Level Health Units by 5% and 2% respectively. Data from a sample of 27 PNFP hospitals indicates that the amount of PHC CG allocated to them for 2009/10 totaled Sh. 7,029,808,417. But they reported actually received only Shs 6,602,434,665, this being 94% of the allocation for the year. The sample of 12 health training institutions (HTIs) (UCMB health training schools) reported actually receiving a total of sh. 333,038,671 for two consecutives years and was only (80%) out of a total allocation of sh. 416,342,920 for each of the respective financial years. In 2009/10 financial year 20 PNFP

Annual Health Sector Performance Report 143 HTIs received funds from the MOH-DP- Bursary Account to support disadvantaged students from the underserved districts. This amounted to sh. 602,000,000.

PNFP facilities have in the past not only reduced user fees but also flattened them selectively as a result of budget support from government. But rising unit costs of services along with now reduced budget support from government to individual facilities means that facilities have to struggle to raise more money through user fees to finance the services. Inflow from users has relatively reduced in its share by 5.5% compared to an increase of both in absolute and relative terms (+4%). This FY user fees financed up to 50% of the overall recurrent cost incurred by health facilities to deliver services. The level of recurrent cost recovered from user fees is still higher in Lower Level Health Centers (68%) compared to Hospitals (43%). Lower level facilities receive relatively less budget support. They are the more rural, placed among the poorer. The external donation both in kind and in cash increased in terms of relative contributions to the PNFP budget by 10% from 24% to 34%. This unpredictable source increased slightly after a consistent reduction over 3 financial years since 2007/08. This increase was observed only in the Hospitals (13%) while the Lower Level reported a reduction of 4%. It is mainly due to capital investments. Donors are less willing to support recurrent costs. The structure of income, financing recurrent cost, described in the graph below, shows the relative proportion of the different source of income for operational cost over a period of 12 years for the FB-PNFP health sub-sector. The sustainability of services is unpredictable as evidenced by the gradual decrease from User fees and Government contribution which are the main sources of financing for recurrent operations in the PNFP sub sector.

Figure 4.7: Trends in income for recurrent cost in the PNFP health sector (Hospitals + Lower Level Facilities)

PNFP Health Sector - Trends in Income for Recurrent Operations 100,000,000,000

90,000,000,000 34%

80,000,000,000 25% 30% 70,000,000,000 39% 32%

60,000,000,000 29%

50% 50,000,000,000 26% 55% 20% 40,000,000,000 48% 42% 38% 43% 30,000,000,000 24% 30% 43% 22% 45% 22% 20,000,000,000 45% 58% 47% 63% 29% 10,000,000,000 36% 31% 23% 24% 22% 20% 16% 22% 33% 15% 18% - 1998-99 1999-00 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 Govt. Subsidies (money and drugs) User Fees Aid Source: Bureaux databases

144 Annual Health Sector Performance Report Hospitals

In this 2009/10 FY, income from user fees contributed (44%) and the main source of financing with an increase of 3% as compared with previous financial year. Aid in form of cash from outside the country (donation of goods, equipment and drugs as well as project moneys) was the larger source of financing (42%) with a slight decrease of 2% compared to the previous financial year. This is the third consecutive year in a row that contribution from aid moneys is reducing. Moreover 79% and 70% of aid money represented the Global Health Initiatives related programs (HIV, TB and Malaria) in 2008/09 and 2009/10 respectively. Government subsidies represent now a proportion of only 14% of total hospital income (a decrease of 1% from 15% recorded in 2008/09). Figure 4.8: Relative sources of income over time – FB PNFP Hospitals

Relative sources of income over time - PNFP Hospitals 100%

90% 33% 36% 37% 35% 36% 80% 43% 40% 42% 44% 47% 45% 44% 70%

60%

50% 38% 36% 36% 40% 49% 44% 34% 56% 36% 35% 39% 41% 44% 30%

20% 27% 27% 23% 24% 10% 19% 20% 15% 18% 16% 11% 15% 14% 0% 1998-99 1999-00 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10

Govt. Subsidies (money and drugs) User Fees Aid

Source: Bureaux databases

Total service output of a sample of 65% of PNFP hospitals (Standard Unit of Output – SUO) increased by 17.4%% in the last year. But the increasing dependence on user fees is likely to affect accessibility if the trend is not reversed. Rural facilities, placed among the poor will be most affected. This underlines the need of an increase of Government support to reduce the increasing share from patients and improve service utilization. Lower Level Health Centres (LLHCs) The largest source of financing in LLHCs is represented by user fees (64%) that have registered an increase of 6% compared to 58% reported last 2008/09 FY. From figure 4.5 below it can be noted that donors’ input and Government subsidies have decreased for the 4th year in a row in their relative contribution. The decrease in the previous 2 years was 2% and 3% for Government subsidies and Aid respectively. Reliance on user fees negatively affects both the Govt and PNFPs objective of increasing accessibility to services. The prevailing reducing Government budget subsidy against rising unit cost of services make user fees the current option of financing health services.

Annual Health Sector Performance Report 145 Figure 4.9: Relative sources of income over time - PNFP LLUs

Relative sources of income over time - PNFP LLUs 100%

15% 90% 18% 22% 24% 25%

38% 36% 80% 41% 43% 46% 53% 70% 60%

60% 43% 43% 58% 64% 50% 49% 37% 31% 35% 40% 32% 44%

30% 36% 26%

20% 35% 33% 28% 27% 27% 26% 23% 10% 22% 21% 14% 11% 13% 0% 1998-99 1999-00 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009/10 Govt. Subsidies (money and drugs) User Fees Aid

Source: Bureaux databases 8.0 Monitoring Framework- The financial performance is monitored through the following modalities; i) Review of financial plans and reports submitted by the various sector institutions. Local Governments submit quarterly Performance Form B while center Sector Institutions submit Performance Form A reports to MoFPED -the basis on which funds are released to the respective institutions. ii) Participation in area team visits. iii) Supervision visits. 9.0 General Health Sector Challenges i) Funds allocated to the sector are insufficient for the sector to implement its activities fully. ii) Unpredictability of donor disbursement due to challenges in meeting the precedent disbursement conditionalities, iii) Increased cost of inputs distorts the set plans and allocations. iv) High population growth puts pressure on existing resources since some activities are for universal coverage e.g. immunization. v) Financial management skills are inadequate among health facility managers at lower level facilities. vi) Monitoring and documentation of off-MTEF investment in health is still a challenge. There is high off-MTEF Donor Project spending. These funds are often spent without stakeholder prioritization in line with HSSP. Much of this is spent in the private sector, and with limited involvement of the private sector in the government HMIS, this creates difficulty in estimating actual per capita investment in health.

146 Annual Health Sector Performance Report 4.2 Human Resources for Health

Human Resource for Health Management in the health sector is coordinated under the oversight leadership of two key divisions of the Ministry of Health, namely the Human Resource Development Division (HRDD) and Human Resources Management Division (HRMD). The HRMD handles the personnel aspects of recruitment, deployment, workplace safety, remunerations, retention, exit and post exit functions. The HRDD on the other hand handles the HRH aspects of education and training such as basic, post-basic, postgraduate and in-service training training to improve skills and technical competences, quality performance and productivity of the health workforce. Some management aspects of HRH are jointly handled by both divisions such as HRH policy development and review, HRH planning, motivation etc.

4.2.1 Human Resources Management

The role of the Human Resource Management Division (HRMD) is to ensure availability of trained and motivated human resources for health and have them equitably distributed throughout the country to contribute to effective delivery of the Uganda National Minimum health Care Package (UNMHCP). The Division spearheads personnel management strategies and processes to strengthen institutional capacity and Stakeholder’s coordination to ensure effective delivery of the UNMHCP.

a) Main Achievements of HRM Division

The main achievements of HRM Division are jointly coordinated with HRDD and are as presented in Table 4.1 below on staffing norms, HRH Policy formulation and reviews and the HRHIS information Systems development.

Table 4.4: Main Achievements of the Human Resource Management and Development Divisions Indicator 2004/05 2005/ 06 2006/07 2007/08 2008/09 2009/10 baseline

Staffing Levels 68% as per No data captured. 38.4% (Target of 38.4% 53% 56% increased from HSSP I norms 65% for HSSPII) Staffing norms 68% to 90% by end of 90% reviewed and new of 2009 target set at 65% (HSSP I ) An integrated Data collected HRHIS developed at HRHIS piloted in HRHIS HRHIS Extended HRHIS in place by for development MoH headquarters 2 districts of extended to extended to to 33 more Dec. 2005 of HRHIS Mbale and Professional 10 districts districts Kapchorwa Councils

HRH Policy and Consultative process HRH Policy and Policy and Policy Policy Strategic Plan in for development of Plan developed Plan in implemente implement place by end of the policy place d ed 2006

Annual Health Sector Performance Report 147 b) Other achievements of the HRM Division To support staff attraction and retention a number of measures have been put in place: A comprehensive motivation and retention strategy has been developed to guide the sector on management and implementation of the hard-to-reach and stay (HTR&S) in an effort to increase staff retention and reduce attrition; and the general staff Motivation Strategies for health workers. i) A “Hard to Reach” policy has been finalized. Government gave 30% increment to all civil servants in the hardship districts starting FY2010/11 ii) Salary enhancement for scientists has been implemented. iii) Workplace health and Safety policy and guidelines were developed and disseminated to all districts during FY 2008/09. Three districts of Oyam, Amolatar and Kabarole have been facilitated to operationalise the Workplace Health and Safety policy and formed committees to oversee the implementation. iv) Draft restructuring report for the National and Regional Referral hospitals and MoH headquarters has been produced and submitted to Ministry of Public Service for approval. v) The posts of Hospital Director for the 13 Regional Referral Hospitals have been approved and declared to Health Service Commission for filling. vi) In order to make Regional Hospitals more efficient and effective in their operations, the following interventions were undertaken: a. Establish leadership and management positions in hospitals. It envisaged that it will make regional referral hospitals efficient and effective in their operations b. Performance Appraisal training was conducted in all Regional Referral hospitals. c. Pay roll support supervision was done in Regional Referral hospitals. d. All Personnel Officers, Medical Superintendents, and Chief Administrative Officers were trained in pay roll management.

Progress on the implementation of the 7th JRM undertakings Resolution Progress Implementation of “Hard To Reach” and “Hard To Reach” strategy was defined by MOPS, and a 30% of “Hard To Stay” strategy to increase staff basic salary allowance has been incorporated into salary of health retention Workers in designated “Hard To Reach areas” w.e.f July 2010. Lobby Government to increase salaries of A Cabinet paper was submitted to parliament and so far a 30% Health Workers increment was awarded to the scientists’ w.e.f. July 2010.

Implement the staff motivation strategy The strategy was developed and is being costed for implementation

Districts that have not reached 60%of their Districts were guided to submit recruitment plans to fill up to 65% wage bill to recruit for the FY 2010/2011 Recentralization of health Workers Cabinet paper was submitted and a response awaited

148 Annual Health Sector Performance Report Major Challenges v) Poor attraction and retention of staff across the country remains critical. The situation gets even worse for cadres like-; Doctors, Midwives, Anesthetic staff, Radiographers Pharmacists and Dispensers. vi) Limited funding for recruitment, Salaries and wages has resulted into high vacancy levels. vii) Inequitable distribution of Health Workers to districts due to peculiar disadvantages of such districts has resulted into some districts not performing to the minimum staffing levels. viii) Inadequate tools and equipment result into staff not applying their skills thus de- motivation.

Recommendations

i) Implement the comprehensive Motivation and Retention strategy. ii) Continue to lobby MOFPED and MOPS for more funding for further salary enhancement, adequate wage bill provision and work facilitation. iii) Enhance capacity for HRH policy formulation, monitoring and review. iv) Strengthen mechanisms for inter-sect oral linkages, coordination and networking maintaining high level representation with minimum delegation to lower cadres. v) Expedite the Recentralization of the function of Recruitment and deployment of Health Workers to reduce inequitable distribution among districts. vi) Harmonize staffing standards and structures at all levels. vii)Develop strategies to strengthen and streamline HRH planning, recruitment and management in districts.

4.2.2 Human Resource Development

The Human Resource Development Division (HRDD) is charged with the Human Resource for Health (HRH) policy development, planning and ensuring education and training of competent, quality and productive health workers.

The core functions of the Human Resource Development Division (HRDD) are to provide input to the formulation of HRH policies, strategies and plans; setting standards for health professional training, and in collaboration with professional councils and Ministry of Education and Sports ensuring compliance to the set standards.

Annual Health Sector Performance Report 149 The other functions include supporting districts in determining the personnel needs, both in numbers and skills in line with the national health policy and standards. The Division has a responsibility to establish mechanisms for continuing education in priority technical areas. It operates in three sections of HRH Policy and Planning, Pre-Service and post basic/graduate training; and In-service Training.

Objectives of the HRDD in HSSP II: The mission of HRDD is to develop and maintain an adequate and competent health care workforce that avails people in Uganda an equal access to quality essential health services in line with the development goals of the country. The overall objective of the HRDD in HSSP II was to increase availability of quality trained, competent and motivated staff (public and PNFP) that are equitably distributed throughout the country and who would contribute to effective delivery of a quality Uganda Minimum Health Care Package (UNMHCP). The specific HRD objectives for HSSP II were to: Provide and maintain an HRH policy and strategic framework to guide the HRH process. Avail in an equitable and balance way the human resource capacity to deliver the UNMHCP with the available envelope. Strengthen institutional capacity for HR policy, planning and management (HR PPM) Enhance capacities and relevance for training of health workers in partnership with other stakeholders. Upgrade and enhance competencies and performance of health workers.

Key Strategic Targets for HSSP II (FY 2005/06 - 2009/2010: i) Develop, produce HRH policy and the Strategic Plan and disseminate them at national, regional referral hospitals and district levels. ii) Develop the HRD Information System in line with the HRHIS and HMIS to enable better HRD and HRM programs planning, monitoring and evaluation. iii) Systematically manage and operationalise the HRH Training function in the country. iv) Set standards for professional training in collaboration with Professional Councils, Local Governments and MOE&S and ensure compliance. v) Build capacity of National, Regional Referral Hospitals and District level health workers in establishing and managing HRD structures at national, district level, in hospitals and at health centres including formulating HRH Development/Training Plans at their levels. vi) Establish mechanisms for continuous facilitation of the districts and health facilities to determine and meet their HRH needs in line with the National Health Policy and Standards. vii)Networking, dialoguing, advocating for HRH development, quality health care delivery and keeping the HRH on the agenda.

150 Annual Health Sector Performance Report The planned HRDD key outputs for 2009/10 were: i) HRH development policy and planning issues aligned to the NHP II and the HSSP III, and integrated into service delivery at national, district and facility levels. ii) Production of 4000 copies of each of the HRH Policy and the Strategic Plan well coordinated, produced and subsequently disseminated and popularized. iii) Capacity to formulate, review and implement HRH policy, planning and management at national, district and facility levels equitably built. iv) HRH development and management information system developed to facilitate data generation, maintenance and dissemination to HRH stakeholders at all levels. v) Resources for and processing sponsorship of students for post basic and post graduate training mobilized and coordinated respectively. vi) Competences and performance of critical health workforce in priority subject disciplines and for hard to reach and stay areas targeted and improved for better service productivity. vii)Capacity for Continuing Professional Development / In-service training (CPD/IST) strengthened. viii) Strengthen the five HRD CPD Centers to promote Distance Learning and e- learning. ix) Mechanisms for coordination of in-service training and/or Continuing Professional Development established and functional.

a) Human Resources Development Main Achievements in FY 2009/10

i. HRH Policy development and planning Through a participatory process, contemporary HRH Policy and Strategic Issues have been identified and incorporated in the NHP II 2010 and the HSSP III. A corresponding HRH Rollout Plan 2010//11-2014/15 is being developed to guide costing the HSSP III HRH Component and subsequent implementation. Substantial copies of the HRH Policy (2006), the HRH Strategic Plan 2005-2020 (June 2007) and the HRH Strategic Plan Supplement 2008 (Health for the People Scenario) have been reprinted for use in HRH agenda dissemination and popularization. ii. Development and operationalisation of Human Resource for Health Information System. An HRH Information System (HRHIS) has been developed in the health sector and is being rolled out to districts and regional referral hospitals to capture data and information on health workforce in the country. There is now regular production of the Biannual HRH Report.

Annual Health Sector Performance Report 151 The basics of HRHIS infrastructure and software were procured and installed in HRM, HRD and Resource Centre Division of the ministry. Various cadres of health workers at national, regional referral hospitals level and district levels are to be trained in the use of the system and the establishment of the subsystems such as the HRDIS. Biannual HRH Report development and production is becoming a regular with rich information on HRH in Uganda. The second issue for 2009/10 came out in May 2010 and is currently in circulation. iii. Mobilisation of resources for and coordination of post basic and postgraduate training Funds for sponsorship of post basic and postgraduate training for in-service health workers in both the Public and PNFP sectors for various types of courses were mobilized. The main source of funding was from GoU, Belgium Technical Cooperation (BTC), DANIDA and ADB. Shortage of Health workers remains a serious constraint to provision of quality health care in many districts especially the hard to reach and stay districts. The Bursary Fund initiated by the Ministry of Health in partnership with the Health Development Partners and the Private Not for Profit (PNFPs) in consultation with the Ministry of Public Service and the Solicitor General was implemented in July 2009. A total of 390 students benefited from the Bursary Fund through bonding and are undertaking nursing, midwifery and medical laboratory technicians’ courses in the various health training institutions. They will work in the underserved districts for a period equivalent to the duration of their training. A total of 725 students post basic/postgraduates were on GoU sourced funding sponsorship during the FY 2009/10, of whom 519 were 1st. year new entrants awards and 206 were continuing student awards (See summaries in Table 4.3 (i) and Table 4.3 (ii) below). Only 86 (about 12%) of the sponsored students got funding directly from GoU MoFPED funding and the rest were donor funded. All sponsored students signed bonding agreements regardless of source of funding to ensure that they remain in Uganda working on completion of their studies for several years.

Table 4.6 (i): Post Basic / Postgraduate 1st. Years GoU Scholarships Awards in FY 2009/10 Up country excluding Urban covering Mbale, Jinja & Health Cadre groups Mbale, Jinja & Mbarara Mbarara Regional towns Total Regional towns. including Kampala Doctors for specialization 13 14 27 Doctors for general courses 2 1 3 Nurses 13 4 17 Allied Health 6 2 8 Non Medicals 0 2 2 Total 34 23 57

152 Annual Health Sector Performance Report Table 4.7: POSTBASIC AND POSTGRADUATE GOVERNMENT SPONSORSHIP in HTIs FY 2009/10: Funding Source New Continuing Total Finalists / students Students Sponsored graduating students st FY 2009/10 (1 Years) (All other Years) studentsFY200 9/10 MoH/GoU direct 57 29 86 20 MoH / BTC 49 150 199 Not available MOH /Devt/Partners/PNFPs 390 none 390 None, just starting Bursary Bonding Fund MOH/ADB/SHSSP 23 27 50 25 Total 519 206 725 45 Source: HRD Division/MoH FY 2009/2010 iv. Strengthening Coordination of the HRH interventions and Support Agencies Various organisations and agencies among the Health Development Partners have taken up interest in HRH issues and are providing financial, technical and infrastructure support to the GoU, the PNFPs, the PHPs and the communities in general. These include agencies such as the European Union, DANIDA, JICA, the World Bank, USAID, SIDA, Belgian Technical Co operation etc through programs such as UHSSP. UCP, PEPFAR etc. This, however, has brought in plenty of challenges of equity, duplication, uneconomical use of resources, ineffective delivery of services etc This multiplicity of actors in HRH interventions, much as it is desirable, requires interventions optimisation and harmonisation; geo-political, economical and gender equity; resource allocation and disbursement coordination etc. Coordination structures must as of necessity be established at the various levels of service delivery and be facilitated to function. The HRDD has developed proposals for reestablishment of Training Committees, Professionals Development Committees, mapping the interventions and support agencies at various levels to take care of such challenges. These coordination mechanisms will be presented during the 1st quarter FY 2010/11 to key stakeholders, the SMC and the TMC for more input and sanctioning. v. HRH leadership and management skills enhancement. A human Resource for Health Policy, Planning and Management (HRH PPM) course has been developed through the HRH Technical Working Group and within the auspices of strengthening the Capacities for HRH policy, planning, Leadership and Management. The course will initially target health managers at national/central, regional referral hospitals and district levels but resources permitting, it should be able to move to general hospitals and lower level health centres. Within the HSSP III period, the plan is to train 150 health managers annually at an average of 30 participants per course. The HRH PPM course curriculum has been developed, costed and with a course management arrangement proposal. It is to be circulated for final input of the SMC quite soon. Initially

Annual Health Sector Performance Report 153 MUSPH will start off the course as further arrangements are made to involve other Institutions of higher learning. Plans are under to enhance other health systems managements in collaboration with other departments/sectors and the health development partners vi. Review of the HRH career guidelines. The 1997 Career guidance documents for potential pre-service and in-service HRH trainees were reviewed and await production and dissemination/circulation. The review was done to provide within the guidance for some old courses for health workers that do not appear in the guide and for the new courses introduced into the health profession but do not feature. This would give students a variety of courses to choose from when making choices for their future careers. The review revealed salient career guidance issues that included: Lack of appropriate dissemination or distribution of the available information on Health Career Guidance Career path for some health professions are either not known or not clear The Health Career Guidance then focused on Nursing and Allied Health Professionals but not on Medical and Dental Professionals (Doctors) and Pharmacists. Documents for Health Career Guidance then were targeting entrants to Pre service training and little to Post Basic and In-Service potential trainees. Parents and guardians were not appropriately empowered in the provision of Career Guidance to students. vii. Enhancement of Competences, performance and productivity of the health workforce • HRH Strategic Plan was reviewed applying the Health Action Framework (HAF) tool and a 5 year Rollout Plan (2010/11-2014/15) was at finalization stage by end of the FY 2009/10. • 34 DHTs underwent a course in district planning and management to improve their management skills for the health services and developed District Plans of Action, including HRH Plans. • Accreditation system and standards for Continuing Professional Development were launched and are being operationised. • A multiplicity of technical skills improvement courses are conducted by various departments, Programs and Health Development Partners but unfortunately these outputs are not captured centrally but by individual providers. It is hoped that the HRDIS subsystem will subsequently harness such achievements.

154 Annual Health Sector Performance Report Table 4.8: The Achievements on Key HRD Indicators FY 2009/10 Indicator Baseline HRD Achievements FY 2009/10 Change 2004/05 Strengthened • HRH Strategic Plan was reviewed applying the Health Training Action Framework (HAF) Tool and provided policy input Management into the NHP II and interventions proposals into HSSP III. Capacity • Work on HRH Information subsystems at the four (4) Health Professional Councils and HRH Information system at the MoH was completed and bi-annual reports are produced to guide planning and decisions at the various levels. • To strengthen further the HRHIS, an HRDIS subsystem is being developed to capture data and information on HRH education, training and professional development. • Course on Policy, Planning and Management for health managers in the sector was developed with assistance of the school of Public Health. • 34 DHTs underwent a course on district planning and management to improve on their management skills for the health services. Training Programs • Accreditation system and standards for Continuing having performance Professional Development were launched and are being accreditation system operationised. • The four (4) Continuing Professional Centres (Arua, Jinja, Lira and Mbarara) received training equipment including internet connectivity Proportion of • Reviewed and repackaged one MLT Distance Education Health workforce course exposed to quality • IST/CPD 22 district health teams were trained on conducting Training Needs Assessment and used the tools for developing draft training plans. • 725 students were awarded GoU sourced funding sponsorship during the year, of whom 206 were continuing students among whom 45 were finalists. Source: Data from the RC, HRM & HRD Divisions of MoH Uganda 2009/10

b) Progress on HRD Resolutions of the 7th National Health Assembly i. Accelerating the strategy of Task Shifting: Documentation of task shifting initiatives, practices and their magnitude in Uganda was done. Drafting of the concept paper started and stakeholder consultation meetings have been planned as part of the development process of the strategy. ii. Reviewing the curriculum of enrolled and registered comprehensive nurses: A taskforce for evaluation of the ECN/RCN program was constituted; preparatory meetings held, Terms of Reference were developed and an external consultant identified and engaged to 176

Annual Health Sector Performance Report 155 evaluate the comprehensive nursing training Programmes at enrollment and registered levels. An internal consultancy to support the exercise is yet to be identified and engaged to join her. The evaluation will consider the purpose why the program was established and its relevancy to date, the curriculum design and implementation, the facilities and trainers’ skills availed to trainees including period of exposure; the competences of the products from the training schools and their utilization in service after qualifying. Reviewing of the ECN/RCN curriculum will therefore be considered following the recommendations of the evaluation. iii. DHOs monitoring and ensuring that schools training nurses and midwives are registered: Various fora with the DHOs, including Area Team supervision visits, were used in requesting them to report to the Health Professional Councils and Ministry of Health the illegal schools training health workers. A list of accredited schools has been developed and circulated in the media by the Uganda Nurses and Midwives Councils for attention of the relevant authorities and the public in general. The vigilance has helped guide the health professional councils, the Human Resource Development Division and the Ministry of Education and Sports on how to follow up quality of training by the schools. On putting in place and building capacity of Health Units Management Committees (functionalise) as part of community involvement in service delivery, the guidelines and the thematic training materials for HUMCs have been reviewed. An initial national training team of 20 trainers has been established and the current functionality of the HUMCs assessed in a few regions. The next step is to focus on training regional training teams which will subsequently train district level trainers and the Hospital Boards members. Training materials are to be printed and used for dissemination and training. The District Trainers will train, orient or sensitise the lower health units HUMCs. These are slated for FY 2010/11. iv. Banning the Training of Nursing Assistants A circular has been sent out by the Ministry of Health banning the formal training of the Nursing Assistants/Aides. Training on job for those already in employment should be done by their supervisors to enable them do their work better. The position of the Nursing Assistant/Aide will be phased out gradually.

c) Progress on the priority actions of the 15th Joint Review Mission for the Health Sector i. Equipping all managers with leadership and management skills: As a start, the health sector under the leadership of the Ministry of Health has jointly with Makerere School of Public Health developed a course in Human Resources for Health Policy, Planning and Management. The course targets health managers at various levels of service delivery and is slated to start in October 2010. It will be conducted jointly by experts in health systems development from MUSPH, MoH, Intrahealth International and other health development partners.

156 Annual Health Sector Performance Report ii. Prioritising training of health cadres who are hard to attract and retain in particularly unique areas: Scholarships for training targeted health workers and school leavers who wished to undertake training in health courses focused in preference to applicants from distances beyond 140 kms from Kampala and also from rural health facilities (hard to attract and retain – HTA&R ).

Table 4.9: POSTBASIC AND POSTGRADUATE GOVERNMENT SPONSORSHIP

Hard To Attract Funding Source Other considerations Total & Retain dstricts GoU Direct 38 19 57 MoH/BTC 32 4 36

MoH/Devt Partners Bursary Fund 225 165 390

Total 295 188 483 Source: Human Resource Development Division/MoH FY 2009/2010 For instance, as indicated in Table 4.5 above, out of the 483 sponsorship awards during the FY 2009/2010, 295 recipients were from the Hard to Attract and Retain (HTA&R) areas as per the following distribution: 38/57 directly by MoH; 32/36 sponsored from MoH/Belgium Technical Cooperation and 225/390 from the MoH/Devt Partners PNFP Bursary Fund. In addition the sponsorship focused on the MoH Training Priorities.

Challenges i) The Division remained very understaffed, especially so, following the departure of several officers from the Division during the same financial year. ii) Low capacity at Health Manpower Development Centre and its unclear legal status in the MOH structure. The legal position of the Health Manpower Development Centre remains unclear as a national Continuing Professional Development Centre and so are the four other regional CPD centres of Arua, Lira, Mbarara and Jinja. A proposal for HMDC to be a semi autonomous Training Institution implementing its own Business Plan was forwarded in the MoH Restructuring Proposal and is still awaited. The CPD centres were also proposed to be provided for under the Regional Referral Hospitals budgets. The units unfortunately continue to miss out funding support and infrastructure development from development partners due to this uncertain position and lack of management structure. iii) Maintenance of relevance of health training policies and strategies in light of health reforms, and changing health needs and technologies. iv) Funding of IST which is largely by vertical programmes with specific agenda makes it difficult to integrate IST as envisaged by HSSP II, donor dependent and difficult to sustain. v) Marked misdistribution of health workers between urban and rural areas and between districts for various peculiar/unique disadvantages of some districts. vi) Insufficient capacities of leadership and management among HRH managers at various levels endangers effective planning for and funding of IST/CPD

Annual Health Sector Performance Report 157 Recommendations I. Strengthen the capacity of HRD Division through promotion and population of the existing vacant positions. II. The Mbale Health Manpower Development Centre (HMDC) should be revamped as directed by the Auditor General and fully implement the Business/Strategic Plan perform its mandatory function. Furthermore the four Regional CPD Centres should be strengthened and linked to Mbale HMDC. III. Implement mechanisms and strategies for increased funding for HRH functions by looking beyond local resources for instance; using advocacy tools including HAF for resource mobilization; improve efficiency and effectiveness in utilization of human resources including those geared to improved HRH management, community resource, task shifting. IV. Review and harmonize the existing laws and regulations in order to have unified accreditation system. V. Revitalize and strengthen the Inter-Ministerial Standing Coordination mechanisms with the Ministry of Education and stakeholders in Health Training using programme of work and maintaining high level representation with minimal delegation to lower cadres

4.2.3 Human Resources for Health in the PNFP Sector

Once again the Private-not-for-profit (PNFP) subsector has remained an important partner complementing government effort in providing health services in Uganda. This section of the report covers PNFP health workers coordinated by the three medical bureaus (UCMB, UPMB and UMMB). With slightly over 11,600 health workers in the medical bureau networks alone, the PNFP still contribute about 30% of a combined Public-PNFP workforce. Ninety percent of these are privately employed. The other 10% comprises of staff seconded by missionary congregations, the local governments, and the Ministry of Health. Over many years the workforce in the PNFP has been perceived and appreciated for being highly productive. But this performance remains under threat by the persistently high levels of staff turnover especially of the clinical staff, a factor that remains most outstanding as affecting human resource for health in the subsector. Gladly there is some stabilization seen in the staff turnover over the last few years and the trend of attrition in both hospitals and lower level health facilities seem to show a downward trend (Figures 4.10 and 4.11 below).

158 Annual Health Sector Performance Report Fig 4.10: General trend of attrition among clinical staff in the PNFP hospitals

Trend of Attrition - Clinical Staff in 65% of PNFP Hospitals 40% 35% 36% 30% 25% 22% 23% 22% 20% 20% 20% 20% 15% 10% 5% 0% 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10

Figure 4.11: General trend in attrition of clinical staff in PNFP lower level health facilities

Trend of Attrition - Clinical Staff in 65% of PNFP Lower Level Units 40%

35% 34% 32% 30% 27% 25% 26% 22% 20% 15% 10% 5% 0% 2005/06 2006/07 2007/08 2008/09 2009/10

There could be multiple likely reasons for this stabilization. Available data (from exit interviews) indicate that over 46% of the leavers in 2009/2010 joined government services as compared to 60% in 2007/2008. This might be because either government recruitment has been less aggressive than earlier envisaged or a combination with other non-monetary processes improving retention in the facilities. Low salaries remain the most common reason given for leaving. Further stabilization of the PNFP is very important considering the significant contribution the sub-sector makes to the HSSIP processes and performance. While retention has remained a challenge to the PNFP facilities due largely to financial constraints, the absolute numbers of staff is always maintained due to rapid recruitment and replacement with fresh graduates.

Annual Health Sector Performance Report 159 The biggest problem caused by staff turnover in the PNFPs is therefore not majorly of numbers but of loss experience and capacity and the repeated rigor and distress of the attrition- replacement cycle. The PNFP networks therefore still remain some sort of centres for “internship” or transit routes to civil service and may be for other employers. Figures 4.12, 4.13 and 4.14 below indicate the trend of attrition of key clinical cadres in 65% of the PNFP hospitals and Lower Level Facilities. The staffing situation in UCMB hospitals Figure 4.12: Trend of attrition of key clinical cadres in PNFP hospitals 2003/04 to 2009/10

Trend of attrition of key cadres of clinical staffs in 65% of PNFP Hospitals

40% 38% 35% 36% 34% 35% 32% 30% 29% 29% 30% 30% 28% 26%26% 26% 25% 26% 25% 21%22% 21% 22% 20% 16% 14% 15%

10%

5%

0% MO CO Combined EN + EMW

2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10

Turnover rates for medical officers and clinical officers in hospitals remain high and are even increasing while a pattern of reduction similar to that in lower level facilities is seen for the enrolled nurses and midwives. In the last three years the attrition among enrolled nurses and midwives in hospitals rose from 25% in 2006/07 to 32% in 2007/08 before reducing to 30% in 2008/09 and now to 26% in 2009/2010.

160 Annual Health Sector Performance Report The situation in Lower Level Units Figure 4.13: Attrition of key clinical cadres in lower level PNFP health facilities

Trend of attrition of key cadres in clinical staffs in 65% of PNFP lower level units 50% 46% 46% 45% 42% 40% 39% 40% 38% 37% 34% 35% 33% 30% 30%

25%

20%

15%

10%

5%

0% CO Combined EN + EMW

2005/06 2006/07 2007/08 2008/09 2009/10 In lower level PNFP facilities the movement of enrolled nurses and enrolled midwives is beginning to stabilise Figure 4.9 above suggests that attrition rate for enrolled nurses and enrolled midwives has further reduced from 46% in 2007/08 to 39% in 2008/09 and now 37% in 2009/2010.. This is favouring of the lower level facilities that serve the poor, operate in much more rural localities and are often constrained to retain key cadres. Attrition in hard to reach districts28 For some years PNFP staff attrition in the hard-to-reach areas has been higher than the overall network situation. Considering 12 hard-to-reach districts, mainly in post-conflict situation, there is now a similar stabilisation for nurses and midwives and a similar rise in attrition for clinical officers and doctors working in hospitals. In fact the attrition rate for enrolled nurses and midwives (23%) is slightly lower than the overall average for the PNFP network hospitals (26%). Figure 4.14: Staff attrition in PNFP hospitals in hard-to-reach districts

Attrition rates in PNFP hospitals in 12 hard to reach districts 2007/08 - 2008/09

60% 54% 50% 44% 43% 39% 39% 40% 34% 35% 31% 28% 30% 27% 23% 23% 20%

10%

0% CO EM EN MO 2007 - 08 2008 - 09 2009 - 10 28 The districts referred to here are the 12 top in level of “hard-to-reach” according to the classification used for the inclusion for payment of hard-to-reach allowances. They are Pader, Kitgum, Nakapiripirit, Kotido, Moroto, Kaberamaido, Katakwi, Bundibidyo, Apac, Gulu, Lira and Soroti.

Annual Health Sector Performance Report 161 There is a similar trend in stabilization in the lower level facilities. But disaggregation of attrition among enrolled nurses and midwives shows that the overall drop is more influenced by the drop among midwives while enrolled nurses’ attrition remains high and even increased again in the last year. The reason for this is not clear but. It could indicate that nurses have more diverse opportunities for employment in various organisations and projects. But it is not clear why this particular trend is only observed at the lower level and not in the hospitals.

Figure 4.15: Staff attrition rates in PNFP lower level units in 12 hard-to-reach districts

Attrition rates for selected PNFP health worker cadres in 12 hard- to-reach districts 70% 66% 61% 58% 60% 52% 50% 38% 40% 40% 30% 30% 25% 27%

20%

10%

0% CO EM EN 2007 - 08 2008 - 09 2009 - 10

Critical Human Resource for Health in PNFP health care in general It should be noted that the PNFPs health facilities have the highest staff attrition rate compared to the government facilities. From the health facilities that reported their performance for this financial year the staff in the Lower Level health facilities reduced compared to last year, with doctors and clinical officers reducing greatly.

Table 4.10: Human resources for health Financial year Financial Doctor Clinical officer Lab Assistant Midwife Enrolled Registered Midwife NurseEnrolled Registered Nurse EN Comp Double Nurse Reg.Double Nurse Comp Nursing Assistant Aide Nursing staff Support 2009/1013427557155122459174114332

2008/09174653554424172412245 289

4.2.4 Health Service Commission

The Health Service Commission is mandated under Article 170(1) (a) and (b) of the Constitution of the Republic of Uganda to advise the President on Recruiting Health Workers in accordance with Article 172 of the Constitution (for Health Workers at the level of Head of Department and above) and also directly appointing all other Health Workers who fall under the jurisdiction of

162 Annual Health Sector Performance Report the Commission, i.e. Public Health Workers, other than those under the Authority of District Service Commissions (see Article 200 of the Constitution). Accordingly, the HSC is responsible for recruiting Health Workers for the Ministry of Health Headquarters, National and Regional Referral Hospitals and Specialized Health Institutions under the Ministry of Health. The Commission has also been recruiting Health Workers for the Prisons Health Services. Over the years, the Commission has been setting a Recruitment Target of 800 Health Workers per year except in the FY 2009/10 when the target was revised to 1000 Health Workers. These Workers include all Health Workers as defined under Section 3 of the HSC Act 2001; hence includes Support Staff. Table 4.11: The total number of Health Workers recruited per Financial Year over a period of 6 years. FY Target Recruitment Actual No Recruited 2004/05 800 651 2005/06 800 735 2006/07 800 626 2007/08 800 638 2008/09 800 640 2009/10 1000 1096 Total (2004/05-2009/10) 5000 4,389

Due to increased recruitment over the years the recruitment has been revised back to 800 Health Workers. However, it is expected that the number will surpass 800 given that validation exercises of the new Regional Referral Hospitals of Mubende and Moroto as well as the Uganda Heart Institute and the Uganda Cancer Institute will be bring more appointments through regularizations and filling of the remaining approved vacancies. The recruited figure may not be impressive given the staffing demands in relation to the actual work load but given the recent analysis of actual staffing situation at Mulago, Butabika and three Regional Referral Hospitals, the recruitments have greatly revamped staffing of the National and Regional Referral Hospitals over the years.

Annual Health Sector Performance Report 163 164 Annual Health Sector Performance Report HOSPITAL CATEGORY APPROVED POSITIONS FILLED STAFFING LEVEL JINJA Medical Officers and Dental Surgeons 37 34 92% as at Aug 200 Pharmacists 6 583% Allied Health Professionals 65 70 108% Nurses and Midwives 120 168 140% Scientific Staff 7 229% Administrative Staff 39 39 100% Support Staff 86 73 85% Overall 360 391 109%

MBARARA Medical Officers and Dental Surgeons 40 15 38% as at Aug 200 Pharmacists 6 350% Allied Health Professionals 68 50 74% Nurses and Midwives 150 131 87% Scientific Staff 11 655% Administrative Staff 37 23 62% Support Staff 61 52 85% Overall 373 280 75%

HOIMA Medical Officers and Dental Surgeons 37 15 41% as at Aug 200 Pharmacists 7 343% Allied Health Professionals 65 33 51% Nurses and Midwives 103 74 72% Scientific Staff 8 450% Administrative Staff 28 10 36% Support Staff 76 47 62% Overall 324 186 57%

SOROTI Medical Officers and Dental Surgeons 37 14 38% as at Oct 2007Pharmacists 7 229% Allied Health Professionals 67 19 28% Nurses and Midwives 103 74 72% Scientific Staff 6 117% Administrative Staff 29 724% Support Staff 65 64 98% Overall 314 181 58%

KABALE Medical Officers and Dental Surgeons 35 720% as at July 2010Pharmacists 6 467% Allied Health Professionals 61 44 72% Nurses and Midwives 141 110 78% Scientific Staff 3 267% Administrative Staff 29 12 41% Support Staff 44 40 91% Overall 319 219 69% Source : Staff lists submitted to HSC by user institutions

Annual Health Sector Performance Report 165 Table 4.12 also reflects the HR challenges the Commission has faced over the years. i) It has been very difficult to attract and recruit Medical Specialists and Medical Officers for Regional Referral Hospitals. ii) Equally difficult to attract and recruit have been some cadres in the Allied Health Professionals, especially Laboratory Technologists and Dispensers. iii) Advertisements for nursing posts have been attracting big numbers of Applicants. Coupled with Support Staff, Scientific and administrative Staff, the Commission has had to handle huge amounts of applications; thus making recruitment exercises lengthy and costly. Under FY under review, the candidates for the post of Nursing Officer had to be subjected to selection exams in order to rationalize numbers for interviews. This is in addition to the Administrative and Scientific cadres. During the Financial Years, 2007/2008 and 2008/09, the Commission filled all posts of Medical Officer, declared for the National and Regional Referral Hospitals as well as PNFP Hospitals. However, in FY 2009/10 both the Ministry and National Referral Hospitals declared posts for filling. The Commission is therefore interested in knowing the exact number of Medical Officers who actually report and remain on duty for at least two years. Apart from HR attraction and recruitment challenges, the Commission has been bedeviled by logistical challenges such as: i) Under-funding leading to the Commission advertising only once each FY and limiting selection exercises only to selection interviews. This FY, the Commission will require the Ministry to assist with funds for the validation exercises ( approximately 100m Ushs). ii) Inadequate work performance tools e.g. computers, and general ICT. This has had a crippling effect on the HR Data base for the HSC. iii) Inadequate staffing at the Secretariat level iv) Inability to carryout Support Supervision in targeted District Service Commissions and RRHs due to inadequate funds and vehicles. During the course of recruitment and arising out of Support Supervision Visits the Commission has been able to conduct; the following recommendations geared at enhancing staffing across the Health Sector and thus improving health service delivery are herewith provided: i) Recentralize recruitment of Health Workers to improve deployment and distribution of Health Workers across the Sector. ii) Enhance the Financial, Human Resource and Logistics components of the Commission as a matter of priority. iii) Affirmative action in supporting training in some specialties such as Anaesthesia, ENT, and Pathology be undertaken by the Ministry of Health.

166 Annual Health Sector Performance Report iv) As a matter of urgency the terms and conditions of Health Workers be improved especially on housing and transport; in order to revamp attraction and retention of Health Workers. v) Government should provide funds for filling 100% of approved Staffing Structures in Local Governments. vi) Staffing Norms of cadres should urgently be reviewed upward e.g Clinical Officers in decentralized health services. vii)The performance management principle of Task Shifting should be studied in order to determine its possible value on addressing acute clinical under-performance in Health Centres. In summary, despite the constraints and challenges outside the Commission’s control, the staffing situation in aggregate terms and average is above 80% for National and Regional Referral Hospitals. Emphasis should be placed on Clinical Areas which are generally below the 68% baseline Recruitment Figure provided in HSSP II and indeed below the 90% recruitment target.

Annual Health Sector Performance Report 167 4.3 Health Infrastructure Development and Management

The overall objective of the HSSP II on health infrastructure is to consolidate existing health facilities to enhance their functionality and to increase accessibility to health services and quality of health care delivery within the available resource envelope. During the reporting period, some progress has been obtained towards the achieving this objective but due to the limited resources a lot remains to be done. The following are the specific objectives of the HSSPII intend to achieve the above overall objective: 1. To consolidate functionality of existing lower level health facilities 2. To strengthen the referral system 3. To rehabilitative secondary and tertiary health facilities 4. To strengthen management of health infrastructure and establish a sustainable maintenance programme 5. To Increase accessibility to within 5km walking distance from 72% to 85% Progress The progress attained on implementation of the planned interventions within the reporting period is as in the annexed table. Additionally, the following achievements have been attained in respect of the resolutions of the 7th National Health Assembly and the priorities agreed upon at the 15th Joint Review Mission. (a) Status resolutions of the 7th National Health Assembly 1. Improve the release and effective use of the development budget to improve functionality of the existing health infrastructure i) Advised all RRHs to prepare mater plans ii) Support regional referral hospitals in preparation of work plans for utilisation of the capital development budget allocation iii) Increased support supervision of the infrastructure improvement programmes at RRHs 2. DHOs should regularly provide and update the infrastructure and equipment inventory i) Guidelines provided to district for inventory update using pictures and equipment to ease understanding. Response of district has greatly improved. 3. Maintenance of equipment should be prioritised In the FY 2009/2010, ring fenced funds for medical equipment maintenance were provided under the development budget to regional referral hospitals. This was an improvement; but the amounts are still meagre to meet the maintenance requirements of regions. Furthermore, the funds provided are only for maintenance of equipment leaving out the other constituents of health Infrastructure (i.e. buildings, Transport & Ambulances and Communication facilities)

168 Annual Health Sector Performance Report (b) Priorities of the 15th Joint Review Mission 1. Focus and consolidate / repair of existing structures before embarking on the construction of new facilities i) This prioritisation has been incorporated in the HSSP III ii) Consolidation has been emphasised in all our current development programmes iii) Districts were asked to concentrate on completing work started on in the past years.

2. Start the process of securing land titles for all health facilities. i) Circular written to all districts (CAOs), Medical Superintendent of RRHs

3. Develop and implement guidelines for the operation of ambulances i) Initiated discussion with World Health Organisation, UNFPA and World Bank Funded health systems strengthening project Discussions still ongoing.

Annual Health Sector Performance Report 169

sindi and Kalisizo. The remaining remaining The sindi and Kalisizo. Ongoing:allocations using capital development of the standardPlan Management and Waste incinerator and Health Care Upgrading the HCs with is still ongoing specialized services Moroto, Mbarara,Project Mbale under SHSSP Recruitment has been slowvacancies in declaring because of delays Theseare cumulative numbers. In all cases the rehabilitationhospitals was partial. The was done. substantial work highlighted are those were institution inintroduce Uganda. Diploma Plans University Course advanced to at significantly increased of existing. on was consolidation focus accessibility. The Added on2009/10 (3) one ward annually except and The percentages of hospitals with ambulances numbers refer to the cumulative action achieved phones me over the HSSP II period namely: namely: period II HSSP the over me reports District transfers Allocation ScheduleAllocation = 55 GoU hospitals of number Total Annual performance performance Annual 0 Constrained by the lack of a training Units) Katakwi 12 (25%) 12 (25%) (SHSSPII) 67% (with 10 New (with 67% ed under the ORET program ORET the under ed , Tororo, Itojo Tororo, Masafu, Anaka, Moyo, Yumbe, Gombe, ma Gombe, Yumbe, Anaka, Moyo, 11% 11% Activity delayed due to delayed finalisation 20% Units) 11 (23%) 11 (23%) Kambuga Apac, Nebbi, (4 RHH added) Itojo & Ultra – refurbish Sound 8 (17%) 8 (17%) for 4 years) commissioned commissioned Bududa, Masafu, Bududa, (6 JICA; 22 Chogm) JICA; (6 (SHSSPI)5 PNFP GoU + 5 Mubende’s after serving serving after Mubende’s 51% (with 28 Units) New 4 58% (with New ngo, Kitgum, Moroto, Iganga, Pallisa, Moroto, Kitgum, ngo, 5 (11%) 5 (11%) 1 (14%)(14%) 1 Lyantonde Kyenjojo Masafu & Added Mbale Added Tororo, Entebbe Tororo, Abim, Kaabong, Kaabong, Abim, 0 0 0 100% 100% Ongoing at Masaka, Lira, Mubende, Jinja, 0 0 0 1 Technician 13% 13% 13% 79% 79% 80% 80% 80% transfers District Soroti) 4 (36%) 4 (45%) Nakaseke their imaging departments – X-Ray – departments imaging their (Fort Portal & Portal& (Fort (Added Fort Portal) Fort (Added Butabika) (Added but de- Entebbe (Added Table 4.11: Achievements in health infrastructureTable 4.11: Achievements II period over the HSSP - 55/55 (100%) 55/55 (100%) 55/55 (100%) 55/55 (100%) 55/55 (100%) All hospitals can be reached on mobile 0 0 1 (14%) 1 (14%) 7% 9% 11% 11% 13% 46% 2 (18%) 11 (100%) 11 (100%) 11 (100%) (7 RRH) 1 Engineer (6 out of 13) out of (6 7 technician, & Mubende) & HC III – 79% HC III HC III – 69% – HCIII 70% 71% 74% 77% 80% respectively 21 at HC IIIs 21 & 8,7,22, HC IV – 36% – HC IV HC IV – 92% – HC IV 92.50% 95% 95.5 97% 97.50% respectively HC IVs 1 at 3 & 4,1, 1, Mulago, Arua, Gulu in financial year 2009/10. financial in ta, Kagadi, Kayunga, Apac, Kiryando 100% of services health mental with provided regional referral hospitals 2No. Engineers / annually Engineering Biomedical in Technicians trained 70% of general hospitals rehabilitated hospitals general of 70% (2%) 1 80% ofrehabilitated regional referral hospitals 100% ofmedical wasteincinerator hospitals equipped with a 7 HCwith specialised diagnosticsservices IV along highways provided 95% hospitals havingtechnician a maintenance 85% to accessibility Increase 72% 72% 72% 72% 72% 72% Very few new HCs were added and have not 100% availability ofat HC III& HC IVs maternity wards 100% of hospitals with ambulances - - - 100% availability ofHCIII & HC generalIVs wards at One national incinerator constructed constructed incinerator national One 0 0 0 0 0 0 Planned to be set up NDA but No fruitful 100% of hospitals facility communication of form with at least one HSSP II Target / IndicatorsTarget II HSSP 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 Source Data Comments Bundibugyo, Itojo, Kitaga Notes Seventeen (17) General Hospitals had had Hospitals General (17) Seventeen Notes hospitals are to be covered to be covered are hospitals 170 Annual Health Sector Performance Report Major Challenges i) Inadequate structures infrastructure management and maintenance staff at the centre, regional referral hospitals and general hospitals ii) Inadequate funds for maintenance of infrastructure

Recommendations i) Adequate funding should be provided for management and maintenance of all components of health infrastructure to avoid having to resort to “Rehabilitation”. ii) The restructuring exercise should consider strengthening the maintenance (Engineering) units at Hospitals, the district and Ministry of Health both in numbers and skills to enable proper Health Infrastructure Development and Management.

Annual Health Sector Performance Report 171 4.4 Management of Essential Medicines and Supplies

The Ministry of Health has continued to collaborate with development partners to support pharmaceutical activities in the country: support has been received from WHO, DANIDA MeTA, SURE and Malaria Consortium. Activities of Pharmacy Division were guided by HSSP II and under takings in the Aide memoiré of the 7th National Health Assembly and 15th Health Sector Joint Review Mission- 2009 The following achievements were realized: i) The National Pharmaceutical Sector Strategic Plan has been developed and is awaiting costing. (WHO) ii) Evaluation of 2007/2008 procurement plan and update of 2009/10- 2011/12 three years rolling procurement for Essential Medicines and Health Supplies (MeTA)and with support from SURE the Division plans to continuously evaluate performance of PSM(Pharmaceutical Supply Management in financial year 2010/2011 iii) Participated in the finalization of National Clinical Guideline 2010 under the leadership of Quality Assurance Department which is now being disseminated. iv) Conducted an policy option analysis on medicine management activities where both merits and deficiencies of current practices at current levels of supply chain were assessed.(SURE) this option analysis will inform future strategies v) Reviewed Logistic training manual and tools with a view of harmonizing data collection tools by different stake holders vi) Vote 116 for medicine and health supplies was created and is managed by NMS: this improved the financial base of NMS. And addressed the challenges associated with the old system of credit line and sending medicine funds to districts and hospitals vii)An MOU on modalities of Vote 116 is in the final stages but operational guidelines were developed and disseminated to stakeholders viii) Routine Monitoring and support supervision to hospitals and districts on medicine management activities ,with special focus on forecasting and rational medicine use, to improve management of EMHS was conducted in hospitals and districts Despite the above mentioned achievements and innovations many challenges still exist. Poor access to medicines in health units persisted mainly due inadequate financing of medicines and health supplies, and poor medicine management at health unit level The continued challenge of inadequate human resources for health in generally and for medicines management in particular still affects the health system and jeopardizes the benefits achieved and capacity development efforts made thus far. Due to lack of capacity at unit level especially at health centre II and III, Kits for essential medicines have been introduced at health centre II and III level; until adequate capacity is developed. DANIDA a major funder for essential Medicines and health supplies and has also been funding a sizeable proportion of the Pharmacy Division’s budget has pulled out of the sector. This has led to the reduction of funds available for these two components. We have not yet got a replacement for DANIDA funding for essential medicines and health supplies but for

172 Annual Health Sector Performance Report other medicine management activities SURE(Securing Ugandans Rights on Essential Medicines) and the World Bank will mitigate the withdraw of DANIDA, DELIVER and SCMS The creation of Vote 116 meant that all funds for procurement of medicine and health supplies were remitted to NMS and therefore NMS should be able to supply all the required medicines to all public health facilities. Prior to the creation of Vote 116, it was anticipated that GoU would contribute 5.17 and DANIDA 6.7 bn and the allocation of funds for the districts and hospitals was based on this. NMS only received 5.17 bn through Vote 116 and this affected its capacity to supply medicines to health facilities. For FY 2009/2010 DANIDA made a provision and most likely they will do the same for 2010/2011 However, there was a mixed picture of the level of availability of EMHS in the districts and the different facilities. In some of the districts poor documentation of movement of medicines within units and the overall supply chain is visibly prevalent in most of the facilities. While in some districts there is some semblance of good records, the majority hardly kept any meaningful records.

Table 4.12: Availability of Essential Medicines at various health facility Levels FY 09-10 FY 08-09 FY 07-08 FY 06-07 FY 05-06

% HU % HU with without no stock stock out Num of out (AL (AL green HU with Num of green not no stock Num Num Num % HU included) included) out % HU of HU % HU of HU % HU of HU HU All 35 21% 41% 34 26% 36 28% 36 35% 28 27% levels HC II 11 18% 24% 13 17% 13 33% 11 12% 9 25%

HC III 13 22% 59% 12 24% 13 30% 15 47% 13 32%

HC IV 11 24% 39% 9 39% 10 22% 10 47% 6 23%

Comments: There was overall improvement in availability from improved 26% to 41% when coartem is not include in the analysis with the improvements seen at level III health centers. When availability of Coartemwas included in the analysis, the availability fell to 21%. As shown in the table two Coartem was not available in half of the facilities on a monthly basis. (for comparison when Coartem is dropped from the results of 2008/2009 the improvement is negligible from 26%to 28% but in 2009/2010 when coartem is dropped the availability improves from 21% to 41%) This is important to note because availability of Coartem is largely not dependant to the performance of NMS or Health facilities but on GLOBAL fund honoring its obligations

Annual Health Sector Performance Report 173 Table 4.13: Availability of Essential Medicines by HSSP indicator drug

FY 09-10 FY 08-09 FY 07-08 FY 06-07 FY 05-06 % HU Stock reporting Stock Stock Stock Stock card stock card % card % card % card % months* outs months* HU months* HU months* HU months* HU

Any HSSP indicator drug 210 79% 204 74% 216 72% 216 65% 156 72% 1 Coartem Green 198 51% 196 34% 204 49% 186 27% 156 13% 2 Sulfadoxine Pyrimethamine tab 181 37% 193 23% 198 28% 184 14% 141 24% 3 Cotrimoxazole 480mg tab 186 26% 194 35% 204 21% 204 32% 159 44% 4

Oral Rehydration Salts (sachet) 158 22% 169 29% 180 20% 153 24% 109 46% 5 Medroxyprogesterone inj ("Depo") 165 30% 148 7% 156 15% 174 16% 93 36% 6 Measles vaccine 150 11% 167 19% 151 22% 158 7% 122 10%

Financing of Medicines and Health Supplies 2009/2010 With effect from financial year 2009/2010, GoU shifted the financing system for EMHS away from the decentralized PHC recurrent wage grant (Fiscal Decentralization Strategy) and the essential medicines account credit line A new vote (VOTE 116) was established for the National Medical Stores. The transition occurred after the release of the MoFPED Background to the Budget 2009/2010 but was subsequently incorporated into the Health Sector Ministerial Policy Statement 2009/2010. In the first year of operation of VOTE 116, MoFPED released 30% of the annual EMHS budget through the decentralized PHC grant system. This means the funds realized to NMS on vote 116 was 70% of the total EMHS budget expected to cover quarter two, three and four of FY2009/2010. In total MoFPED realesed 75.7 billions to vote 116 in FY2009/2010, this included about 47 billion for ACTS&ARVS,0. 0.5 billion about 6.7 billion for Butabika and Mulago respectively .The 30% released to districts prior vote 116 is not considered because we are not sure how much of it was used for procurement of EMHS by health facilities. The amount that was available for EMHS for the whole public sector including Mulago complex and Butabika for FY 2009/2010 was about 28.7 billion; this compared to result of national quantification report of 2009 which put this requirement at about 100 billion means that the gap between available funding by Government and the need of the country in regard to EMHS is still very big. MoFPED did not transfer any funds to the EMA; whilst the approved MoFPED budget estimates 2009/2010 included the annual DANIDA contribution of UGX 6.8 Billion to the EMA, these funds were withheld. DANIDA instead transferred UGX 3 Billion directly to JMS to support the PNFP credit line

174 Annual Health Sector Performance Report NMS is the de facto sole supplier for EMHS to all GoU facilities with VOTE 116 and has been set up as a designate service provider. MoFPED pays NMS a standard handling fee based on the value of commodities procured; 18% on EHMS, 7 % on ACTs and ARVs. The increasing contribution of global health initiatives like Global Fund PEPAR CHAI, GAVI and others is not captured The new arrangement addresses some inherent challenges posed by the decentralized PHC grants and EMA credit line. VOTE 116 eliminates i) lead times for transfer of funds to regional referral hospitals, general hospitals and health sub districts (12, 20 and 27 days respectively)29 ii) delayed release of PHC funds earmarked for EMHS to districts as a result of non compliance with accounting guidelines iii) health facilities’ non compliance with PHC grant expenditure guidelines iv) reallocation by local governments of funds earmarked for EMHS to other budgets v) accumulation of unpaid debt that negatively affected NMS capacity to procure EMHS In addition, it addresses non-utilization by health facilities of PHC funds at NMS or JMS as well as significantly shortening the NMS operating cash cycle where payment delays by the MoH and health facilities stretched to over 3 months. There are strategic issues that need to be considered if GoU is to maintain the new system; the potential efficiencies outlined above have to be placed within the context that: i) Availability of EMHS in the entire public health system is dependent on the performance of NMS as the sole procurement and supply agency. ii) There is no provision for health facilities to procure EMHS from alternative sources in case of non-availability at NMS. Operationally, the National Medical Stores management and human resource capacity has to adjust to new challenges: i) Responsibility for allocation of funds to health facilities has shifted from MOH and HSD to NMS ii) NMS must now manage 2400+ health facility accounts as opposed to 281 accounts iii) NMS is wholly dependent on service provider fees charged on ACT/ARV (7%), EMHS (18%) and third party handling fees to cover its operating costs.

Utilization of services provider for Medicines (Vote 116)

Annual Health Sector Performance Report 175 Table 4.14: Funding for Essential Medicines and Health Supplies in 2009/10 DANIDA Contribution 3,000,000,000 (Through Joint Medical Store) Vote 116 28,400,000,000 ARVs and ACTs 47,310,446,000 Third Party Supplies (RH) 1,500,000,000 TOTAL 80,210,446,000

DANIDA was supposed to contribute about 3.5 billion to Vote 116 Since DANIDA was winding up in June 2010 and again no provision was made to finance EMHS to PNFP through JMS for FY 2010/2011, DANIDA has decided to put the balance to this cause.

Table 4.15: Utilization of vote 116 in 2009/1 Name Total Allocation Spent % utilization All Districts 17,169,329,501 13,311,415,835 78 All General Hospitals 5,617,320,451 4,457,078,436 79 All Regional referral Hospitals 5,074,759,511 4,609,930,110 91 BUTABIKA HOSPITAL 500,000,000 410,054,392 82 MULAGO HOSPITAL 6,907,679,000 5,199,229,652 75 UGANDA CANCER INSTITUTE 333,333,000 327,364,712 98

UGANDA HEART INSTITUTE 49,600,000 38,114,081 77 7,790,612,000 5,974,762,838 77

The general utilization of Vote 116 is at 77 % and yet it is expected to be above 90 given that the funds are released to NMS well in advance. For Districts, RRH and General Hospital the withholding of 3.5 billion by DANIDA affected their performance.. Also at the end of September most units had a balance on the 2008/2009 Credit line allocation this amount was also added to total amount available for 2009/2010 The denominator used in this report includes DANIDA funds and the balance from 2008/2009 Credit line allocation since NMS included it when allocating funds to these entities. This explains why most districts and hospitals did not hit the 100% mark.

176 Annual Health Sector Performance Report Figure 4.16: Vote 116 utilization by Districts in 2009/10

Figure 4.16 above show that average utilization is around 78%; there are some districts that surpassed the 80% mark, districts like Isingiro, Masaka, Kabuula, Bushenyi, and Mayuge among others. This means districts that were ordering timely managed to utilize a big proportion of their allocated budget. While on the other side there are districts who performed poorly (Kabarole53.95%, Nakaseke24%, Arua 51% Nakasongola 23%, this performance cannot be explained by the withholding of funds by DANIDA or by inability of NMS to supply. The problem must be from the district and there is need to understand this further.

Annual Health Sector Performance Report 177 Overall average utilization by general hospital stands at 79% but again there those hospitals that performed exceptionally well with 90% and above, hospitals like Mityana,Tororo,Entebbe,Kamulii,Masafu and Kitagata while only Yumbe was below 50%.

Figure 4.17: Vote 116 utilization by General Hospital in 2009/10

The average utilization for this category of hospitals is 91% utilization. It is only Jinja and Hoima which were below 80%. Graph: Vote 116 utilization by National Referral in 2009/10

178 Annual Health Sector Performance Report Figure 4.18: Vote 116 utilization by Regional Referral in 2009/10

Mulago performed at 75% Bitabika at 82% Cancer insititute 98% Heart Insititute 77% Since the financing and management of Vote 116 is different from the way PHC and Credit line funds were managed we are reluctant to compare the two. However, Vote 116 in FY2009/2010 had fewer funds for EMHS than PHC non wage and credit line in FY 2008/2009 but at the same time Vote 116 had a high utilization than PHC non wage and credit line in FY 2008/2009.

Figure 4.19: Vote 116 utilization by National Referral in 2009/10

Annual Health Sector Performance Report 179 180 Annual Health Sector Performance Report Batch no Amount Date submitted 173 149,254,402/= 16/10/2009 174 460,921,004/= 19/10/2009 175-179 3,567,730,902/= 27/01/2010 Total 4,177,906,308 It is unlikely that the Ministry of Health will settle these outstanding debts given that Danida pulled its support out of the Ministry of Health effective 1st July 2010. To that end we went ahead to request for the Accountant General’s inclusion of the said debts in the domestic arrears. OTHER DEBTORS Global Fund settled the outstanding amount of Ushs1.8billion but this excluded the Vat Tax element of Ushs 1.1 billion that has since been forwarded to the Ministry of Health and also included in the domestic arrears request. Other debtors include the Uganda Aids Commission with an amount of U Shs 395 million. The bill for UAC has since been routed to Ministry of health as advised by project administration. Clinton Foundation had an outstanding amount of U Shs 114million which was settled in July 2010. UNFPA has an outstanding amount of UShs 666million they promised to settle this amount as soon as they receive funds from the Federal reserves. PHC DEBTORS This debt amounts to a figure UShs 722 million. The settlement of these amounts stagnated on the granting of the vote as most facilities had no funds to use for settlement of these debts. We have however gone ahead to agree on schedules of how to deduct them from the various facilities allocation in a phased manner. Some funds have been recovered from numerous facilities allocation as agreed upon and this amounts to Ushs. 233million.

Challenges and Way Forward Introduction of the vote status: With this, NMS had to procure specialized medicines for which it had no prior pre-qualified suppliers. To resolve this, and in addition to the in-house pre-qualification, NMS has adopted the PPDA register of suppliers to enrich the supplier data-base, increased funding for trading stock procurements, but without equivalent increase in appropriate human resource. Challenges arise from the poor interfaced between the MACS Management Information system and the SAGE financials system which has required the Finance team resort to manual information analysis. However, the Corporation has sought technical support to resolve the MIS constraints.. Continuous activating and reactivating of health facilities as new information emerge. This has led to the manual transfer of funds from facility to facility in line with the changes requested for but without any system log to refer to the changes at a later date. Need to publish the facilities database to obtain a holistic feedback about its accuracy. The delayed submission of delivery returns that has made compilation of invoicing and accountability difficult and in other cases to debts that cannot be substantiated without proper

Annual Health Sector Performance Report 181 documentation. There is urgent need to fast track submission of delivery paper work from dispatch section to aid verification of domestic arrears as well as accountability of funds usage. The inability to process payments denominated in foreign currency due to lack of an EFT Cash Clearing account with . There is need to get away of paying foreign providers whose liaison offices in Uganda don’t conduct local trade and therefore can’t be paid in local currency. Way forward: The Department has been restructured and re-aligned to meet the increased workload for procurements of medicines and related medical supplies. Recruitments are underway to get the candidates suitable for the available positions

JOINT MEDICAL STORE

Credit line

Table 4.16: Laboratory Credit Line overview by beneficiaries Hospitals HCIV HCIII Total

UCMB 28 1 121 150

UPMB 15 1 70 86

UMMB 3 0 20 23

Local NGO/CBO 8 1 48 57

Private 2 1 3

Total 56 3 260 319

Table 4.17: Laboratory Credit Line overview by level of care Number of Level of care May 09-April 10 units Credit line Utilization % tage Balance shs shs shs utilization

56 Hospitals 441,354,506 441,567,485 100 (212,979)

3 HCIV 11,597,353 9,647,676 83 1,949,677

260 HCIII 1,406,636,3551,341,565,752 95 67,070,603

319 1,861,588,214 1,792,780,314 96 68,807,301

182 Annual Health Sector Performance Report Number of Authority May 09-April 10 units Credit line Utilization % tage Balance shs shs shs utilization

150 UCMB 848,189,814 929,195,141 110 (81,005,327)

86 UPMB 530,988,694 539,833,598 102 (8,844,904)

23 UMMB 128,137,433 132,681,586 104 (4,544,153)

57 LNGO/INGO 338,715,504 176,225,162 52 162,490,342

3 Private 15,556,770 14,844,827 95 711,943

319 1,861,588,215 1,792,780,314 96 68,807,901

The funds under the laboratory credit line for HIV test kits, associated accessories and co- trimoxazole were utilized 100%. The utilization increased from 60% in FY08/09 to 96% in FY09/10. This has been attributed to the inclusion of sundries in the supplies. In addition there has been improved utilization of laboratory services by most health units prior to treatment.

Figure 4.20: Distribution of beneficiaries of laboratory credit line

Figure 4.20 and Figure 4.21 show the number of units and the performances. There is high probability of maintaining this high level of utilization as emphasis is being put more on laboratory analysis for most of the major illnesses prior to treatment.

Annual Health Sector Performance Report 183 Figure 4.21: Laboratory Credit Line Utilization by authorities

200 185 180 160 140 120 110 102 104 2006/7 81 96 100 71 67 73 2007/8 68 64 67 66 62 2008/9

%tage 62 80 64 67 59 60 2009/10 60 44 40 20 0 B B B rs UPM UCM Othe UMM Total

Essential Drug Program Credit Line JMS has continued to play a key role in the health service delivery through the implementation of the Essential drug credit line program. During the year MoH issued commitment for the first cycle covering period September to December 2009. Thereafter, JMS received a deposit of UGX 3bn for serving the EDP needs for the PNFP health units. By end of June 2010, the total amount utilized was UGX 3.2 bn out of UGX 3.3 bn allocated. This figure included some balances brought forward from the allocation of year III of the program. The utilization for the months of July & August 2009, the other half of the third cycle for year III was UGX 417,179,658.

Table 4.19: Essential Medicines and Health Supplies utilization by authority Category Allocation Utilization %Utilization Balance

UCMB 1,393,689,016 1,345,507,511 96% 48,181,505

UPMB 898,271,143 860,799,922 96% 37,471,221

UMMB 229,443,353 1,000,894,201 98% 22,138,653

INGO 135,053,859

LNGO 527,120,999

Others 131,414,463

Total 3,314,993,013 3,206,307,433 97% 108,685,580

184 Annual Health Sector Performance Report Table 4.20 Essential Medicines and Health Supplies Summary of utilization Authority Credit line (UGX mn) Utilization (Sales UGX bn) %tage utilization

UCMB 1,394 1,345 96%

UPMB 898 861 96%

Others (UMMB, NGOs) 1,023 1,001 98%

Total 3,315 3,206 97%

Tables 4.19, 4.20, 4.21 and figures 4.22 and 4.23 summarize the utilization by the various authorities. The total utilization level of 97% has been the highest among all years we have operated the credit line. This is an indication that with an early availability of funds, the absorption rate for the credit line can improve significantly.

Table 4.21 Percentage utilization trend over four financial years Category 2006-7 2007-8 2008-9 2009-10

UCMB 95 88 70 96

UPMB 97 90 69 96

Others 77 91 52 98

Figure 4.22: EMCL utilization in Million UGX

3500 3315 3207

3000

2500

2000 Credit line 2053 1500 1345 Sales 1023 1001 898 1000 861

500

0 UCMB UPMB Others Total

Annual Health Sector Performance Report 185 Figure 4.23: EMCL utilization over the last four years

120

97 98 97 100 95 96 96 91 92 88 90 89

77 80 70 69 66 2006/7 %tages 60 52 2007/8 2008/9 40 2009/10

20

0 UCMBUPMBOthersTotal

186 Annual Health Sector Performance Report 4.5 Diagnostic and Blood transfusion services

4.5.1 Laboratory services The Central Public Health Laboratories is a unit under the National Disease Control of the Ministry of Health. It provides laboratory support for disease surveillance through investigation and confirmation of disease outbreaks and feeding into the HMIS database at the Ministry of health resource centre. It is also currently the unit in charge of coordination of health laboratory services in the country and is as such responsible for development of policy/guidelines, training and of implementing quality assurance schemes for laboratories. With funding support from GOU and PEPFAR through the MoH-CDC Cooperative Agreement, CPHL has played a key role in strengthening laboratory services through support supervision, HIV TB and malaria diagnosis. Through monitoring and evaluation CPHL has used this as a platform for strengthening and improving other areas of health laboratory services. Strategic objectives for laboratory services in the HSSP II i) Develop a comprehensive National Health Laboratory services policy ii) Build capacity in laboratory service delivery at National, regional, district, health sub district and primary health care levels iii) Establish a sustainable laboratory supplies system as part of the Essential Medicines and Health supplies management system that will ensure availability of laboratory reagents, equipment, reagents and supplies at all levels. iv) Consolidate and strengthen the National Laboratory Quality Assurance Scheme and establish laboratory linkages within the region to ensure an effective sustainable laboratory referral system v) Establish and effective management structure in the Ministry of Health to provide stewardship, coordination and management of laboratory services

Progress on implementation of interventions planned in HSSP II Targets set (activities) for year 4 of HSSP II i) Finalize and disseminate the National Health Laboratory services policy ii) Develop a comprehensive National Health Laboratory Strategic Plan (NHLSP) iii) Advocate for creation of laboratory coordination structure at MoH HQ iv) Upgrade or establish National Public Health Laboratories as national institution as proposed in HSSPII with clear mandate. v) Secure land and draw up plan for the construction of CPHL. vi) Participate in human resource development at pre and post service levels vii) Implement an external quality assessment scheme (EQAS) in 250 (25%) laboratories viii) Establish boisafety and bioecurity progammes in the laboratory network ix) Maintain the laboratory supplies credit line for 100% of all government and PNFP health facilities x) Support 80 districts to conduct support supervision of laboratories xi) Conduct quarterly support supervision and mentoring of regional /district laboratories xii) Provide laboratory support for investigation and confirmation of all disease outbreaks Major achievements and output (impact) attained during the 4th year of HSSP II

Annual Health Sector Performance Report 187 1. Health laboratories policy finalized during 2008/2009 and eventually launched during Q1 of 2009/2010 2. The process to develop a NHLSP is in the final stages 3. Land for construction of a new CPHL building at Butabika was secured and the construction process will soon be underway. 4. Proposal for a semi-autonomous CPHL presented to the restructuring committee for approval. 5. New National Health Laboratories Technical Committee appointed and facilitated to meet. This committee provides technical advice stewardship on laboratory issues 6. Up to 1000 laboratory staff were trained in HIV testing, blood collection and shipment for early diagnosis of HIV among infants (EID), T.B smear microscopy, laboratory management 7. 80 districts were supported to conduct 2 rounds of support supervision of peripheral laboratories 8. EID was integrated into child days plus and the number of sites offering EID increased to 403 9. Continued to collect and collate laboratory data from peripheral facilities for forecasting of laboratories supplies needs and feeding into the resource centre for surveillance 10. Provided laboratory support for the investigation of various out breaks including, Cholera, typhoid fever, brucellosis, epidemic meningitis, bacillary dysentery, food botulism, H1N1 influenza, Hepatitis in various localities in the country. 11. Conducted one round of support supervision of general and regional hospital laboratories in 80 districts 12. Participated in writing grant applications for funding of laboratories services in Uganda to the World Bank and to CDC. Under the CDC proposal, CPHL, all General and Regional Hospital Laboratories would be supported. Under the World Bank Proposal, the National T.B reference laboratory, 5 regional Hospital laboratories and CPHL would be supported.

Major challenges 1. Lack of a strategic plan for laboratory services in the country 2. Lack of a defined structure for coordination of laboratory services at the Ministry of Health Headquarters 3. Status and mandate of CPHL(NPHL)not at national institution level and no written mandates 4. CPHL is accommodated in a rented residential house in the middle of the city 5. Recruit personnel to fill the vacant GoU positions at CPHL 6. Slow release of funds dedicated to activities for improvement of laboratory services 7. Weak regulatory framework for laboratory services in the country 8. Limited number of available laboratory professionals to implement the activities 9. Biosafety and bio-security in laxity status and limited 10. Insufficient funding from Government for laboratory services, rely heavily on donor funds

188 Annual Health Sector Performance Report

service isorganised verymanagement ans crucial for systematic accommodationnationalreference labs befitting Many and CPHL partners program by in-service training laboratories However, stock outsfrequent have been dueresponding to orders to delays in Numbers have still lacking personnel increased but Policy has been launchedQ1 during of 2009/2010.for Strategic plan its implementationdeveloped is being WHO(IHR),CDC Requirementestablish that Nationalinternational level and standard ref countries labs at restructuring Stewardship of laboratory CPHL/CDC Important to have a dedicate databases HSSPII CPHL Essential function of health CPHL CPHL CPHL CPHL Labdocument Policy Survey ofland the CPHL design at andclearance done Butabika NEMA 2009/10 Data source comments IncludedMoHrestructuring of in the Includedrestructure of MoH in the attended WHO/ACILT in training JohannesburgNHLS dissemination started MoH MoH communicated to ULC,Butabika Hospital Included inrestructuring the MoH of Included inrestructuring the MoH of MoH MoH communicated ULC to 500 900 1150 CPHL/ partner Included inrestructuring the of MoH Included inrestructuring the of MoH 1079 1297 1297 Surveys by 1079 1198 1198 Surveys by Drafts 2 -3 Finalized Policy Policy launched and Started Started advocacy ProposalHSSPII the 2CPHLstaff attended WHO training in Nairobi 125 250 250 310EQA Additional CPHL Drafting initiated Proposal HSSPII the in No Policyplace in HL during the HSSP II period II the HSSP period HL during No Policy in place Participate in human resource Secure land and draw up plan for for plan up draw and land Secure the construction of CPHL. Upgrade orPublic establish Healthnational institution National as Laboratories proposed mandate with clear HSSPII in as HSSP II target/ indicators 2004/05 2005/06 2006/07Advocate for creation of coordinationlaboratory structure 2007/08at MoH HQ 2008/09 Establish and bio- bio-safety in the progammes security network laboratory Training: development atservice levels pre and the lab Consolidate strengthen and post scheme assessment quality Number of laboratoriessupplies receiving Line Credit Laboratory on the National Number offunctional heath facilities(Government and PNFP) with laboratories DevelopNational a policy services Health comprehensive Laboratory Table 4.22: Achievements of the CP Achievements Table 4.22:

Annual Health Sector Performance Report 189 4.5.2 Uganda Blood Transfusion Service

The main goal of the Uganda Blood Transfusion Services is to make available adequate quantities of safe blood and blood products for the management of all patients in need of blood. The specific objectives are to: i) Expand blood collection to operate adequately within a decentralised health care delivery system ii) Increase annual blood collection necessary to meet all the blood requirements of all patients in the hospitals iii) Test all blood for transfusion transmissible infections and operate an effective QA program iv) Ensure continuous education and training Progress UBTS has been implementing the PEPFAR grant for “Rapid Strengthening of Blood transfusion Service in Uganda” in addition to the Government of Uganda funding through Vote 151. The total grant for year 5 ended 31st March 2010 and a no-cost application was submitted for April - 30th September 2010 to bridge the gap as a decision was awaited for the application submitted to PEPFAR 11 for the period 2010-2015 The strategies that were implemented to expand the blood collection within a decentralised health care delivery system included: i) Operationalising two Regional Blood Banks and the expansion of Blood Bank ii) Securing of additional space at Kitovu hospital and land for Gulu Blood Bank. Also, plans for construction of Gulu/Fort Portal Regional Blood Banks are in final stages iii) Improvement of institutional capacity • Three generators for three Regional Blood Banks • Computers procured and distributed • Vehicles: 7 Suzukis, 1 minibus; 4 land cruisers procured and distributed iv) Expansion of staffing structure to include – Economist, Procurement officer, internal Auditor were recruited Not achieved: i) Completion of external works Mbale/Mbarara Regional Blood Banks ii) Provision of alternative source of power for Arua Regional Blood Bank iii) Adequate equipment for Regional Blood Banks iv) Exploration of alternative testing techniques v) Full functionalisation of BBMIS in regional Blood Banks vi) Efficient handling of vehicles in the Regional Blood Banks

190 Annual Health Sector Performance Report Blood collection is the largest activity of UBTS. It includes: Recruitment of Blood donors, Blood donor education (pre-donation counselling), and selection, collection of blood and post-donation counselling (notification) and donor retention. This activity is jointly carried out by the staff of UBTS and Uganda Red Cross Society (URCS). Increment in collection depended largely on the dedicated operation of mobile teams that collected up to 90% of all blood units while fixed sites collected 10%. For instance, each blood collection team had a target of 37 units per session and a total of 740 units per month. The 20 teams and all the fixed sites collected a total of 170,191 out of the targeted 195,360 units. This was an overall 0.56% increase in blood collections for the FY 09/10 as compared to FY 08/09 Figure 4.24 summarizes this information for collections by centre and shows that the largest increase is attributed to the central region.

Figure 4.24: UBTS units collected per Regional Blood Bank

UBTS UNITS COLLECTED PER RBB FOR JULY2009-JUNE2010 COMPARED TO THE SAME PERIOD 2008-2009

70000

60000

50000

UNITSJULY2008- 40000 JUNE2009 UNITSJULY2009- 30000 JUNE2010 TARGET 20000 10000 0 F/PORT CENTR MBARA KITOVU MBALE ARUA GULU AL AL RA UNITSJULY2008- 9305 16032 24244 7722 19545 58305 34097 JUNE2009 UNITSJULY2009- 8851 15565 23943 7540 18242 63919 32131 JUNE2010 TARGET 8880 18960 27840 8880 18960 65160 36720

In order to secure blood safety, it was necessary to ensure that all blood was tested for TTIS as well as operationalise a nationwide quality assurance (QA) program. Progress was realised in that:

Annual Health Sector Performance Report 191 i) All blood that was collected in the 2009/10 was tested for HIV, Hepatitis B, C and Syphilis in addition to grouping before issue to hospitals in a quality controlled manner. ii) An effective testing algorithm has been established and is already in use. iii) Quality manual for QA processes for Blood donor recruitment, Blood donation, laboratory testing and issuing of blood was reviewed and is now ready for print thanks to support from SCS. Consolidation of quality control practices will include ensuring that samples are sent to reference laboratories for quality control tests, supervision is strengthened in all departments and that there is continued improve in occupational safety and waste management. It will also be necessary to strengthen the clinical interface. iv) Component production has commenced in the Regional Blood Banks, though on a small scale. v) Hepatitis B vaccination was conducted for all staff Figure 4.25 shows that the target for prevalence of hepatitis amongst donors has been met in 2009/10. Figure 4.25: Trends of Hepatitis C among blood donors July 2009 to June 2010

UBTS TREND OF HEPATITIS C AMONG BLOOD DONORS FOR A PERIOD OF JULY2009- JUNE2010 COMPARED TO THE SAME PERIOD JULY2008-JUNE2009

9 8 7 HEPCJULY2008- 6 JUNE2009 HEPCJULY2009- 5 JUNE2010 TAREGT 4 3 2 1

0 F/PORTA MBARAR KITOVU MBA LE A RUA GULU CENTRA L L A

HEPCJULY2008-JUNE2009 2.55 3.16 4.26 4.26 7.87 2.83 2.53 HEPCJULY2009-JUNE2010 3.54 0.12 4.85 3.35 4.57 1.39 1.75 TAREGT 3333333

Training has been a core activity of UBTS in the past FY. All cadres of staff including nurses, technicians, doctors and administrative staff have benefitted from capacity building exercises locally and internationally. A number of staff has been trained at Sanquin Blood Bank in the Netherlands. Clinical seminars were conducted in all regional Blood banks for improvement of Hospital transfusion practice and clinical interface

In the previous YR, UBTS has conducted M&E activities to improve efficiency and effectiveness of BTS activities. Supervision from the headquarters to the regions was strengthened. Area team supervision was introduced. Efforts will be made to improve on the supervision reports and appropriate feedback to supervisees and follow up on recommendations are made.

192 Annual Health Sector Performance Report 4.6 Information for decision making

4.6.1 Resource Centre The National Health System needs information in order to ensure that the needs of the population particularly the vulnerable groups are catered for, measure the effects of the interventions, inform policy and assess and improve health sector performance. Substantial progress was made in HSSPII, with increasing data available on health services utilization and system performance. The MOH, Research Institutions, Universities, other government ministries and departments, NGOs and partners are involved in generation and utilization of health information. We hereby outline the Health Management Information System as an integral part of the National Health system. The overall objective of the HMIS is to strengthen the health information system to enable timely and quality data collection, analysis, dissemination and utilization at the local, districts, national, regional, global levels and assist in the measurement of progress towards achieving the HSSP, PEAP and MDG goals. Health information is important for monitoring the performance of the health sector. During HSSP1, guidelines and generic data analysis formats for all levels were developed and distributed in order to improve the analysis and interpretation of HMIS data. New quarterly performance assessment formats for the HSSP and programme indicators for all levels were developed and distributed to all districts. This is an effort to improve HMIS data. Timeliness and completeness of HMIS reporting (a key process indicator for the implementation of the HSSP1 and whose 5year target was set at 80%) improved during the HSSPI and II. HMIS reporting has improved from a national average of 21% in 2000, 53% in 2001, 63% in 2002, 79% in 2003 and 84% in 2009_10 financial year.

Challenges of the HMIS The major challenge has been harmonization and streamlining of various data sources and ensuring that they are leveraged to provide a better impact measurement of health sector interventions. The on-going analysis of the old HMIS data revealed lack of accuracy, timeliness and completeness of reports, consequently affecting decision making at all levels. Lack of coordination, leadership, clear strategy, policy and guidelines, as well as shortage of skilled human resources, were the key factors affecting the HMIS performance. Furthermore, the effect of parallel reporting with multiple and redundant formats compromised data quality and increased administrative workload. Among the many shortcomings, we have the following;

1. The multiple information systems (silos) largely contributed to by donors and disease specific vertical information systems leading to fragmentation of health information. We have therefore come up with a draft National Health Information Strategic framework that will inform all stakeholders on criteria for setting up information systems, standards, and codes allowing for interoperability. In this case, much greater advocacy is required to build the case for a country owned, harmonized and coordinated health information system. 2. Integrating public and private practitioner’s information system is still a challenge. Data from private practitioners (clinics and hospitals) is critical for having a holistic picture of a population’s health. We plan to engage them in a dialogue to get them on board through public private partnership initiative. 3. Need for increased prominence and support There is need for leaders, both within government, and within the Ministry of Health, to provide much required financial and human resources for an effective and efficient integrated HMIS. They also need to champion principles of transparency and the value of good information for good governance of a health system. Annual Health Sector Performance Report 193 4. Developing a culture that values and uses information is still a challenge: The sector needs to promote use of data for evidence based decisions, planning, and performance measurement and reporting. This will inevitably lead to increased demand for data and improved quality, reliable and complete data. 5. Lack of data collection tools at facility level remains one of our biggest challenges. Due to lack of adequate financial support HMIS forms are not adequately distributed to data collection facilities thus making it difficult for the records officers to fill them and submit on a timely basis to the next levels. 6. Training and follow-up supervision of district information and records officers: Funding has been inadequate to meet the demands of training, and follow-up of these carders. 7. Regular data quality checks cannot be conducted within districts and across the country as is expected due to inadequate funding. 8. Ever increasing number of districts makes data entry at the national level difficult and allows for lots of transcription errors. This requires carrying out double data entry in order to clean the data yet have a small staff structure. We plan on developing a versatile electronic HMIS at district ands facility level. Lessons learnt 1. Involve all stakeholders in revision of HMIS One way to instill an appreciation for good health information is to involve people from all levels of the data chain in determining what data is needed and how it will be used. This is particularly critical for local health workers who may be skeptical about changes to what data is collected and how it is to be collected. The aim of any changes should be to try and reduce the amount of data collected at clinic level and should focus on how data can be better used at a local level. 2. Start with perfecting the paper based system Much attention in HMIS has been given to improving IT aspects of the information system, when in fact the fundamentals of diagnosis, coding and reporting are not yet in place. The most successful experiences of HMIS in resource poor countries have been those that ensure that the routine record keeping is of sufficient quality before considering the use of IT systems. 3. Ensure the feedback loop is continuous and reliable Health workers and managers who have to undertake the data collection are more likely to remain motivated if they see the outputs of their work. This can be further enhanced if data generated is used for performance management. 4. Human resource capacity One of the most difficult parts of improving HMIS is ensuring that the people filling in the forms at health unit level are skilled enough to report accurately, whether on diseases diagnosed or resources used. Further more, the staff examining these forms at the National level have to be suitably qualified for the tasks they are performing, and the numbers of staff dealing with the data have to be increased too especially bearing in mind the fact that the system is purely paper based.

194 Annual Health Sector Performance Report 5. Data storage and use One of the temptations in HMIS has been to get carried away with the technical aspects of data storage and analysis, rather than focusing on the more fundamental issues of making sure the data is correct in the first place. In terms of data use, the centre has been consistently poor at providing adequate facilitation for district information officers to carry out lower level support supervision. Some observers speculate that facilitating greater local use of data could improve data quality overall, as those doing the data collection should be more facilitated. Recommendations 1. Improving prominence of the Resource Centre and finalizing the National Health information Strategic framework 2. Country ownership, harmonisation and coordination of all parallel health information systems (silos) 3. Provision of adequate human and financial resources 4. Establishment of a MoH data warehouse that is accessible by all stakeholders 5. Provision of revised integrated data collection tools 6. Operationalise the Community-Based Health Information System 7. Provision of quarterly web-based feedback to all stakeholders

Annual Health Sector Performance Report 195 Information and Communication Technology (ICT) for Health Care Delivery ICT in the ministry of health has undergone many changes in the health care sector and management over the years. Specifically looking at improving the business processes for effective and efficient health care delivery system; ICT are useful tools that enable transmission of health information between geographically distant parts. It makes it possible to ensure that information is available in real time for evidence-based decision making. National Health Information Strategic framework is being finalised. Besides health information, the HIS Strategic Framework will also provide direction on electronic and mobile health (e-health and m-health respectively).

A number of interventions have been undertaken: i) ICT appreciation and behavioural change towards the use of ICT ii) Expansion of the Local Area Network to a Wide Area Network and availing it wirelessly at the Headquarters. iii) Redesigning of the Website and constant updating iv) A number of systems have been developed to ease the storage, retrieval and analysis of health data such as the HRIS system for Human Resource, HMIS for Medical records v) Addition of human resource with the help of development partners vi) Acquiring a state of art server room at the ministry of health. vii)Improvement of internet connectivity at the headquarters from 256 kbps to 2 Mbps over the years. viii) Management of our own mail server. ix) Maintainace of the LAN at MOH has greatly improved over the years. x) Allocation of an ICT budget this year. xi) Internet connectivity and LAN establishment to most of the districts Health Offices with help from UCC xii)Establishment of basic Tele-medicine at most hospitals with help from UCC and its on going. Challenges 1. Limited awareness about eHealth, 2. Lack of enabling policy environment, 3. Weak leadership and coordination, 4. Inadequate human capacity, 5. Weak ICT infrastructure and services, 6. Inadequate financial resources and 7. Weak monitoring and evaluation.

196 Annual Health Sector Performance Report Despite the challenges there are existing opportunities: rapid advances in ICT, increasing accessing to mobile phones and broadband connectivity, increasing donors and in country support through strengthening health systems and partnerships. Recommendations i) To strongly advocate for presentation to TWG of all new ICT projects which seek to use government health structures or employees and have an impact on the national HIS,while they are still at Concept Stage, for review and recommendation for implementation ii) To provide recommendations on project alignment to current programmatic objectives and strategies of the MoH and the developing HIS framework iii) To assess viability of initiatives, ensuring that they use appropriate technologies, and are sustainable, replicable, scalable, and interoperable. iv) Provision of adequate human and financial resources. v) Redesign the Wide Area Network by adding MoH remote sites like UNEPI, Health Infrastructure Wabigalo, Chemotherapy and TB vi) Upgrade connectivity from leased copper lines to fibre for fast speeds and reliable connectivity. vii)Upgrade from 2 Mbps to 5 Mbps both upload and down load viii) Establish an intranet at MOH ix) Establish an area storage network x) Shift from the use of analogue phone communication to IP telephone technology xi) Increase technical support to the hospitals and districts, training in basic ICT to deliver health services. xii)Establish Hospital Profiles on MOH website. xiii) Establish a Data Ware House at the MoH Head quarters to streamline reporting of the different health system modules.Establish a Document Management System.

Annual Health Sector Performance Report 197 4.7 Health policy, research and development

4.7.1 Policy Analysis Unit

The policy Analysis unit is under the planning Department, it is entrusted with the responsibility of formulating, reviewing, analyzing researched policies and legislations for the sector. These units were instituted in all line ministries to have a streamlined way of dealing with policies and programmes. Also in collaboration with other divisions of the planning department, has taken part in developing of the sector papers in respect of National Development Plan and the Ministerial Policy Statement.

Functions of PAU

i) Advising Permanent secretary on important policy changes ii) Legislation process iii) Liaison with relevant units on Ministerial policy statement iv) Result Oriented Management (ROM) v) Regional integration of Health policy vi) Optimal utilization of resources

Achievements in Financial Year 2009/2010

i) Carried out 2 consultation workshops ii) Carried out 4 health acts workshops iii)Attended 4 workshops for policy document development. iv)Carried out 4 policy surveys v) Conducted 6 legislation task force meetings. vi)Attended 2 international conferences/ courses vii) Procured furniture and equipment for PAU office viii) Procured 2 consultancies for legislation on human organ transplant and policy effectiveness

Table 4.24: Health Policies/Bills and their status No Name Status

1 Pharmacy Practice and Profession Bill Referred back to MOH

2 Traditional and Complimentary Medicine Cabinet Principles

3 National Drug Act Cabinet/Top Management

4 Health Tertiary Institutions Bill Cabinet

5 Mental Health Act MOJCA

198 Annual Health Sector Performance Report No Name Status

6 Public Private Partnership in Health Policy Top Management

7 National Health Insurance Bill MOJCA

8 Draft NHPII Task Force

9 Draft HSSPIII Task Force

10 Mental Health Policy MH Division

11 Human Resource for Health Policy Referred back to MoFPED

12 Research Policy MoFPED for certificate of Financial Implication

Note:

A great number of policies have remained unapproved by the cabinet due to challenges of meeting cabinet requirements. Costing policies and plans remains one of the biggest challenges in the sector.

Challenges

i) Lack of integration and linking into the development of policies. ii) There is a limitation of funds. The funds allocated to the unit are limited and thus carrying out some activities is put on hold. Recommendations i) Strategies should be made to integrate and link the development of policies.

Annual Health Sector Performance Report 199 4.7.2 Uganda Virus Research Institute

a) Mandate and objectives UVRI is one of the constituent institutions under UNHRO an -autonomous organization under the Ministry of Health (MoH). The Institute’s broad mission is to carry out scientific investigations concerning communicable diseases especially viral diseases of public health importance and to advise government on strategies for their control and prevention. b) The General objectives for research and development are to:- i) Improve coordination, dissemination and utilization of health research results ii) Mobilize and establish a funding mechanism for health research iii) Develop capacity for health research at the district level

c) Specific objectives to UVRI: i) To conduct relevant research in viral and other infectious diseases ii) To contribute towards the strengthening of laboratory networks iii) To contribute to effective infectious diseases, surveillance and monitoring systems iv) To provide critical information from research for policy, development and decision making The requirements for the above objectives to be achieved are adequate infrastructure, well- equipped laboratories, highly trained and well motivated personnel to ensure retention. Summary of achievements The Institute’s programmatic activities currently comprise basic research, applied research (intervention, diagnostics, clinical, operational), social/economic research, capacity building, and advice for regulation, policy development and quality improvement in health care. The Institute has played a major role in surveillance for the world AFP polio and is happy to report that no cases exist in Uganda. In addition, the institute had 666 sites provided with QA services from 30th September 2008 to 29th September 2009 and 439 sites as of 15th may 2010.The Institute with support from our collaborators from MRC IANPHI, EDCTP , Welcome Trust and THRIVE among others is carrying out a lot of capacity building in the area of clinical research to improve and strengthen health research in the East African region. There is, in addition, a major function of training that is spearheaded by a Training Committee and the UVRI Clinic that serves both Institute staff as well as the surrounding community and also undertakes research.

200 Annual Health Sector Performance Report

No cases of Plague were reported Only two populations Only have been tested in and resistance Mityana detected in Kamuli but was incomplete testing funds. due to insufficient No AFP PolioUganda in No AFP Overall CFR plague was <14% mortality Surveillance Not done because funds were not availed No measles cases reported Mosquitoescollected were from ,Mbale Molecular Bugala. and insecticide resistance detected allele and no Kdr- W detected. confirmed in Amuru OPV was although district potent Polio cases reported World AFP case The overall mortality was mortality The overall <20% Results of 188 samples Results of awaited Of the 270 suspected cases 12 with were confirmed (4.4%) measles and 14.9 confirmed Rubella suspects. DDT resistance of 7% in in Rakai 22% Nsanzi Island, 26% in and Mbale. in 4% in Nakiwogo,5% Icon: Entebbe,19% in Kigungu- and 5% inMityana Rakai. in 25% Deltamethine: and 5% inMityana Rakai 2007/08 2008/09 2009/10 Overall CFR CFR Overall mortality plague was <20% No isolates out of the 22 samples collected from ,Entebbe and Nsambya hospitals Observed some Observed resistance to IRS lake of in Islands with Victoria variable prevalence I out of 207 (39) I i.e 2.56% measles suspects confirmed and I 39 districts out of confirmed with Rubella stitute in 2009/10 stitute in Overall CFR plague plague CFR Overall was <26% within a mortality setting facility care No cases detected out of the 30 samples from collected Kisubi ,Entebbe and hospitals Nsambya Investigated 2273 and 739 Investigated (22.5%) measles cases confirmed 350(15.4) suspectedcases rubella cases confirmed and 5 out of 12 confirmed with districts Rubella no indoor residual spray no indoor residual spray (IRS) nda Virus Research In Research nda Virus 1% Reduce the Case ( Ratio Falality CFR) forplague Surveillance of in arboviruses patients duly with infected malaria and arboviruses. 201 (13.8%)out of 1453 suspected cases of measles confirmed and 5 out of 12 suspected cases rubella confirmed. There was no indoor residual (IRS) spray 2004/05 Baseline No cases reported cases reported No cases reported No No Indicator 2005/06 2006/07 Strengthened Strengthened outbreak/epidemic response and detection Co-infection of malaria and aarboviruses Laboratory confirmation confirmation Laboratory of Measles outbreaks Mosquito resistance to spraying residual indoor Zero cases of AcuteZero AFP Polio Table 4.25: Achievements of the Table 4.25: Achievements Uga

Annual Health Sector Performance Report 201

th 439 sites provided with with provided sites 439 QA services15 as of may 2010. may Maintained the data unit unit data the Maintained and resource center More efforts are being for solicit to made health for support research for policy. September 2008 to 2008 September th 29th September 2009. September 29th management unit and unit and management Resource centre 666 sites were provided from services QA with 30 Resource Mobilization for Mobilization for Resource MoH/GoU from Research collaborating and institutions/agencies WHO,CDC,IAVI mainly:- EDCTP , ,MRC IANPHI, Welcome Trust and THRIVE Resource centre completed centre Resource data centralized Functional QA provided to 350 antenatal antenatal 350 to provided QA sites Resource Mobilization for for Mobilization Resource Research from MoH/GoU and collaborating mainly:- institutions/agencies ,MRC WHO,CDC,IAVI EDCTP and IANPHI, Welcome Trust No centralized data management unit, resource centre and website QA provided to to provided QA sites antenatal 210 Resource Resource for Mobilization from Research and MoH/GoU collaborating institutions/agenci es mainly:- WHO,CDC,IAVI ,MRC and IANPHI No centralized data data centralized No unit, Resource management centre and website QA provided to 33 antenatal antenatal to 33 provided QA sites Resource Mobilization for Mobilization for Resource Research fromMoH/GoU collaborating and mainly:- institutions/agencies and MRC WHO,CDC,IAVI To set up a up a set To centralized data unit, management centre Resource website a and 2004/05 Baseline Strengthen to labs regional provide for surveillance assurance Quality Resource Resource for Mobilization Research from MoH/GoU and collaborating institutions/agencie s mainly:- WHO,CDC,IAVI MRC and Health management Health management System Information National Quality National Scheme Assurance Resource Mobilization for Research Indicator 2005/06 2006/07 2007/08 2008/09 2009/10

202 Annual Health Sector Performance Report UVRI Investments in 2009/10 i. Expansion of the National HIV drug resistance laboratory. The laboratory is equipped and its functional. ii. Accredited laboratories for polio and measles isolation with support from WHO. iii. National and central data management Unit established

Challenges 1. Weather fluctuations affected mosquito activity and probably the population size of required samples. 2. Inadequate funds were availed for expansion and equipping the laboratory. External funding was obtained 3. No funds were availed for Monitoring of diseases, performance of their interventions and investigate out breaks. Funding was obtained from CDC. 4. Monitoring districts for co-infection with malaria and arboviruses was carried out. Funds were inadequate to complete testing.

Recommendations 1. More funding and attention should be accorded to health research than its currently the case in Uganda 2. More fora should be given to research institutions to disseminate their findings to inform and shape policies in Uganda

Annual Health Sector Performance Report 203 4.7.3 Natural Chemotherapeutics Research Laboratory

The Natural Chemotherapeutics Research Laboratory is a government research and development centre under the Ministry of Health (MoH). It was created in 1964 with the mandate to carry out applied research on natural products (plants, animal parts and minerals) with the view of justifying therapeutic claims from traditional medicine practitioners (TMPs) in Uganda. The centre undertakes the development of quality natural products and services for improved health care delivery by applying both indigenous and modern technologies. NCRL is constituted of a multidisciplinary research team of skilled and technical scientists. This team, in collaboration with other partners and stakeholders, ensures that the centre fulfils its mandate to coordinate research and development on traditional medicine. Its goal is the “Transformation and sustainable utilization of Traditional and Complementary Medicine contributing towards its integration into the Health Care Delivery System.” In order to attain the aforementioned goal, NCRL undertakes the activities described hereunder: 1. Spearheading national policy formulation in the area of traditional medicine, in cooperation with other policy agencies. 2. Standardization of products, involving the promotion and evaluation of their safety, efficacy and quality. This involves: a) Identification of specimens b) Phytochemical screening of both active and inactive ingredients c) Finger printing of analyzed products for consistency and reproducibility of both results and products d) Evaluation of efficacy, derived from both chemical and pharmacological analyses e) Safety studies in laboratory animal models f) Accelerated stability tests that give an indication of the possible shelf-life of the products among others g) Microbiological analyses h) Quantification of both micro and macro nutrients 3. Promotion of health and prevention of disease in the communities involved in the production and utilization of herbal medicines. 4. Collection and documentation of ethno-botanical information and its maintenance in a data bank.

204 Annual Health Sector Performance Report Progress Financial Year 2005/06: i) Held the Third African Traditional Medicine Day who’s Theme was: “Traditional African Medicine Contribution to Preventing HIV/AIDS infections”. ii) Zanthoxylum chalybeum was evaluated for anti-malarial, anti-cickling effects and painkilling effects. iii) Carica papaya was evaluated for anti-malaria and anti-diuretic properties. iv) Herbal products in the market were monitored and evaluated. v) Warbugia salutaris was evaluated for anti-fungal, ant-malarial and expectorant properties for cough. vi) A leader of 200 Traditional Healers from Bushenyi (Issa Nkondo) was facilitated with a motorcycle to assist him with his mobilization activities. Financial Year 2006/07 i) Scientifically verified the non-effectiveness of the Ellahi anti-HIV/AIDS product. ii) Trained herbalists and herbal research students. iii) Developed anti-cough herbal syrup based on natural herbs. iv) Coordinated medicinal plants and biodiversity network for the East African Region. v) Participated in the development of the Draft TCM Policy Implementation Guidelines. Financial Year 2007/2008 i) Draft policy in place ii) Code of Ethics for Traditional Health Practitioners developed. iii) Embarked on Scientific validation of a commonly used immunobooster herbal. Financial Year 2008/2009 i) 6th and 7th Annual African Traditional Medicine days held. ii) Safety and efficacy of priority medicinal plants in reference to Malaria carried out. iii) Conserved medicinal plants in Maziba, Kabaale District. iv) Conducted research of herbal plants used for immune booster in Kitgum District. v) Held official introduction of herbalist representative on NDA Board to stakeholders. vi) Held a stakeholder training workshop on quality of herbal medicine. vii) Currently carrying out police investigation of herbal material exhibits from Traditional Healer’s shrines in Wakiso District. viii) Carried out Routine Laboratory work in relation to a herbal detox formulation from Bugiri.

Annual Health Sector Performance Report 205 Major challenges The main challenges are: i) Late release of funds affects the schedule of activities. ii) Staff not promoted affects morale and performance. iii) Inadequate office equipment. iv) Delays in procurements of services e.g. vehicle repairs etc v) There is lack of a national database for research done hence hindering it difficult to access. Recommendations: 1. Operationalisation of the UNHRO Act.

206 Annual Health Sector Performance Report 4.8 Legal and Regulatory Framework

4.8.1 National Drug Authority

National Drug Authority (NDA) was established by the Act of Parliament in 1994 currently the National Drug Policy and Authority (NDP/A) Act, Cap. 206 (Laws of Uganda 2000 Revised edition). The mandate of NDA is to promote use of safe, efficacious and good quality medicines. TARGETS FOR FY 2009/10 i) Evaluation of dossiers (applications for registration) within 6 months ii) Number of counterfeit and substandard drugs identified and removed. iii) Number of samples picked from the market for analysis iv) Regularly inspect local manufacturing facilities. 1 cGMP audit and 3 follow-up inspections per factory. v) Support supervision carried out in 87 districts. vi) At least one inspection team sent out every month to inspect 6 foreign manufacturing facilities vii)All drug promotions and adverts are authorised by NDA

Progress Product Registration:- i) Of the 513 human & 37 veterinary medicine applications received; 365 and 12 were approved for registration respectively. ii) 250 applications underwent initial assessment while 175 of these have been reviewed by a second assessor. iii) 26 applications for notification of Dietary supplement applications were evaluated. iv) 31 applications for notification of herbal drugs were evaluated. v) 07 applications for notification of Public Health Products were evaluated. vi) 588 registration amendments were received, of which 352 were approved and 236 applications deferred.

GMP Inspection and Licensing of Manufacturing sites:- Conducted GMP inspection of 119 foreign pharmaceutical manufacturing plants. Out of which 94 were compliant, 17 non-compliant and 8 partially compliant. 12 (92.3%) local pharmaceutical facilities were inspected. 2 were licensed while others were requested to provide corrective actions prior to consideration of licensing. Also the first local Medical Device manufacturing facility called Astel Diagnostics was approved.

Annual Health Sector Performance Report 207 Licensing of Drug outlets i) Inspected 516 and approved 459 (89%) pharmacies ii) Inspected 4,497 and approved 4,077 (90.6%) drug shops iii) Controlled import and export of medicines through issuance of verification certificates; 3,058 verification certificates were issued Post Market Surveillance i) Support supervision was conducted in 70 districts at regional level and 51 districts for the Veterinary unit. ii) 1,905 samples of products from ports of entry and market were picked for analysis out of which 593 passed, 63 failed and 1249 are pending outcome of analysis. iii) Recalls of drugs was implemented following the NDA procedure for product recall. 20 products manufactured by facilities in Uganda, Kenya, India and China were recalled. iv) Supervision of drug destruction was made in 14 trips with total weight of 49.3 tonnes. v) Investigation in the quality of Pethidine used in where patients experienced adverse drug reactions were made. The sample provided was confirmed to be registered; tests from the laboratory reveal the presence of Pethidine and no contamination by Suxamethonium. Quality Control: Testing of medicines samples Table 4.26: Analyzed drug samples at the laboratory

Category Tested Passed Counterfeit Failed %age Failure

ARVs 5 5 0 0 0 Anti-malarials 179 139 9 31 22 Antibiotics 176 163 0 13 7 Vet Medicines 22 22 0 0 Analgesics 99 94 0 5 5 IV 15 15 0 0 0 Antiprotozoals 36 36 0 0 0 LLINS 65 65 0 0 0 Other Medicines 14 13 0 1 7

208 Annual Health Sector Performance Report Annual Health Sector Performance Report 209 Figure 4.28: Trends of outcomes of gloves tested in FY 2010

Vetted 147 applications of drug promotions and adverts; 140 applications were approved and 07 rejected. Pharmacovigilance Activities (a) Support Supervision on Pharmacovigilance Activities Conducted support supervision to support the core team members improve on the implementation of Pharmacovigilance activities in the regions. The following were the health units visited; 58 Hospitals 83 HC IV 135 HC III 24 HC II 9 Health Training Institutions Sensitized 576 health workers and 1,073 students from training institutions on Pharmacovigilance activities especially on reporting adverse drug reactions in the regions. Sensitised 177 District Veterinary Officers and other Veterinary Professional (Private), 600 stakeholders (public) on monitoring and reporting adverse drug events in the districts of Kabarole, Budibujo/Rwebisengo, Kyenjonjo, Hoima, Kibale, Kiboga, Masindi, Bulisa, Mubende and Mityana.

210 Annual Health Sector Performance Report (b) Adverse Drug Reaction Reports Received 162 ADR reports (human) during the financial year. As of December 2009, a total of 556 reports had been received. The five (5) most reported drugs were; Cotrimoxazole (58 reports), Nevirapine (49), Zidovudine (43), Atemether / Lumefantrine (41) and Triomune (35). The graph below shows the number of reports received.

FigureFigure 4.29: 4.29: Adverse Adverse drug drug reactionreaction reports fromfrom 2005 2005 to to 2009 2009

NumNum ber ber ofof ADR reports received received through through spontanous spontanous reporting reporting

250250 229229

200200 180180 150150 100100 7575 4949 5050 2929 00 20052005 2006 2006 2007 2007 2008 2008 2009 2009

ReportsReports

Figure 4.30: Adverse drug reactions in FY 2009/10

Annual Health Sector Performance Report 211 Skin reaction (with Cotrimoxazole, Nevirapine and Artemether / Lumefantrin) was the most reported reaction. Other reactions were Gastro intestinal events (nausea vomiting and diarrhea), and anemia Most of the reactions reported are expected. Approximately 80% of reports have missing information.

• 159 ADR reports were entered into vigiflow database, • 123 ADR reports were committed to UMC. • Received more than 220 reports of adverse events resulting from clinical trials.

Issues of concern were; • Tenofovir and birth defects • Tenofovir and renal toxicity • Artemther Lumefantrin and birth defects

(c) Follow up of adverse event reports

Table 4.27: A summary of adverse event reports

Drug/complaint Complaint source Action taken Results Pethidine injection reported to Nakasero hospital Survey of 10 regional referral No similar reaction observed and have caused fasciculations and hospital. no conclusion drawn as we could convulsions. It was suspected to be not get post mortem results. Batch tested in NDQCL contaminated with Lab results showed no Suxamethonium. contamination with Suxamethonium Malaria medicines implicated to Newspaper about 2 cases Presented to NDA Technical Case could not be concluded due have caused steven johnsons of death in Jinja Committee and CNF; the case to incomplete/poor records at the syndrome is still to be presented to facility Pharmacovigilance & Clinical Trials Committee 223 cases of Gulteal fibrosis and Kumi hospital during To be notified to MoH Irrational drug use was cited as 17 of quadriceps fibrosis were sensitization on the problem identified in 2008 and 2009. pharmacovigilance Nitroxinil (troxahel 34%)batch Kyenjojo Sensitized farmer to consult a The drug was not expired but was no.1323/3 loss of 6 Friesian professional when using drugs administered by a quack and and to report adverse events if injected the drug using a wrong observed route, site and there was an overdose

212 Annual Health Sector Performance Report Conducted studies on Quality of Medicines on the Ugandan Market 1. Post Marketing Surveillance (PMS) Study commissioned by the Authority and focused on various essential medicines i.e.: antibiotics, analgesics, anthelminthics, antifungals, antiasthamatics, and antiprotozoal agents. GPHF Minilabs were used and full scale QC testing for those for which no Minilab procedures existed. Samples were drawn from 7 sentinel sites, these being the 7 regional offices of the NDA.

Findings: i) 5.1% of samples failed Minilab testing including visual, identification, disintegration and thin layer chromatography (TLC). ii) 11.5% of samples failed full scale Laboratory testing iii) Only two (2) samples from the public sector failed 2. Quality of Antimalarials in Sub-Saharan Africa (QAMSA) study A survey was conducted on the quality of SELECTED antimalarial medicines circulating in Madagascar, Senegal and Uganda; they included ACTs & SP acquired from the public sector, the regulated private sector and the informal market. 90.4% of samples were subjected to testing using Global Pharma Health Fund (GPHF) Minilab test kits. The remaining 9.6 % of samples, for which there were no Minilab procedures, underwent full scale laboratory testing at the USP Headquarters (Rockville, Maryland, USA). They were: i) Artesunate+amodiaquine (co-packaged) ii) Artemether/ Lumefantrine (fixed dose combination-FDC) iii) Sulfadoxine/ Pyrimethamine iv) Others (mefloquine+artesunate; dihydroartemesinin/piperaquine-FDC; sulfamethoxypyrazine/pyrimethamine-FDC) Findings: i) Failure rates using Minilab: 41% Senegal, 12% Uganda, and 6% Madagascar ii) Failure rates after full QC laboratory testing: 44% Senegal, 30% Madagascar and 26% Uganda. iii) Failures were attributed primarily to dissolution and impurity tests. iv) All samples taken from the public sector in Uganda passed the quality tests. 3. Presidential Malaria Initiative (PMI) / USAID sponsored project The survey employed the use of Global Pharma Health Fund (GPHF) Minilab test kits to ascertain the quality of antimalarials drugs. Testing was carried out primarily at Level 1 (mini lab) which employed thin layer chromatography (TLC) plates at 7 sentinel sites located at NDA regional officers. Level 2 testing at the NDQCL focused on product for which there were no mini lab testing procedures and those that failed testing at Level 1. idi

Annual Health Sector Performance Report 213 4. MAMBA I & II Operation Mamba is INTERPOL-WHO initiative targeting counterfeit pharmaceuticals in Eastern Uganda. The first operation Mamba I (2008) took place in Tanzania and Uganda. It demonstrated the way in which multiple law enforcement agencies can be mobilized to achieve a common goal. Mamba II involved Police, Customs and Medicine Regulatory Agencies from Kenya, Tanzania and Uganda as well as the Fair Competition Commission (FCC), and the Office of the Presidency in Tanzania. This was a continued effort at fighting the dangerous trade of counterfeit medicines in the region. Findings: i) These operations succeeded in unearthing unscrupulous dealers, and the operations also identified substandard and counterfeit drugs at various levels; i.e. ii) MAMBA I: Products being peddled as general sales cosmetics, but which actually contained pharmaceuticals e.g. (corticosteroids). Follow-up and involvement of KACITA was enlisted to both educate and increase vigilance. Worst affected area was Kikuubo in downtown Kampala. iii) MAMBA II: confirmed two (2) cases of counterfeits (Metalkefin & Cialis) , though the source could not be ascertained iv) MAMBA II: 18 court cases were opened (for among others, suspected dealing in smuggled drugs, re-packing of expired drugs; so far 6 convictions have been secured, while 12 of the 18 cases are still ongoing. Challenges i) Inadequate funding that has hindered: % Recruitment and deployment of Zonal Inspectors % Recruitment and deployment of Inspectors at all border entry points ii) Implementation of an integrated MIS for the entire organization iii) Delays in amendment of the legislation iv) Extended mandate to NDA not backed up by resources v) Liberalization of media industry and abuse by herbalists and other quacks vi) Conflicting mandates of professional bodies vii)Inadequate capacity to handle expired drugs in both public & private health facilities 236

214 Annual Health Sector Performance Report 3.0 Budget Performance Table 4.28: A summary of performance for each budget line during the financial year 2009/2010 Output Description FY 2009/2010 FY 2009/2010 Budget Budget – Ushs Performance – Ushs (millions) (millions) 1 Dossier evaluation 105 69 2 Inspection of medicines at ports of entry 43 27 3 Inspection and licensing of local 72 4.5 manufacturers 4 Inspection and approval of foreign 761 804 manufacturers 5 Support supervision to districts 320 213 6 Post Market surveillance 181 127 7 Testing of samples 13 20 8 Destruction of drugs 35 49 9 Pharmacovigilance Training at Regional 32 69 Centres 10 Sensitization, follow-up & collection of 29 23 ADR forms Recommendations i) Advocate for direct funding of NDA by Government of Uganda. ii) Initiate meetings with professional councils to improve working relations. iii) Enlist support of media council to combat media abuse by herbalists & other quacks. iv) Amendment of legislation to address weaknesses in the existing one. v) Increase presence of NDA at the community level through rolling out of Zonal Offices. vi) Establish an integrated MIS platform for all NDA operations with web-based provision for public access to relevant information. vii)Strengthen collaboration with health professional councils and other agencies involved in the pharmaceutical sector.

Annual Health Sector Performance Report 215 4.8.2 Medical and Dental Practitioners Council

The Uganda Medical and Dental Practitioners Council (UMDPC) is a statutory body, established under statute No 11 of Medical and Dental Practitioners’ Statute, 1996. Vision A reputable council that protects society from abuse of medical and dental practice as well as research on human beings in order to effectively contribute to a healthy and productive population Mission To regulate and enforce standards of medical and dental practice and supervise medical and dental Core Functions i) To supervise medical and dental education in all university medical and dental schools in Uganda. ii) To register all legible medical and dental practitioners and private medical and dental health units in Uganda iii) To inspect all private medical and dental health units in Uganda, to ensure compliance with established standards of practice iv) To enforce ethical standards and professional code of conduct among medical and dental practitioners in Uganda. Objectives for 2009/2010 i) To register and license qualified practitioners and all private health units that meet the requirements of the Council. ii) To conduct regular inspection of private clinics in Kampala area and up country. iii) To investigate all reported cases of alleged professional misconduct and take appropriate disciplinary measures. iv) Participate in the joint EAC Medical Council/Boards Activities. v) Ensure effective management of the Council Major Achievements i) Registered a total 500 practitioners, and licensed 2000 of them during the year while 1500 private health units were licensed. ii) Inspected 100 private clinics in Kawempe and Rubaga Divisions in Kampala area, and 85 private clinics in upcountry towns.

216 Annual Health Sector Performance Report iii) Inspected 8 Reflexology centres in Kampala area to assess the activities of a self styled group of people called Reflexologists operating in Uganda and make recommendations to Ministry of Health in order for it to make an informed decision. iv) Investigated four reported cases of professional misconduct in Mbarara, Masindi and Kampala and took appropriate disciplinary action. v) Finalized draft proposal on establishment of DSA vi) Participated in EAC Medical Council/Boards meetings held in Arusha and Mwanza in Tanzania. vii) Participated in the joint EAC Medical Council/Boards inspection of medical and viii) dental schools in Rwanda and Burundi in Febuary 2010 ix) Recruited 3 members of staff at the secretariat for post of Secretary, Finance and Administration Officer, Data and Research Officer. x) Overhauled one of the double cabin pick trucks Major Challenges i) Inadequate funding. The Council was allocated UGX 35m as subvention from government for the whole FY2009/10. ii) Inadequate staff at the secretariat. iii) General malaise among practitioners to pay for their APL iv) Inadequate guideline regarding establishment and operation of private clinics v) Lack of regulatory policy in Uganda on traditional and complementary medicine practice in general and for reflexology practice in particular. vi) Lack of efficient transport for field activities. Recommendations i) More funding ii) Expansion of staffing at the Council Secretariat, with creation of inspectorate division iii) Regular inspection of Health Units in Kampala and up country Towns. iv) Regular district support supervision. v) Establishment of District Supervisory Authorities vi) Establishment of an independent umbrella National Regulatory Authority vii) Review of guidelines for establishment and operation of private clinics viii) Operationalization of PPPH policy in Uganda in order to have traditional and complementary medicine practitioners regulated if they must exist. ix) Purchase of a double Cabin Pick-up for field activities.

Annual Health Sector Performance Report 217 Table 4.29: Health Sector Annual Performance Report for 2009/2010 Output Description Annual planned Actual output Comment target

Inspection of private clinics 200 100 in Kampala

Inspection of private clinics 400 85 Inadequate up country Funding

Inspection of reflexology Nil 8 This was an centres in Kampala exploratory inspection visit

District Support Supervision 40 20 Inadequate funding

Investigate reported cases of Nil Investigated four reported cases of Cases to professional misconduct professional misconduct in Mbarara, investigate are Masindi and Kampala and took appropriate disciplinary action. handled as and when they come

Attend meetings of EAC 4 meetings Attended 2 meetings of EAC Medical Medical Council/Boards Council/Boards in Arusha and Mwanza

Participate in the joint EAC Nil Participated in the joint EAC Medical Medical Council/Boards Council/Boards inspection of medical inspection of Medical and and dental schools in Rwanda and Burundi in Febuary 2010 Dental schools.

Attending a course in Nil Attended a course in EDMS in Nairobi EDMS

Finalize draft proposal on - Finalized draft proposal on establishment Inauguration of establishment of DSA of DSA the DSA will take place in Sept 2010

Recruit staff at the 3 Recruited 3 members of staff at the secretariat secretariat for post of Secretary, Finance and Administration Officer, Data and Research Officer.

Overhaul one vehicle 1 1

218 Annual Health Sector Performance Report 4.8.3 Pharmacy Council

Mission: Protect the Society from Harmful and Unethical Pharmaceutical Practices.

Overall Goal: Ensure National and International pharmacy practice standards and codes of ethics are adhered to, both in the public and private sectors and control the conduct and discipline of registered pharmacists.

Specific Goals: i) Set and Enforce Pharmacy Practice standards and ethics country wide ii) Attain the Highest Educational qualification for pharmacists iii) Capacity Building of pharmacists and pharmacy auxiliaries iv) Community sensitization

Objectives: i) Enforce standards of pharmacy practice in all districts ii) Regulate the conduct of and discipline of all pharmacists iii) Maintain a register of registered pharmacists iv) Ensure pharmacy training institutions conform to set standards v) Approve all pharmacy practice outlets both public and private vi) Conduct Continued Pharmacy Education vii) Empower the community to seek quality pharmaceutical services

Relevance to HSSP II The pharmacy council contributes to the attainment of the HSSP program output 3; which focuses on ensuring a well functioning and operational Legal and Regulatory framework to support the attainment of the HSSP objectives.

Annual Health Sector Performance Report 219

sible to cover all the over 100 districts hence need for commensurate level of facilitation facilitation of level commensurate for need hence districts Very useful and must be districts plus 100 the in and within Kampala supported coverage wider with the logistics it deservesAn for interim Pharmacy Boarddisciplinary matters is in accordance being to established the Act 1970. Drugs and provisions to of the take Pharmacy care of Need for additional to fruition this see to provisions budgetary support to the health professionals’ current Need for an affirmative action to schools pharmacy train proper lecturers to serve in the Need for alternative means ofbonded be pharmacists sponsored Government attracting e.g. service public the and retaining pharmacists in t) Inadequate funds makes it impos ogistics(HR, Financial and transpor and Financial ogistics(HR, maternity units &pharmacies were inspected) were &pharmacies units maternity Proper disciplinarystagnation actions of hampered the 2006 Bill pharmacy pharmacy by profession the and the Only a few lecturers are adequately trainedthe to gap lecture, is filled withafter (i.e. students they recruited are to registered teach hencewanting in some cases. quality of out put-KIU is & Mbarara havelecturers an abroad, exchange hence program highsustainability of problem and consistency with turnover and lack-difficulties of inthe universities at pharmacists attracting and retaining local Funds for the operationsdistrict supervisors CPD the an body of the CPD accreditation Difficulties in attracting and retaining interns to these hospitals supervise government the pharmacists in ce developedand disseminated tricts 100 health units(drug shops, clinics, nursing homes, pharmacy and drugs act 1970 1970 act drugs and pharmacy i) Internship centers accredited in Jinja, Gulu hospitals Lacor, Rubaga, Mbale, Kabale, Lira, in use and disseminated developed manual Internship ii) -Continuous Professional Development guidelinesinterim developed CPD accreditation and body an isguidelines and the accreditation system being established to implement the - the registrar pharmacy councilcourse sponsored for a management training - Annual CPD for pharmacistsrequired and pharmacy assistants organized as -1,900 copies of the pharmacydisseminated and printed profession and pharmacy practice bill -Guidelines practi for pharmacy 25 standard of practice/ethics enforcement visits enforcement practice/ethics of 25 standard Collaboration with the three Universities (Makerere,strengthened KIU & Mbarara) l adequate In Joint inspection of health unitsJointhealth of inspection Investigation into reported misconduct dis in Kampala units Health Several cases were reported and handled within the provisions of the Capacity building Output descriptionOutput Achievements Challenges Comments Setting standards and quality assurance quality and standards Setting MonitoringStandards/ethics. and enforcementTechnical support to of universities students pharmacy training parliament yet by law into Bill not enacted Overseeing internshippharmacists training of

Table 4.30: Achievements of the Pharmacy Council the Pharmacy of Achievements 4.30: Table

220 Annual Health Sector Performance Report

The procurement processes is always to loss of funds leading caught by the financial year There is an urgent need for the PPP into law. enacted Bill to be re tabled, supported and A proposal is awaited for the task force for the task is awaited A proposal The interim pharmacy Board will help push theparliament PPP bill 2006 back to Some service providers do not deserve to be on the listbe on to not deserve do service providers Some vehicle Need for a new the students.from effort required More t processes; even with the procurement plan, no change. plan, no procurement Council decisions not backed by anyof legislation (Act Parliament) hence difficultiesthem in implementing Parliament as some activities have legal implications legal have Parliamentas some activities service providers service effective to maintain as it breaks down more to maintainbreaks as it effective Low annual out put fromfailure the universities rate and of high examination Pre - registration and eligibility Delays in the procuremen s & fax machines & Hampered by slow procurement processes and fake each year, during the period during year, each The process is on MoH PS the to proposal and a taskforce has been appointed to make a 153(51 Female 102 male) pharmacists pharmacists. registered registeredout of 450 during the HSSP II meetings attended out of ten three Only attended one outof five meetings Only constraints Financial constraints Financial i) Bill Stagnation Pharmacy Participation in the EAC Health ii) HR, office space and lack of transport for field visits.) Inadequate logistics (Financial, Office equipment maintenanceequipment Office computer two desktop and Two printers Procurement of office StationeryProcurement of office were procured Office stationery Pharmacy Council Strategic Plan Council Strategic Pharmacy meetings council Monthly printing dissemination awaiting and Developed 12 ordinary council meetings and several special council meetings held Implementation ought to be supported by an Act of Establishment of authority professional the national health Telephone and fax and Telephone Vehicle Maintained as required Services provided as requiredand maintained repaired Vehicles association and Boards professional The one pickup is nine years old and not cost Fuel, oils & Lubricants Lubricants oils & Fuel, Pharmacists registration financeswithin the available serviced Vehicles International Pharmaceutical annual meetings regulatory /health above As As above Output description Achievements Challenges Comments Challenges:

Annual Health Sector Performance Report 221

Table 4.34: Pharmacy Council Output description Annual output Planned activities to Actual annual output target deliver the outputs

Standards/ethics 3 districts visited Standards Enforcement 3 districts visited enforcement. Visits

Technical support to 3 universities Visits to the 2 universities universities training (Makerere, KIU universities (Makerere pharmacy students &Mbarara) KIU &Mbarara) ( KIU & Mbarara)

Joint inspection of All Health units Inspection of status 100 health units(drug health units in Kampala and quality of health shops, clinics, nursing districts care in private health homes, maternity units units &pharmacies were inspected)

Investigation into cases handled as investigations 4cases handled, but due to reported misconduct complaints arises lack of appropriate laws, could not be disciplined as required

Monthly council 12 meetings Payment of allowances 13 meetings held meetings and TP refunds

4.8.4 Allied Health Professionals Council

The Allied Health Professionals Council is a statutory body put in place by an Act of Parliament in 1996. The main functions of the Council are: 1. To Regulate standards, conduct and exercise disciplinary control of Allied health Professionals 2. Approve courses of study, supervise and regulate the training institutes for the different categories of AHPs 3. Approve qualifications awarded by the different institutes in respect of the different categories of Allied Health Professionals 4. Supervise registration of Allied Health professionals and publication of registered professionals in the Uganda Gazette 5. Advise and make recommendations to the government on matters relating to the Allied Health professions.

222 Annual Health Sector Performance Report

Planned activities: i) Registration and renewal of Annual practicing licenses of the professionals ii) Licensing of Private Allied health Units iii) Inspection of government and private health facilities. iv) Sensitization of employers of allied Health Professionals on annual practicing licenses in districts. v) Investigation of cases of unprofessional misconduct vi) Inspection of new Allied health training schools vii)Visit to training Institutions viii) Develop terms of reference for Allied Health District supervisors. ix) Develop Continuing Professional Development work plans for all cadres x) Conduct meetings of Council, Committee and Professional Boards xi) Travel abroad to share practices with other Councils xii)Creation of awareness on Council activities in some regions Achievements:

i) Registration, renewal and licensing of professionals a) 1088 new professionals were registered b) 294 new allied health clinics were licensed c) 424 clinics renewed licenses d) 1234 professionals renewed their annual practicing licenses

ii) Inspection of private health facilities. A joint inspection team of all the four Councils inspected reflexology clinics in Kampala district and the report was forwarded to top management. Another joint inspection was carried out in Kampala district covering and Kawempe divisions.

The Council and Board members carried out inspection in the districts of Wakiso, Mukono, Jinja, Iganga, Masaka and Kayunga. The findings were as follows: a) 90% of Allied Health professions are registered with the Council b) The majority of the allied health professionals do not posses practicing licenses. Only13% were found to have valid Annual practicing licenses. c) The majority of the units were found to be run by Nursing Assistants d) 50% of the health units visited have conducive working environment e) Most units have record keeping and referral system.

iii) Sensitization of professionals and Employers Sensitization visits were conducted in the districts to inform the District health officers and Medical Superintendents about the legal requirement for registration and Annual

Annual Health Sector Performance Report 223 practicing licenses. The districts were visited: Wakiso, Mityana, Kayunga, Jinja, Masaka, Mbarara, Kabale, Bugiri, Bududa, Budaka, Mbale, Butaleja, Busia, Tororo, Nebbi,Zombo, Arua, Maracha, Terego, Yumbe, Moyo and Adjumani. The findings were: a) The majority of Allied health professionals working in government are not aware of the requirement to possess the annual practicing licenses. b) Complaints about the transport costs to process the Annual practicing licenses were highlighted in most districts. c) The delay in issuing of annual practicing licenses by the Council

iv) Investigation of cases of unprofessional conduct 2 cases of unprofessional conduct of two Clinical Officers in Kamwenge and Kabale Districts were investigated. The disciplinary committee of the Council recommended reprimanding the two officers because of unprofessional conduct.

v) Inspection of new Allied health training schools The education committee of the Council together with Ministry of Education and Sports conducted an Inspection of Gulu Institute of health sciences. The institute is planning to train Medical Clinical officers.

vi) Visits to training Institutions Consultative meetings on pre-registration of students were conducted in Mulago Paramedical Schools, Fort portal school of Clinical Officers, Mbale School of hygiene and Kampala International University. The Council is planning to start pre- registration of students next financial year to track the students and reduce on forgeries.

vii)Continuing professional Development (CPD). The Council with assistance of the capacity program conducted a series of meeting to develop CPD work plans for all Allied health cadres. A document on CPD work plans has been developed.

viii) District supervisory Authorities The Council planned to appoint district supervisors as away of reaching its members working upcountry. Terms of reference for appointing the District Supervisors were developed and appointments will soon follow. ix) Meetings of Council, Committee and Professional Boards a) Full Council and committee meetings were conducted as planned. b) Six board meetings were held to discuss issues on training and schemes of service for various cadres. These boards are Medical Clinical officers, Radiography, Orthopaedic Technology, Pharmacy and Medical Laboratory Technology. c) The Finance and Administration committee retreat was conducted at Sun-set Hotel Jinja to approve the budget, work plan and the new employment policy.

x) Travel abroad The Registrar and Chairman traveled to Health Professions Council South Africa to learn and share best practices. The Registrar attended conferences in Rwanda and United states.

xi) Staffing The Health Service Commission appointed the Deputy Registrar for the Council

224 Annual Health Sector Performance Report quarter to nd & 2 & st working in government working in government of institutions are not aware annual practicing licenses. The funds released were not enough to cover all the planned districts 54.4% were registered Only 12.34% renewed practicing licenses 89.75% private clinics were licensed the 1 for disciplinary action. officers 3 schools not ready. on consultative meetings from pre-registration of students. health workers were developed complete the activity complete Comments Comments 1.0M 2.3M 3.8M Only two cases were reported 1.7M The school to train Clinical 3.6M Positive response received 2.3M CPD work plans for all allied 1.86M 12.3M Not enough funds released in 24.59M of professionals The majority

Actual expenditure 1,088 members registered 1,088 members 1,234 renewed APLs 718 Licensed Clinics the districts of Kampala, the districts of Kampala, Wakiso, Mukono, Jinja, Iganga, Masaka and Kayunga Districts were held with meetings (DHOs and employers Medical Superintendents) on registration and renewal of practicing licenses and Kamwenge districts sciences was inspected private institutions were consulted Kampala Actual achievement Actual achievement 2.5M 4.5M 2 cases handled in Kabale 4.0M Gulu Institute of health 3.5M and 1 3 Government ng the FY 2009/2010 2.5M 12.5M Planned Expenditure of the Council duri Council of the 2,000 10,000 8008888888800 40 districts 30 districts 33.2M Inspection carried out in 50M 17 districts visited and 8 cases to be investigated 4 schools to be inspected 4 institutions to be visited for consultations 8 CPD meetings 2.5M held in 6 CPD meetings Annual Target Table 4.31: Summary main of achievements the Output description Registration of new members Renewal of practicing licenses Licensed of private clinics Inspection of Government and private health facilities of allied health Sensitization professionals and employers Investigations of unprofessional conduct Inspection of new training institutions Visits to training Institutions Continuing Professional held meetings Development

Annual Health Sector Performance Report 225 approved by council. developed students was studied in South next Africa to be implemented financial year. Comments Comments Funds not enough employed on contract terms. on contract terms. employed 100% achieved Funds not enough to conduct all meetings condition the planned activity. activity. the planned Awareness created by Media condition 0 3M Funds not enough to complete 3M in good working Equipments 17M of pre-registration A system 5.5M Budget proposals were 3.8M 3.5M More staff to be recruited 7.6M good working Vehicle in fairly 14.5M 21.4M Actual expenditure 4 meetings held 4 meetings held 6 meetings held 4 meetings Jinja Sun-set hotel UG1654M developed South Africa , USA and Rwanda and serviced Actual achievement Actual achievement 2 computers procured 2 computers Photocopier not procured about regulation of Professionals 5M policy Employment 6M 2 adverts in monitor and 3M maintained Equipments 10M 3.5Myet appointed Not 1.6M of reference have been Terms 5.4M 1 retreat conducted at 4.0M 14.5M 28.8M Planned Expenditure 40 districts to be covered 1 policy document 4 meetings 8 meetings 12 meetings conducted papers 3 printers Repair 1 vehicle 3 computers 1 photocopier 9M Repair of Vehicle Annual Target Output description District Supervisory Authorities of employment Development Policy/guidelines retreat Meetings of Council, Boards and Committee Retreats 1 relations public and Advert 4 adverts in news abroad Travel Maintenance of Equipment trips 4 6 computers Vehicle repair and maintenance of office Procurement equipments 25M to 3 trips were made

226 Annual Health Sector Performance Report Challenges

i) Some cadres practice beyond their scope of training and fail to refer patients on time ii) The majority of Professionals have not renewed their annual practicing licenses. iii) Funds were not released to council to carry out inspection of health facilities iv) Inadequate office space v) Understaffing vi) The Council has one old vehicle which is too costly to maintain

Recommendations

i) Increase vigilance in inspection of health units to eliminate quacks and ensure safety to the public. ii) Sensitization of employers to ensure that all the Professionals posses valid annual practicing license iii) Appoint district supervisors to work with the District Health Officers’ office to ensure compliance iv) Purchase of a new vehicle to carry out inspection in all health care facilities. v) Recruit more staff for the Council secretariat

4.8.5 The Nurses and Midwives Council

The Uganda Nurses and Midwives Council is a statutory Professional Body responsible for the regulation of the Nursing and Midwifery Professions in Uganda From 1964, the Uganda Nurses and Midwives Council was governed by the Uganda Nurses, Midwives and Nursing Assistants Act. This Act was later revised and replaced by the Uganda Nurses and Midwives Act, 1996 which continues to regulate the Council. Mission To protect the public from unsafe nursing practices through Regulation of Nursing Professionals Vision To develop, improve and maintain the quality of Nursing Services delivered to individuals and the Community in Uganda in accordance with government policies and guidelines of International Council of Nurses (ICN). Mandate

• Protect the public from unsafe practices • Ensure quality of services • Foster the development of the profession • Confer responsibility, accountability, identity and status of the Nurses/Midwives.

Annual Health Sector Performance Report 227 Core functions of the council

• Regulate the standards of Nursing and Midwifery in the country • Regulate the conduct of Nurses/Midwives and exercise disciplinary control over them • Approve courses of study for Nurses and Midwives • Supervise and regulate the training of Nurses and Midwives • Grant Diplomas and Certificates to persons who have completed the respective courses of study in Nursing or Midwifery • Supervise the Registration/Enrolment of Nurses and Midwives and publication of their names in the Gazette • Advise and make recommendations to government on matters relating to Nursing and Midwifery profession • Exercise general supervision and control over the Nursing Profession and to perform any other functions relating to the profession.

Objectives

i) To strengthen collaboration with line ministries (MoH, MoE & Sports) and other stakeholders on issues related to nursing training and practices ii) To assess the performance of selected health facilities and training schools iii) To renew and confer practicing licenses to eligible Nurses and Midwives iv) Assess the capacity and suitability of new schools intending to start the training of Nurses and Midwives v) Provide technical support to Nurses and Midwives in clinical placement.

Achievements

During the financial year 2009/2010 the Council was involved in the following activities: i) Committee, sub-committee and sector meetings ii) Registration/enrolment of Nurses and Midwives both locally and foreign trained iii) Licensing Nurses/Midwives intending to open up private domiciliary practice iv) Renewal of practicing licenses for Nurses/Midwives in private practices both general and domiciliary v) Inspection of health facilities around Kampala vi) Inspection of new schools intending to start the training of Nursing and Midwifery vii)Technical support supervision to Nurses/Midwives on clinical placement attachment viii) Court/legal issues involving Nurses/Midwives ix) Inauguration of Nursing/Midwifery school

228 Annual Health Sector Performance Report Table 4.32: Activities carried out during 2009/2010 fiscal year Output description Annual Output achievement Comment target

7.0 MEETINGS

7.1.1 UNMC full council 1 One meeting of the full council was Issues related to the operations of conducted council were discussed and streamlined

7.1.2 Finance & 4 Four meetings were held to review the Other sources for funding council administration financial status of the council activities were identified

7.1.3 Disciplinary committee 1 One meeting was conducted to hear cases Five Nurses had their documents of alleged forgery and unethical conduct. returned, 1 Nurse was removed In all twenty- seven Nurses/Midwives from the roll and 2 other cases appeared before the committee were concluded

7.1.4 Enrolment & training 4 Two meetings were conducted and Specific issues were identified for committee addressed issues for Nurses and Midwives discussion with the Ministry of during training Education & Sports- BTVET, Department

7.1.5 Inspectorate committee 2 Two meetings were conducted Appropriate measures set for schools found training illegally and hospitals not providing a conducive environment for practicum

7.1.6 Secretariat staff 12 Four meetings were conducted where the Some of the gaps identified were day to day operations of the council were addressed to strengthen the assessed UNMC secretariat

7.2 Inter-ministerial/sector Representatives of the council attended Areas of collaboration were meetings over 57 inter-ministerial meetings identified with various organized by Ministry of Health, Intra stakeholders Health and Ministry of Education and Sports

7.3 Registration & enrolment 4992 Three thousand seven hundred Nurses and Eligible Nurses and Midwives of Nurses and Midwives Midwives who trained within the country who completed their courses were trained within the country during 2009 and 2010 were licensed to practice. registered/enrolled

7.4 Registration &enrolment 110 Sixty-five Nurses and Midwives from Those eligible were licensed to of nurses trained abroad Japan, Palestine, Germany, UK, USA, practice temporarily/ permanently Eritrea, Somalia Ethiopia were

Annual Health Sector Performance Report 229

Output description Annual Output achievement Comment target

registered/enrolled

7.5 Opening up of private 60 Twenty Midwives were licensed to operate Eligible Private domiciliary homes private domiciliary homes Midwifery

Practitioners were

licensed to

practice.

7.6 Opening up of private 30 Eight Nurses were licensed to open up Eligible Nurse were licensed to nursing general homes private nursing homes practice

7.7 Renewal of private 500 Three hundred and eighty two Midwives Eligible private midwifery domiciliary practices renewed their licenses for private practice practitioners

renewed their

licenses

7.8 Renewal of private nursing 50 Nineteen Nurses renewed their licenses of Eligible serving general homes practice Nursing Private

general nurses

renewed their

licenses

7.9 Inspection of health Three inspection visits of health facilities This was to ascertain illegal health facilities around Kampala were undertaken facilities & unprofessional nurses/midwives

7.10 Inspection visits to Fifteen inspection visits were conducted to Schools that met the required schools intending to start the proposed schools: Busoga University, standards were given provisional training of nursing/midwifery Saleem brotherhood, Victoria Institute of licenses; Saleem Brotherhood, Health Sciences, Florence Nightingale, Busoga University & Florence DAF College of Health Professionals, Nightingale Good Samaritan International, Natiki, Mutufu

7.11 Technical support Twelve hospitals were visited: Arua, Gulu, These hospitals were selected for supervision Lira, Soroti, Mbale, Jinja, Masaka, Iganga, visits as they are used for Nurses

230 Annual Health Sector Performance Report Output description Annual Output achievement Comment target

Kabale, Itojo, Hoima, Buhinga to follow up and Midwives sent for attachment nurses and midwives

7.12 Court/legal issues Three cases were attended as state On the later case further involving Nursing/Midwifery witnesses - 2 at Buganda Road Court and 1 investigations are being carried out in Kapchorwa. before final verdict is given

One incident involving maternal death in Mityana Hospital was investigated

7.13 Inauguration of 1 One school of Nursing & Midwifery was Saleem Brotherhood School of nursing/midwifery schools inaugurated Nursing/Midwifery was officially opened to commence training.

7.14 Publishing a list of The full list of accredited Both public and private schools of accredited training schools for Nursing/Midwifery training schools in nursing and midwifery were Nurses/Midwives Uganda was published published in the New Vision to guide the general public

7.15 Regional and international 2 Two conferences were attended Attendance at the two conferences conferences was an opportunity to discuss issues related to the training of Nurses and Two officials attended the Association of Principals of Health Training Institutions in Midwives in the region Kigali-Rwanda; the Registrar and SNO/T

One official (Registrar) attended the Human Resource for Health in Accra – Ghana organized by WHO

7.16 International health days 2 Two health days were attended Issues and papers related to the Nursing Profession and the Health • The international Nurses Day in Sector were discussed Moroto • World Health Day in Nakulabye - Kampala

Achievements i) Registered & Enrolled Nurses and Midwives who successfully completed their training ii) Sensitized nurses/midwives on professionalism, ethical code of conduct and the need to renew their practicing license iii) Participated in joint inspection of Health facilities in Kampala District iv) Granted practicing licenses to eligible nurses/midwives v) Published a list of accredited schools of nursing and midwifery in Uganda – New Vision

Annual Health Sector Performance Report 231 Challenges

• Increased forgery of professional and academic certificates • Inadequate staffing at the UNMC secretariat • Many mushrooming illegal Nursing/Midwifery schools • Inadequate mentors and clinical instructors to supervise students • Inadequate office equipment • Inadequate funding • Training and employment of Nursing Assistants to carry out nursing duties • Admission of too many students in some Government schools i.e. Jinja, Mulago, Kabale, Lira etc. • Deteriorating standards of code of conduct & professionalism among some Nurses and Midwives • Inadequate equipment in the practicum areas for students • Establishment of District Supervisory Authorities • Intensification of registration and enrolment of nurses and midwives • Inspection of Health facilities and training schools in selected • Sensitization of nurses and midwives on professionalism and code of conduct. • Streamlining the screening of professional and academic papers • Development and operationalization of a Five-year Strategic Plan • Review of the UNMC Act (1996). • Strengthening of collaboration with line ministries and other stakeholders • Development of strategies for resource mobilization to carry out planned activities • Conducting research in Nursing and Health related issues • Sharing of professional information with other councils in the region • Consolidating the formation of the National Regulatory Authority of Health Professional Councils in Uganda. • Renovation of UNMC office premises

232 Annual Health Sector Performance Report 4.8.6 Uganda National Association of Community and Occupational Health

This report relates to the activities of Uganda National Association of Community and Occupational Health (UNACOH) that took place in the period July 2009 to June 2010 Tobacco Control program UNACOH has been an active member in the National Tobacco or Health Forum. During the reporting year, UNACOH developed a number of project proposals on tobacco control on submitted them to potential funders like IDRC, Canadian Public Health Association, Bloomberg Tobacco Control Initiative, among others The UNACOH 17th Annual Scientific Conference and 8th Dr. Mathew Lukwiya Memorial Lecture The 17th Annual Scientific Conference and 8th Dr. Mathew Lukwiya Memorial Lecture of Uganda National Association of Community and Occupational Health (UNACOH) took place on September 24th – 25th, 2009 at Hotel Africana Kampala. The theme of the conference was “The role of Health Systems in the improvement of the Health of Ugandans.” The conference was attended by 111 participants. The conference drew participants from across the country, with over 22 districts represented, plus international participants from Finland. The 2009 Dr. Mathew Lukwiya’ Memorial Lecture was delivered by Dr. Joaquim Saweka, WHO Representative, Uganda. The Guest of Honour was Hon. Kakooza MP/Minister of State for Health – PHC, who represented the Honourable Minister of Health, Dr. Stephen Malinga MP. The Lecture was also attended by the widows and family members of the late Drs. Mathew Lukwiya and Jonah Kule. Both doctors died of Ebola fever, in course of their duty, during two Ebola epidemics, coincidentally on the same date of 05 December 2000 and 05 December 2007 respectively. The respective families received from WHO and UNACOH, post-humus commemorative plaques on behalf of the deceased. In addition, UNACOH held the Annual General Meeting at the time of the Annual Scientific Conference in September, 2010. New office bearers were elected for the 2010/2011 term. Dr Joseph Herman Kyabaggu was re-elected President, and Dr.D.K. Sekimpi offered to continue as Acting Executive Director. ` Project Development Several project proposals were developed and submitted to prospective funders, including one on Pesticide Safety to DIALOGOS of Denmark and one on VHT in Kyenjojo/ Districts to UNICEF Uganda Office. These two proposals got funding. Canadian Public Health Association (CPHA) also invited UNACOH to participate in two international project proposal concepts to be submitted to European Commission on Injury Prevention and Human Resources for Health. In addition, two concept notes, one on Tobacco Control and the other ICT for Primary Health Care communication were submitted to IDRC, Canada for consideration. The response is still awaited. There was remarkable success in the local fund-raising drive for the 2009 UNACOH Annual Scientific Conference as reported above. On- going programmes The three year Pesticide Use, Health and Environment (PHE) Project started implementation in June, 2010 and will be focus on the districts of Wakiso and Pallisa. The other project is on Monitoring and Quality Assurance for the implementation of VHT training programme in Kyenjojo and Kyegegwa Districts.

Annual Health Sector Performance Report 233 Monitoring and Quality Assurance for the implementation of VHT training programme in Kyenjojo and Kyegegwa Districts.

Representation at International fora UNACOH was represented, by the Acting Executive Director, at the Annual Conference of the Canadian Society for International Health in Ottawa Canada, October 2009, thanks to funding from the Canadian Public Health Association. UNACOH was represented by three members at the Second training of American Public Health Association’s Strengthening of Global Public Health Associations Initiative in November 2009 in Durban, South Africa. The training workshop in Planning was funded by Pfizer Medical Group. The delegation also had the opportunity to attend the fifth Public Health Association of South Africa (PHASA) Scientific Conference and the Africa Public Health Associations Forum. WHO-AFRO was represented at these meetings by Professor Khaled Bessaoud, from WHO AFRO Headquarters in Brazzaville, Congo. UNACOH remained the Convenor of the East, Central and Southern Africa Public Health Association (ECSAPHA) and co-Convener of the Africa Public Health Associations Forum, mainly communicating using ICT technologies.

234 Annual Health Sector Performance Report 4.9 Public Private Partnership in Health

The TWG on PPPH and the drafting of NHP II and HSSP III After some years of slow pace implementation, due to thinning support from the MoH and external donors, the Public Private Partnership has gained new momentum during FY 2009/10. The Italian Cooperation and other donors (USAID, IFC) have renewed their commitment in support to the partnership activities, while the MoH appointed new staff and dedicated more time to the issues related with the Partnership. The TWG on PPPH has conducted several meetings during the year producing a relevant contribution to the drafting the NHP and HSSIP III. A stakeholder meeting was held, last June 2010, to validate the formulation proposed by the TWG with the additional comments and integrations received. Furthermore, the TWG contributed to the definition of the M&E log-frame which will guide the implementation of the program during the HSSIP. The TWG has developed a new Plan of Action (2010/12) to address the activities of the partnership in view of the new support provided by the Italian Cooperation, with the aim to operationalize the partnership at district level. The new PoA focuses on key activities, some of them already planned in the HSSP II, but never realized. Following a decision from the TWG on PPPH, a survey of private facilities has been conducted in the district of Kampala. The survey generated reliable data on the presence and distribution of private health facilities and will facilitate the process of regulating and defining an accreditation system for this sub-sector. It was also planned that similar surveys will be conducted in other districts of the country where the presence of PHP is more relevant. The approval of the National Policy on PPPH and other legislation Following the priorities defined in the Aid-Memoire of the 15th JRM, new efforts have been devoted to the complete the legislative process for the approval of the National Policy on PPPH by the Cabinet. As required by the legislative procedure, an assessment of the cost implication of the National Policy on PPPH was conducted by a team of health economists, under the guidance of the PPPH Technical Working Group. Although the implementation of the policy may require additional resources, the benefits will largely outweigh the costs in all possible scenarios. Furthermore, the study was able to quantify the resources needed, mostly covered by already allocated HDP funding. Another important activity to finalize the policy draft has been its distribution to all the Ministries in the Country, through their Permanent Secretaries. Comments have been received from the Ministry of Tourism, Trade and Industry and from Ministry of Finance, Planning and Economic Development and incorporated in the draft. Additional comments were received and incorporated from the representative bodies of Civil Society Organizations (CSO) and consumers’ associations. A consultative meeting was conducted in July 2010 with the Social Services Parliamentary Committee. During that meeting additional comments and suggestions on the draft and the Cabinet Memo were received. The TWG has been also engaged in a discussion with members of the Cabinet secretariat to finalize the cabinet Memo and the agenda for submission. The new final draft of National Policy and Cabinet Memo were presented to the Top Management Committee (meeting of 22 June 2010) and endorsed as a final draft. Subsequently,

Annual Health Sector Performance Report 235 the MoH has requested the definition of a date for submission to the Cabinet Secretariat. Also, the regulatory bill for the Traditional and Complementary Medicine Practitioners (TCMP) is still undergoing revision after comments from the Top Management Committee of the MoH. A full involvement of this sub-sector will only be possible after the bill has been finalized and approved. Dissemination of the National Policy on PPPH The TWG on PPPH decided to proceed with the dissemination of the National Policy, even before its definitive approval from the Cabinet, in order to utilize the additional resources made available by the Italian Cooperation for such activities. After copies of the draft Policy have been distributed to all the Ministries a national dissemination workshop was organized (30th March 2010) with the aim to contribute to the dissemination of the National Policy and lobby for its approval by the Cabinet. Members of Parliament, high officials from other Ministries and representatives of the Private Sector at national level participated to the workshop. The calendar for ten Regional Workshops30 to disseminate the National Policy at district level was finalized and the implementation of the workshop started in September in Jinja. Twelve districts31, with a relevant presence of private structures and representing all the regions of the country, were selected to pilot the district implementation. Support was provided to those districts by the Italian Cooperation to strengthen the PPPH desk officers making them able to perform their role as liaison with the private sector representative at district level and collect data on their contribution. Additional pilot districts will be selected and will benefit the support from Health Initiative for Private Sector (HIPS), an USAID funded project. Broadening the Partnership The HSSP II clearly spelt out the need “to strengthen and broaden the partnership through more active engagement with other health related sectors, professional associations, private health care providers and TCMP, civil society and representatives of the principal consumers”. To this aim efforts were directed toward a greater involvement of the private sector. A Workshop was conducted (15-16 June 2010) to facilitate the coordination and the establishment of representative structures for the PHP. The participants at the workshop decided to create a federation which will include health personnel with different qualifications from small, medium and big sized health facilities, and all the private entities which face the same problems and need a unique representation towards the government ministries. The workshop also presented the occasion to launch the International Finance Corporation program “The Business of Health in Africa” which aims to facilitate access to credit for the private health providers while supporting the organization of this sub-sector.

.

30 Jinja, Moroto, Mbarara, Fort Portal, Gulu, Mbale, Wakiso, Rakai, Hoima, Arua, 31 Nakapiripirit, Moroto, Pader, Gulu, Kitgum, Jinja, Rakai, Bushenyi Bundibugyo, Kabale, Nebbi, Arua

236 Annual Health Sector Performance Report CHAPTER FIVE IMPLEMENTATION MONITORING OF THE HSSP II

Quality Assurance Department (QAD) has the mandate to ensure that the quality of services provided in the entire health sector is within acceptable standards. The departmental objectives are to: i) Ensure that standards and guidelines are developed, disseminated and used effectively at all levels. ii) Ensure that regular supervision and monitoring is established and strengthened at all levels. iii) Facilitate establishment of internal quality assurance capacity at all levels including operations research on quality of health services.

5.1.1 Development and Dissemination of Standards and Guidelines

The Department of Quality Assurance has continued to play a leading role in developing and dissemination of key standards and guidelines for the sector. The Uganda Clinical Guidelines (UCG) 2010 edition were finalized and disseminated to 80 districts during the Area Team support supervision conducted in fourth quarter for the FY 2009/10. In addition the UCG is also currently available on the official MoH website www.health,go.ug The Patients’ Charter was completed and dissemination started with fifty three (53) districts in North, Eastern, West, Central and Karamoja regions. The two standards Uganda Clinical Guidelines and the Patients’ Charter are due for launching during the JRM meeting in Kampala, November 2010. The Clients’ Charter was disseminated to 24 districts in Central, West and Eastern Uganda. Six thousand (6,000) copies of the UCG are expected to be printed during the first half of the 2010/11 FY but the demand for UCG will still remain high. The sector currently has more than 20,000 (twenty thousand) health workers (HSSP II) a situation which gives rough estimate on the number of UCG needed to meet this demand. The Radiation and Imaging Standards have been drafted and are due for finalization and subsequent dissemination.

5.1.2 Supervision, Monitoring and Evaluation of the HSSP II

Supervision, monitoring, and evaluation of the overall health sector performance is one of the core functions for the Ministry of Health. It is a key determinant of quality of services provided and the extent to which efficient utilization of resources within the system is achieved. During HSSP II supervision and monitoring visits to districts were carried out and the Yellow Star Programme (YSP) was taken on as the quality improvement strategy to be used for in districts. The Mid Term Review of HSSP II found that supervision was generally inadequate including areas for supervising the National Referral Hospitals and central level Institutions i.e. Autonomous and semi-autonomous institutions. Area Team visits although with some constraints, have continued taking place throughout the whole period of HSSP II addressing locally available challenges and also mentoring leadership in the districts. Area Team visits have faced a number of challenges like inadequate funding and lack of effective follow-up on issues

Annual Health Sector Performance Report 237 found in the districts. Senior Top visits were introduced in the later period of HSSP II to look into issues that Area Teams identified and considered more appropriate for members of TMC and HSC to handle. The Supervision and Monitoring framework for HSSP II aimed at supporting the local government, health facilities at all levels, the central programmes within MoH and the other central health institutions. Health sector performance indicators, regular reports on supervision and monitoring have been used to provide of information on sector monitoring during this period. The monitoring structures used currently in the sector include: the bi-annual National Health Assembly (NHA), the Joint Review Mission (JRM), the Technical Review Mission (TRM) and the Health Policy Advisory Committee (HPAC). HSSIP (2010/11 – 2014/15) will focus on strengthening current system for supervision and monitoring in the sector.

5.1.3 Supervision

Supervision of the Center, National Referral Hospitals and Institutions The supervision and monitoring of National Referral Hospitals, central level programs and other autonomous or semiautonomous institutions (e.g. Uganda Chemotherapeutic Research Laboratories, Uganda Blood Transfusion Services, National Drug Authority (NDA), National Medical Stores (NMS) and Uganda Virus Research Institute (UVRI) has been carried out within the long term institutional arrangements (LTIA) which is one of the mechanisms adopted by the Top management of the MoH. The LTIA process involves building the capacity of programs / institutions in the planning process and then supporting them develop their respective workplans and budgets. The performance of these central level institutions is monitored by reviewing their set targets in the workplans against actual achievements. This is done through the established structures such as the quarterly performance review meetings, the monthly departmental and senior management meetings and fortnightly Top Management meetings. In addition the monthly technical working groups (TWG) meetings offer an opportunity for discussion of various issues, while HPAC reviews program/institutional performances with a view of providing policy guidance. During the FY under review most of these structures carried out their functions effectively. All the planned four quarterly reviews were conducted (one review per quarter), the TWG, SMC and HPAC meetings were held regularly. The reports of the sector quarterly reviews were finalized in time, printed and disseminated to stakeholders. TMC has also used the process of preparing Ministerial Policy Statements to critically review the performance of MoH programs and institutions. The TMC carried out supervision and inspections visits to some of the central level institutions such as Mulago National Referral Hospital and the National Medical Stores. MTR for HSSP II points out lack of a well defined mechanism for supervising central level institutions (autonomous and semi-autonomous). This deficiency will need to be addressed in the new strategic plan for the sector.

238 Annual Health Sector Performance Report Supervision of Local Governments

Integrated support supervision, mentoring and monitoring of Local Governments and Referral Hospitals continued to be carried out through the Area Team Strategy in line with the UNMHCP. Five district support visits: three for area team integrated support supervision; one for district planning and another for the pre-JRM/NHA of October 2009 were conducted. Members of the TMC participated in the 4th quarter FY 2009/10 area team support supervision to selected good performing and weak districts which covered over 64 districts for a focused follow up of outstanding issues from previous visits that needed top level interventions. The participation of members of TMC is in line with the HSSP II Mid Term Review Report which recommended top leadership of the MoH to play a more active role in supervision activities. In addition the Political Leadership of the MoH carried out several impromptu inspections of health facilities. Technical programmes also carried out their own technical support supervision to the Local Governments and referral hospitals. The area team supervision, mentoring and monitoring visits’ main areas of focus included; follow up of actions taken to address issues that were identified from the previous visits, financial resources inputs, human resources for health, medicines and health supplies, support supervision by the DHTs and HSDs and quality of care issues, planning and performance assessment, general health sector management and partnerships and health infrastructure. The area team usually interacts with the district political and administrative leadership before visiting the health facilities, and thereafter conducts debriefing meeting with the District Health Teams. Internal supervision of health facilities

Internal supervision of health facilities though very effective in improving service delivery has not been effectively done during the period under review. There have been attempts to build capacity for internal supervision of health facilities and districts by several quality improvement initiatives/programmes. These programmes have supported the districts to supervise HSDs and lower level facilities. The challenge is lack of harmonized performance measurement tool and supervision framework to guide the different stakeholders. This is compounded by inadequate human resource even at district level and lack of transport. The YSP strategy was designed for this purpose but presently will have to be reviewed and institutionalized in the new sector strategic plan for sustainability.

Annual Health Sector Performance Report 239 5.2 Monitoring of the HSSP II Indicators

The HSSP II elaborated a monitoring framework for the sector with a range of indicators at various levels, regularity for reports, monitoring structures and source of information. The performance indicators for 2009/10 FY are outlined in the second chapter and are also summarized in the annex tables of this report. HSSP II performance monitoring is extended below the national level including the local government and health facilities.

5.2.1 District League Table

The District League Table (DLT) and Hospital /HC IV Performance Assessment (HPA) initiatives were introduced during HSSP I and continue to be used in HSSP II. The performance for 2009/10 FY is summarized in the annex tables of this report. The District League Table in particular has been useful in stimulating interest and competitiveness among health service providers and other stakeholders with increased utilization of data at the different levels of service delivery. National average performance improved from 60.8% in 2005/06 to 65.9% in 2008/09. There is varying level of performance among districts with most newly created districts ranking lower than the parent districts.

Figure 5.1: Trends in National Performance in the District League Table during HSSP II

Districts in more disadvantaged environment like Karamoja have a challenge to compete favourably and appreciate change under the current league table ranking. The new strategic plan for the sector will have to address this with more contextualized analysis such that districts with similar characteristics can be compared in terms of performance each year. This has also been considered to some extent in chapter two section of this AHSPR. It is also important to have an M&E plan to avoid ad hoc indicators for assessing performance by the different programmes and at various levels of the sector.

5.2.2 Joint Action Framework (JAF) Indicators

In 2007, the government of Uganda and development partners agreed on joint framework for budget support. This is in agreement with the Paris Declaration and the IHP+ contract for both of

240 Annual Health Sector Performance Report which Uganda is signatory. The Office of the Prime-Minister is mandated to conduct monitoring of government performance and reporting on JAF is done every quarter. Currently there are ten development partners that have agreed to participate in the Joint Budget Support Framework (JBSF), including the World Bank, the European Commission, the African Development Bank and Governments of the United Kingdom, Germany, Ireland, Belgium, Sweden, Norway, Denmark, and the Netherlands, with anticipated annual disbursements of $300 million, equal to approximately 15% of Government revenue. Under the JAF agreement, GoU and development partners have agreed upon a JAF for budget support intended to lower transaction costs, strengthen country systems and foster mutual accountability. The JBSF is designed to support the GoU National Development plan, through a strong focus on improving service delivery. The final JAF includes three main sections:

I. Preconditions for effective and efficient implementation of government policies. II. Cross-cutting reforms aimed to improve value for money in service delivery through removal of barriers in public financial management and public service management systems while reinforcing compliance with regulations and avoidance of leakages. III. Focused reforms in four key service delivery sectors: health, education, water and sanitation and transport.

During JAF II for the FY 2009/10 there was noted decline in delivery in health facilities 33% against the set target of 50% while access to family planning supplies was extended to cover all the eighty districts. Performance on routine immunisation was reported at 79% (target set was 90%). The rate of absenteeism, contraceptive prevalence rate are both waiting for the panel survey currently being conducted by UBOS. The JAF III indicators for 2010/11 FY have been harmonised and aligned with the budget framework paper and Ministerial Policy Statement used by the Ministry of Finance and Economic Planning.

5.2.3.1 Decentralisation and heath service delivery

The HSSP II was implemented through the decentralised system with clear roles for the central, district and lower levels of government in the delivery of health services. The central government concentrated on the policy and the strategic issues and moved away from the more operational and implementation issues. The local governments in line with the Health sub-district strategy, the routine management and delivery of health services were devolved further to the Health Sub-District. The challenges of some technical programes such as the control of vector-borne diseases being left to run as vertical programes resulting in poor ownership at the local government level was addressed. This was achieved through the DHO taking coordination roles an ownership of all the programs at district level. The DHOs Association was registered and played a key role in policy formulation. Also regional and national hospitals played a key role in contributing to policy formulation through annual meetings, making presentations to the social services committee of parliament and being key participants in implementation and policy reviews. Some of the national level institutions (e.g. Uganda Blood Transfusion Services UBTS, Natural Chemotherapeutics Research Laboratory NCRL) and the regional level (especially the Regional

Annual Health Sector Performance Report 241 Referral Hospitals) were adequately involved and made part and parcel of the central level of in the National Health System. UBTS and NCRL is active in Senior and Top Management committees and, Technical Working Group. During the implementation of the HSSP II, emphasis was put on making sure that the different levels carry out their mandated functions. This was achieved through: i) The sector developed Joint Assessment Framework indicators which are reported on both at a District and national level. However, the sector did not develop an elaborate monitoring and evaluation framework which has been addressed in the Sector strategic and investment plan ii) The sector used a resource allocation formula which is now being revised with assistance from WHO and the formula will be used in FY 2011/2. iii) Annual work-plans were developed at the different levels for the operationalisation of the mandates right from central level, both at regional referral hospitals and districts. They are now part and parcel of the Ministerial Policy Statement. iv) Quarterly, annual (including technical and Joint Review Missions), and mid-term reviews were carried out to ensure adherence of the different levels with the responsibilities/functions laid out for them. In addition, three National Health Assemblies were carried out ; v) Frequent assessment at the different levels including comparison of performance between like entities was carried out to encourage competition and better performance. The District League Tables were constructed in the Annual Health Sector Performance Reports, and Hospital Performance Assessment using the Standard Unit of Output in the Annual Health Sector Performance Report were used in the plan period to access outputs. However, a league table for assessing Ministry of health headquarters was not made and this shall be considered in the HSSIP. League tables for Departments at National and Regional referral hospitals were also not made and this shall form a program of work in the next plan period.

5.2.3.2 The SWAp, and working together as partners in the health sector

Thus, all the stakeholders in the health sector used the agreed on programme of work (the Health Sector Strategic Plan) and the point of involvement of the various players.

Memorandum of Understanding

The Government, Health Development Partners (HDPs) and Civil Society Organizations (CSO) worked under a Memorandum of understanding (MoU) that was signed for the implementation of the second Health Sector Strategic Plan. The MoU facilitated the implementation of the National health Policy and HSSP II using a Sector-Wide Approach (SWaP). The MoU is aligned with international agreements that have been ratified by the Government of Uganda (GoU) which include the Global IHP+, Harmonization for Health in Africa, Accra Agenda for Action and the Paris Declaration on Aids Effectiveness.

242 Annual Health Sector Performance Report The GoU continues to provide a stewardship role in the health sector; strengthen links with with stakeholders working in the health sector; continuously improve on public financial management and procurement systems; ensure improved aid effectiveness and provide feedback on health sector performance to all parties.

Sector-Wide Approach In this period, 2004/5 to 2009/10, the health development partners placed emphasis on providing financial, technical and management support through the broad framework of SWAp using government procedures for disbursement, procurement and overall management. However, some projects continued to be implemented in partnership with the central and local governments. Global Funding Initiatives (e.g. GFATM, PEPFAR, GAVI) carried out direct disbursement of funds Central level institutions, districts and both public and private providers of different health services for specific activities. During the HSSP II, there has been a strain in partnership with the Private Sector and specifically the Facility-Based PNFP providers. There are also still challenges in dealing with the Non- facility based PNFPs, the PHPs and the TCMPs. Progress has been made with the PPPH policy and submitted to Cabinet for approval. The role of government as the overall steward was strengthened, and the other stakeholders accounted to government and through government to the population. This contributed to efficient and equitable utilization of all resources, from the government budget, global initiatives, development partners, the local governments and households while minimizing duplication and overhead costs. This was achieved through the following: i) The different roles and responsibilities of the government (at various levels) and the development partners was elaborated in the MoU for HSSP II implementation; ii) Regular assessment of performance against these roles and functions was carried out – quarterly, by HPAC and the Inter-agency Coordination Committees, and annually by the Joint Review Mission. The Long Term Institutional Arrangement (LTIA) was elaborated on with support from WHO country office and published as the blue print for relationship of partners in the health sector. iii) The coordination and consolidation of activities was carried out by different players – public, PNFP, PHPs and CSOs, with focus at the district and HSD levels; iv) Involvement of the community was main cornerstone in reaching households through VHTs.

5.2.3.3 Delivering an integrated package of services

The UNMHCP was delivered as an integrated package of services. This was particularly done at the service delivery levels where the same health workers and similar inputs were used to provide the whole range of services to the population. The horizontal linkages between the clusters was emphasized but posed challenges especially with programs which are donor driven like some aspects of HIV/AIDS control program sometimes with duplication. The challenge was due to the need to account for resources separately for the resources provided and failure to develop an integrated reporting system at some levels.

Annual Health Sector Performance Report 243 Integration during the HSSP II was achieved through: i) Using Generic Planning Guidelines to develop district and HSD work-plans and are being updated to further help the different entities to work towards the provision of an integrated package of services. These guidelines put emphasis on: ii) Use of Generic Inputs and logistics systems - allocation of these inputs is determined by level of care and therefore by health care needs, and the minimum service standards and not generic supervision, monitoring and evaluation framework for example: o a comprehensive performance assessment framework like the district Planning Guidelines; o the use of the integrated Teams for supervision and monitoring – the Area Teams; and o the use of generic Quality of Care tools like the National Supervision Guidelines and the Yellow Star Checklists.

244 Annual Health Sector Performance Report 5.3 Quality of Care

Addressing quality of care issues is important as it is one of the key elements of the right to health. Over the years the MoH in collaboration with Development Partners has built capacity for establishment of internal quality assurance at all levels. Due to increasing number of districts and demand for improved quality of services the QA department is faced with the challenge of ensuring that it is able to address this demand across the country. During the last financial year human resource capacity for the department was increased from 3 to 5 officers.

5.3.1 Quality Improvement Initiatives

Since 2005 a number of quality improvement initiatives have been introduced in the country mostly donor driven basing on the principles of; meeting the needs of the clients, focusing on systems and processes, using data to improve services, teamwork and better communication. Some of the initiatives are programme specific such as the Uganda Capacity Programme (UCP) Performance Improvement with focus on human resource improvement, while others are disease specific such as Health Care Improvement (HCI), HIV QUAL, STOP Malaria. Maternal and clinical death reviews/audits are irregular yet are mandatory for any deaths on table in theatre, maternity, psychiatric and peadiatric wards. Death audit committees have been formed in a number of RRHs. General Hospitals and HC IVs are yet to be covered. The 5S – Total Quality Management (TQM) which focuses on continuous improvement through all aspects of life by improving standardized activities and processes was piloted by JICA in Tororo hospital since 2007. Other sites that are implementing this initiative are; Kapchorwa GH, Mbale RRH, Gombe GH, Busolwe GH and Kabale DHO. The differences between these initiatives are in the approach to implementation but the concept and principles are largely similar. All these initiatives have registered improvement in quality of care and therefore need to design and implement a national roll out strategy. The current quality management system is not well developed and needs to be reviewed and improved. There are weak mechanisms to coordinate the many QI initiatives both at the Central and Local Government levels. The initiatives are not harmonized and integrated within the existing health care system for continuity. Each quality actor has their own standard and approach. This weak coordination and the obscure reporting mechanisms tends to weaken the intended result of the initiatives and also raises concerns of effectiveness and sustainability of such initiatives especially when donor funding dwindles. In addition it becomes very difficult to assess, evaluate and measure quality improvement after an intervention has been initiated.

The QA department has identified the need to develop a national quality improvement framework and Performance Monitoring Plan to guide coordination and institutionalization of quality improvement.

Annual Health Sector Performance Report 245 5.3.2 Responsiveness, Accountability and Client Satisfaction

Responsiveness of the health system is measured by the level it meets peoples’ expectations as regards the way they desire to be treated by providers of preventive, curative or health promotion services. During this FY no study was conducted but there is one scheduled for 2011, 2013 and 2015 in the new health sector strategic plan. All districts and health facilities are expected to establish feedback mechanisms like suggestion boxes for regular feedback. The MoH passed a circular regarding operationalization of suggestion boxes and their functionality needs to be assessed. Other feedback mechanisms like the media indicate that clients are mostly dissatisfied with cleanliness of facilities, long waiting time even for emergency cases, non-availability of medicines and qualified staffs, health workers attitude to patients, inadequate access to specialized services, etc. These are much similar to the 2008 client satisfaction survey findings which showed that the level of satisfaction with regard to physical access to physical to health services was above average (66%), hours of service was 71% and waiting time by users in health facilities was 46%. The Clients Charter was launched in 2008 and has been disseminated to 24 (twenty four) districts out of the current 112 (one hundred and twelve) districts. There is need for wider dissemination and sensitization on the purpose for its effective utilization. The Charter spells out roles of the different stakeholders in health and is due for review in the year 2012.

The Patients Rights are recognized as the inherent dignity and the equal and unalienable rights of all members of the human family. In Uganda, The Patients’ Charter was completed early this year and has been disseminated to 53 (fifty three) districts in the country. There is a big gap to bridge in-order to improve level of awareness on patients’ rights, responsibilities and obligations in the community. The Charter will have to be translated into the key different languages in the country and sensitization carried out widely to increase demand for quality services.

Other strategies to improve responsiveness, accountability and client satisfaction include empowerment of individuals, households and communities to take their role as health producers and consumers. Guidelines for establishment of Health Unit Management Committees (HUMCs) are in place but need to be reviewed. All HUMCs at Regional referral Hospitals are functional however; functionality and guidelines for establishment of HUMCs at general hospitals and lower level units need to be reviewed. The sector together with Civil Society Organizations have to get the community more involved in ensuring quality services are delivered in the health system in the country.

5.3.3 Coordination of Research The Quality Assurance Department as per its core mandate has continued to coordinate research through the Supervision, Monitoring, Evaluation and Research (SMER TWG). The SMER TWG actively participated in preparation for the Uganda Demographic Health Survey (UDHS) which will be conducted during 2010/11 and 2011/12 financial years. Collection of baseline information on Non-Communicable Diseases has been integrated in the forthcoming UDHS. The proposal from the implementing agency Uganda Bureau of Statistics (UBOS) was discussed by the SMER TWG and the Senior Management Committee. The tools were reviewed and the relevant working committees to get the work done have been set-up. This survey takes place every after five years and the final report is expected to be ready by January 2012. There is need to strengthen the research coordination function of the Department in order to promote evidence based policy making and planning.

246 Annual Health Sector Performance Report Challenges for supervision and monitoring i) Lack of a comprehensive supervision and performance measurement framework. The mechanism for the inspection function is also not clearly set up for this to be properly accomplished by the Ministry. ii) There is a poor feedback and follow-up mechanism on issues identified during supervision visits conducted. iii) Weak coordination in implementation of quality improvement initiatives by a number of agencies operating in the country at present. Quality improvement initiatives like the Yellow Star Programme introduced in several facilities in the country has not been well integrated into routine support and supervision. iv) Inadequate resource allocation to the centre and districts for them to carry out proper supervision in their respective areas of operation. Supervision by local government to districts is irregular, inadequately facilitated, and is further hampered by lack of transport and inadequate staff in districts. Most districts particularly the new ones don’t have reliable means of transport to conduct the required top downward supervision. The center also does not receive enough funds to conduct regular support supervision and mentoring as required.

Recommendations for supervision and monitoring i) Review the current supervision mechanism in the country and develop a comprehensive national supervision framework with an elaborate inspectorate function to address the current inadequacies in the supervision system in the sector. ii) Review the supervision tools (YSP) to enable full integration and utilization of the capacity built in the country. iii) Introduce a framework to coordinate and institutionalize all quality improvement initiatives in the country. iv) Expedite the restructuring process in order to increase capacity for Quality Assurance Department to fulfill its growing mandate v) Improve funding for supervision both at national and district levels.

Annual Health Sector Performance Report 247 5.4 Health Services and health status in recovery areas

Following the restoration of peace in the Northern region, the Government of Uganda in 2007 launched the Peace Recovery and Development Plan for by then 40 districts in the region. This is a comprehensive three year plan whose implementation is coordinated by the Office of the Prime Minister (OPM). The plan aims at addressing the causes of conflict and instability in the region, restoring livelihoods and revitalize social sectors. The Health Sector Component of the Peace, Recovery and Development Plan focuses on ensuring equitable access to communities in conflict and post-conflict districts of Northern Uganda (PRDP) to Uganda Minimum Health Care Package. Though the launching had been done, full implementation of PRDP could not start immediately due to lack funding. However, in financial year 2009/10 funding was availed and implementation of the plan started.

Table 5.1: Grouping of the forty32 districts in Northern Uganda under PRDP as of 2007 Northwest (West Location North Central North East Nile) Type of Conflict Armed Rebellion Armed Rebellion Deterioration of Law and Order Gulu, Kitgum, Pader, Kotido, Moroto, Nakapiripirit, Moyo, Adjumani, Lira, Soroti, Districts Kumi, Pallisa, Kapchorwa, Nebbi, Arua, Apac, Amuru, Dokolo, Mbale, Sironko, Kaberamaido, Katakwi, Yumbe, Koboko, Amolatar, Oyam, Abim, Kaabong, Bukwo, Maracha Masindi and Buliisa Bukedea, Budaka,

Achievements During the last financial year, PRDP district received financial releases from the Government of Uganda through Office of the Prime Minister to implement planned activities. Priority for this initial funding was Health infrastructure development. Follow up supervision by MOH teams indicated that districts were at different stages of utilization of these funds. Most districts had committed funds for infrastructure development. The target for the funds was in rehabilitation/construction of health facilities and staff houses. The figure below show one of the 8 staff houses being constructed using PRDP funds in Amuru district. All the 8 staff houses were at that advanced stage of completion. Similar progress was note in other PRDP district

32 Please note that PRDP focuses on geographical area. Thus, the splitting of PRDP district, increases on the numbers of district in the PRDP plan. The PRDP districts are currently 55 in total

248 Annual Health Sector Performance Report Figure 5.2: Amuru district, one of the 8 staff houses in final stages of construction using PRDP funds

The MOH health with support from World Health Organisation and other development partners worked with Uganda Bureau of Statistics (UBOS) to establish district specific baseline data on key health indicators in Acholi and Karamoja sub-regions. A Mini-Uganda Dermographic and Health Survey was conducted during the first half of FY 2009/10. Preliminary reports results were disseminated to key stakeholders. The results indicate the followings: i) Contraceptive use by currently married women (modern methods) 9.8% for both Acholi and Karamoja sub-regions were low ii) Total Fertility Rate for both subregions were higher than the national average (6.7), highest in Pader 9.4 and lowest in Gulu and 7.7 iii) Unmet needs for family planning for both regions was 57.5% iv) Pregnant women aged 15-49 who slept under an ITN the night before was 50.8% and 64.4% for Acholi and Karamoja sub-regions respectively v) Children <5 years with fever in the 2 weeks preceding the survey who took coartem within 24 hrs after developing fever was 6.9% and 5.6% for Acholi and Karamoja sub- regions respectively vi) Full immunization coverage (12-23 months) was 72.5% and 57.9% for Acholi and Karamoja sub-regions respectively vii)Proportion of children who had diarrheal disease and were given any ORT was 62.8%

Planned activities for 2010/11 i) Inadequate supervision of the construction works by the local governments leading poor quality work in some districts ii) Inadequate human resources to operationalise the new infrastructure – though there had been improvement in many PRDP districts in some the staffing level (key cadres) was still poor

Annual Health Sector Performance Report 249 Planned activities for 2010/11

During the next financial the Ministry of Health working with OPM and development partners will support the 55 PRDP district through implementation of the following activities

i) Monitoring of the ongoing utilization of funds and infrastructural development activities ii) Implementation of other components of the PRDP plan – equipping the facilities, attraction and retention of human resources for health etc iii) The finalization and dissemination of Mini-UDHS report to stakeholders (first half of FY2010/11)

250 Annual Health Sector Performance Report 5.5 Functionality of Health Centre IVs

The health sub-district strategy remains crucially important in getting essential services nearer to the people and increase service utilization. The key feature of the HSD Strategy was that each HSD of approximately 100,000 people would have a Hospital or a Health Centre IV with the capacity to provide basic promotive, preventive and curative services, including Emergency Surgical and Obstetric Services and to supervise and support planning and implementation of services by the lower health units in the zone. This was in a bid to address the poor health indicators especially Infant Mortality Rate and Maternal Mortality Ratio. Countries with comparable economic development levels like Cuba, Sri Lanka have been able to improve these indicators to levels of much wealthier countries because of extensive access to essential services33. Being a key strategy of the sector, the functionality of Health Centre IVs has been reviewed every year in the last 4 AHSPRs.

Methodology The District Annual Reports included information on HC IVs with input, management, output and even outcome information. 117 HC IVs from 56 districts provided information of varying degrees of completeness. Functionality was determined by outputs from selected components of the minimum service standards i.e. Maternity (deliveries), Inpatient Blood Transfusion, Theatre (caesarean section, Major and Minor surgery), HCT, PMTCT, ART, Long Term Contraception and Outpatient services. This is similar to the analysis done in the previous financial years.

Level of Functionality

PHC Service Outputs at HC IVs Out of 117 HC IVs, only 4 HC IVs had outputs in all the 12 (100%) service areas considered, these were Kaberamaido HC IV in , Packwach HC IV in Nebbi District, Rugazi HC IV in Bushenyi District and Kabwohe HC IV in Bushenyi District. Out patient is the only service present in every health centre IV of the sample. The next common services in order of frequency are: Deliveries 98%, PMTCT 96% and HCT 94%. The least common services were cesarean section 23%, blood transfusion 24%, major operations 34% and Long term family planning methods 49%. Key primary reasons for establishing HC IV were to provide cesarean section and blood transfusion; it is therefore disappointing that these are the services least available in the HC IVs. Even when 40 HC IVs can do major operations, only 24 of them did cesarean sections moreover 63 of the HC IVs had functional theatres. Over the last 4 years, the trend for blood transfusion service availability is positive but, the one for cesarean section is still fluctuant. The figure below shows the trend over the last 4 years for blood transfusion and cesarean section service. On average only 8 of the 12 services are provided.

33 See the Health Financing Strategy 2003 for more detailed discussion of this.

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Figure 5.3: Trends in Caesarean Section and Blood transfusions in HC IVs TrendinCesareanSectionandBloodTransfusioninHCIVs 30% 28% 25% 24% 23% 20% 19% 19% 17% CesareanS. 15% 14% 15% BloodTransf 10% 5% 0% 2006/0 2007/0 2008/0 2009/1 %ofunitswithservice 7 8 9 0

Years

The 117 HC IVs that submitted information made 3,431,156 outpatient visits, 237,269 inpatients, 65,187 deliveries, 60,945 patients on ART. The average outputs from each HC IV were 28,833; 2,894; 557 and 635 respectively. However there was a wide range in all services, for example OPD patients ranged from 1,638 in Kiyumba HC IV in Masaka to 302,310 in HC IV in Pallisa. Compared to 2008/09 there was improvement in the following indicators – proportion of HC IVs with a functional theatre, proportion of health centre IVs providing at least 10 of the 12 key services, bed occupancy rate, HC IVs with at least 1 medical officer and percentage providing ART services among others. The table above shows these improvements.

TABLE 5.2: Provision of selected key health services by HC IVS FY 2009/10

IPD OPD OPD HCT ART LTFP Blood Minor Dental Section PMTCT Caesarean Deliveries Operations Laboratory Transfusion Major Surgery Major Surgery Number of H/C IVs 103 98 92 85 74 68 63 47 44 23 20 14 103 offering service FY 06/07

As % of respondent HC 100 95 89 83 71 66 61 46 43 22 19 14 100 IVs FY 06/07

Number of H/C IVs 93 86 81 85 66 65 70 58 38 28 26 16 93 offering service FY 07/08

As % of respondent HC 100 92 87 91 71 70 75 62 41 30 28 17 92 IVs FY 07/08

Number of H/C IVs 134 114 116 116 87 90 96 68 63 20 20 25 134 offering service FY 08/09

As % of respondent HC 100 85 87 87 65 67 72 51 47 15 15 19 100 IVs FY 08/09

252 Annual Health Sector Performance Report

Number of H/C IVs 117 115 110 112 86 80 94 74 57 40 27 28 111 offering service FY 09/10 As % of respondent HC 98 97 92 94 72 67 79 62 48 34 23 24 93 IVs FY 09/10 % Change FY 08/09 to -2 12 5 7 7 0 7 11 1 19 8 5 -7 09/10 % Change FY 07/08 to 0% -7% 0% -4% -6% -3% -3% - 6% - - 2% 8% 08/09 11% 15% 13% % Change FY 06/07 to 0% -3% -2% 8% 0% 4% 14% 16% -2% 8% 9% 3% -8% 07/08 Average Outputs FY 286 151 - 2006/07 28,2 1,53 737 533 537 3,10 122 65 21 5 27 0 6 Average Outputs FY 116 38 - 2007/08 27,2 961 1,98 970 1,01 2,48 270 92 20 106 84 5 6 6 Average Outputs FY 214 - 2008/09 28,4 566 2,74 1,06 887 3,19 429 105 54 44 150 38 6 8 4 Average Outputs FY 288 557 343 908 18 289 635 384 98 71 28 207 - 2009/10 33 4 4 Gross Change 06/07 to -943 -569 124 437 479 -620 -170 148 -113 27 -1 101 0 07/08 8 Gross Change 07/08 to -390 834 126 -394 58 65 -12 21 -38 24 44 - 08/09 1,15 4 Gross Change 07/08 to 395 -9 688 -160 -869 -300 421 -45 -7 17 -16 57 09/10 Data for 2009/10 is based on annual reports submitted by 119 health centre IV; Source: Ministry of Health/Resource Centre-HMIS Unit

Table 5.3: IndicatorsTable showing 5.3: INDICATORS the functionality SHOWING of H/C THEIVS FYFU NCTIONALITY2009/10 OF H/C IVS FY 2009/10 Indicator Baseline Achieved Achieved Achieved Achieved FY 2004/05 FY FY 2008/09 2009/10 2006/07 2007/08 Proportion of health centre IVs with a functional No baseline 22% 30% 15%(61) 52.9 (63) theatre data Percentage of Caesarian Sections done out of the total No baseline 1.4%(918) 1.2%(808) deliveries in health centre IVs data Proportion of qualified/trained health workers staying No baseline 49%(917) 52%(921) at the health facility data Percentage of health centre IVs providing at least 10 No baseline 14% 23% 15%(20) 23.5%(28) out of the 12 key health services recommended for data H/C IV level Average length of stay No baseline 3days 3days data Daily Average Occupancy at health centre IV level No baseline 15patients 17patients data Bed Occupancy at health centre IV level No baseline 34% 43% data Proportion of health centre IVs with a functional No baseline 20% (19) 16%(19) surgical ward data Proportion of health centre IVs with at least 1 medical No baseline 45%(60) 57.1%(68) officer data Death rate (deaths out of the total patients admitted) No baseline 0.8%(2,077) 0.7%(1,665) data Maternal deaths No baseline 55 27 data Percentage of health centre IVs providing ART No baseline 62% 72%(96) 79%(94) services data Data for 2009/10 is based on annual reports submitted by 119 health centre IV Source: Ministry of Health/Resource Centre-HMIS Unit

Annual Health Sector Performance Report 253

Since the main objective of setting up HC IVs was to provide Comprehensive Emergency Obstetric Care CEmoC – that is being able to provide intervention in case of complications during delivery, which includes the ability to provide a Caesarean Section and Blood Transfusion, HC IVs have been judged “functional” if they have been able to carry out at least one Caesarean Section. Using these criteria, 23% of the HC IVs were ‘functional’ in 2009/10 – an increase from 15% found in 2008/09.

5.3.1 Factors affecting HC IV Functionality Just like the previous 2 Financial Years, there are a number of key issues that are associated with HC IV functionality. These include: presence of appropriate infrastructure and equipment; presence of qualified health workers especially medical officers; and local government management capacity and interest in HC IV functionality.

Infrastructure and Equipment Many HC IVs still lack crucial infrastructure to make them fully functional for example 56 (49%) health centres have either no theatre, or have an incomplete or non functional theatre. Forty seven (40%) theatres have no equipment, 100 (85%) HC IVs have no surgical ward or have an incomplete or non-functional surgical ward. Fifty one HC IVs have no kitchen or have an incomplete or non-functional kitchen. Staff housing remains a major problem with only 52% if the qualified workers staying at the health centre. Human Resources Shortage of human resource continues to hinder full functionality of the HC IVs. For medical staff, overall 75% of the positions are filled however only 36% of the doctors positions are filled and 19% of the positions for anesthetic officers/assistants. Apart from clinical officers and laboratory assistants all the other cadres of medical staff have below optimum. The table below summarizes the analysis of the HC IV human resource in 2009/10.

Table 5.4: Human resource in HC IV 2009/10 Medical Anestheti Clinical Registere EN, EM, LabTec Lab Ass Theatre Total Officer c Officer d Nurses ENM, Assistant attendant/ assistant and MWs ECN Cleaners. Total in post 117 HC IV 84 45 310 308 692 93 137 108 1777 Average 0.7 0.4 2.6 2.6 5.9 0.8 1.2 0.9 14.9 Min 0 0 0 0 0 0 0 0 0 Max 3 2 6 8 14 3 4 4 30 Staffing 2 2 2 3 7 1 1 2 20 Norm Expected total in post 236 236 236 354 826 118 118 236 2380 % Filled 36% 19% 131% 87% 84% 79% 116% 46% 75%

254 Annual Health Sector Performance Report Local Government Management Whereas presence of a medical officer and infrastructure are essential for functionality of HC IV, there are local government factors that contribute to non functionality even when these critical elements are there. Whereas 69 HC IVs had a medical officer many with essential equipment only 27 of the HC IV conducted caesarean section. The districts are not capable of supervising presence of medical officers and key personnel in health units and addressing local problems that may hinder service delivery. Many HC IVs are operating beyond their resource budget, when the centres are fully functional the service utilisation is very high and some instances coming close to that of some hospitals, this makes shortages and related quality failures more prominent. This constraint is however beyond the solution of the local governments however well they plan.

Service performance and outcomes The HC IVs have a bed occupancy rate of 43% up from 34% the year 2008/09, although improving this is an inefficient level of utilization. There were a total of 237,269 admissions and 0.8% deaths as in the previous year. There were 27 maternal deaths in the 117 health units (average 0.23 per health unit), compared to last year’s 55 maternal deaths in 134 units (average of 0.41 deaths per health unit). Recommendations The Health Centre IVs are crucial in increasing access to referral facility services and ensuring that the lower units in the health sub-district do perform to their expectation as such HC IVs greatly contribute to universal access to the UNMHCP elements that will directly impact health outcomes. Currently 23% can be considered ‘functional’ and are significantly contributing to the key national outputs intended. The sector needs to devise mechanisms for ensuring that adequate resources and improvements in management capacity are directed towards HC IVs if we are to achieve the maternal & child health MDGs. A number of steps need to be taken by the different stakeholders including: i) Increased Monitoring of HC IV Functionality: to ensure better tracking of HC IV functionality both the inpatient and outpatient monthly reports should be submitted regularly to DHOs who should in turn submit a summary of HC IV outputs to MoH. ii) The budget of HC IVs need to be revised to reflect increasing cost that goes with increased utilization once the health centers are fully functional. Differential budgets based on the utilization volumes have to be adopted. The need for accurate financial reporting should be emphasized to all HC IVs; the funding gap for recurrent and infrastructure requirements at HC IVs should be accurately estimated and resources mobilized to have this need addressed iii) Invest more in infrastructure development and this should be targeted to critical structures like staff houses, theatres and equipment. iv) Staff motivation in these usually remote health centers is key to improving service delivery. In addition to providing funding for wage increase, accommodation should also be addressed and mechanisms should be put in place to ensure that key staff at HC IVs especially Medical Officers, midwives, and Anesthetic Assistants when available deliver the expected outputs. Shortage of anesthetists and doctors is the most severe and there needs to be a concerted effort to address this at national scale rather than leave it to district recruitment. Training of anesthetic assistants needs increase and task shifting with appropriate capacity building may need to be instituted. The staff should also have refresher training, frequent and regular supervision and mentoring visits for medical officers at HC IVs in surgical skills should be carried out systematically across the country.

Annual Health Sector Performance Report 255 v) Health care quality indicators need to be developed for HC IVs rather than depending on service out puts per se. Given that some of the centers operate nearly as hospitals these indicators should be in line with those of hospitals.

5.6.1 Scaling up of the priority interventions

The Uganda National Minimum Health Care Package included a set of interventions which are known to improve the population’s health, with particular emphasis on improvements in child and maternal morbidity and mortality. During the HSSP II, a number of interventions such as VHT, HBMF, VCT, and PMTCT were scaled up to improve on geographical and/or functional coverage throughout the country. Limitations like inadequacy of funding and fragmented prioritization process in the sector, with often new initiatives taken on before old ones have been rolled out across the country were minimized. A concept like VHT is the main thrust of prevention in HSSIP. During the HSSP II explicit and transparent mechanisms for prioritization were implemented at all levels. The process of prioritization was guided by: i) long term targets as set out in the Vision 2025, the Millennium Development Goals and the National Health Policy; ii) medium term targets as set out in the PEAP and HSSP II; and iii) Short term targets as set out in the Annual Budget Framework Papers, and by the National Health Assembly and Joint Review Mission and the work-plans at the various levels. All public resources (government budget including donor budget support, donor projects and global initiatives) were aligned with these priorities. In HSSP II efforts were made to ensure: i) Completion of decentralization of routine management and delivery of health services to the HSD level. However, there were challenges with creation of new districts which are virtually HSD and guidelines shall be developed in HSSIP to elaborate on operational relationship of a DHT and HSDT. ii) Operationalisation of all the HCIVs to avail emergency surgical and obstetric services including blood transfusion services. The limited change is attributed to lack of staff, poor workmanship of infrastructure and lack of staff accomodation; iii) Availing Basic Emergency Obstetric Care (BEmOC) at the HC IIIs and Comprehensive Emergency Obstetric Care (CEmOC) at HC IVs and Hospitals; iv) HIV/AIDS prevention and care – provision of VCT, and PMTCT at all HC III and higher level units; and provision of ART at all HC IV and higher level units; v) Malaria prevention and control a. provision of adequate preventive materials (ITNs) - free/heavily subsidised ITNs was made available for the most vulnerable – children and pregnant women; and b. medicines and supplies at the health unit and community levels (HBMF); vi) TB CB-DOTS was scaled up to the whole country; vii)Availing appropriate and adequate vaccines;

256 Annual Health Sector Performance Report Annexes

Annex I: HSSP II monitoring indicators

Indicator 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 HSSP II target 1 Percentage of Government of Uganda 9.7 8.3 9.6 9.6 9.0 9.6 13.40% (GoU) budget allocated to the health sector

2 Percentage of PHC conditional grants 100% 89% 94.50% 94.50% 95% 100% released on time to the sector non salary recurrent and capital by quarter 3 Total public (GoU and donor) allocation to $7.8 $9.98 $7.8 $8.4 $10.4 $11.1 $16 health per capita

4 Percentage of disbursed PHC conditional 99% 88% 79.40% 79.40% 92% 100% 100 grants that are expended quarterly 5 Proportion of districts submitting HMIS 85% 75% 68% 68% 78% 84% 100 monthly returns to MoH on time 6 Proportion of districts submitting quarterly 20% No data 20% 20% 80% No data 60% assessment reports 7 Percentage of facilities without and stock 35% 27% 35% 28% 26% 41% 70% outs of first line anitmalarial drugs/Fansidar, measles vaccine, Depo provera, ORS and cotrimoxazole 8 Percentage of the population residing 72% 72% 72% 72% 72% 72% 83% within 5 kames of a health facility [public of private not for profit (PNFP)] 9 Percentage of health units by level 77% No data No data No data No data No data No target providing all components of the UNMHCP

10 Percentage of health units providing EmOC 20% No data 30% No data No data No data 60%

11 Percentage of children < 1 year receiving 3 89% 89% 90% 82% 82% 76% 95% doses of DPT/pentavalent vaccines

12 Proportion of approved posts that are filled 68% 75% 38.40% 38.40% 56% 56% 65% by health professionals 13 Couple years protection (CYP) 234,259 309,757 357,021 361,080 549,594 460,825 494,908 14 Proportion of surveyed population ******No target expressing satisfaction with health services

15 Urban/rural specific HIV sero-prevalence 6.20% 6.30% 6.30% 6.20% 6.20% AIDS 3% Indicator survey due 16 Percentage deliveries taking place in a 38% 29% 32% 40% 34% 33.0% 50% health facility (GoU or PNFP) 17 Total GoU and NGO/capita OPD 0.9 0.8 0.9 0.8 0.8 0.9 1 utilisation 18 Caesarean sections per expected No data No data No data 2.4 2.4 2.8 7% pregnancies (hospital) 19 Proportion of tuberculosis cases notified 50% 50% 50% 50% 57.40% 56.0% 65% compared to expected 20 Proportion of tuberculosis cases that are 70% 71.3% 73% 73% 75% 85% cured Data not yet available 21 Proportion of < 5 years with a fever who 55% No data 71% 71% 70% 13.7% 70% receive malaria treatment within 24 hours from CDD 22 Percentage of fever/uncomplicated malaria 65% No data No data 71% 60% 13.7% 95% cases (all ages) correctly managed at health facilities 23 Proportion of pregnant women receiving a 30% 37% 42% 42% 44% 39.6% 70% complete dose of IPT2 24 Percentage of household with at least one 15% 16% 16% 42% 46.7% 54% 70% ITN 25 Percentage of households with a pit latrine 57% 58% 58.50% 58.50% 67.50% 69.70% 70%

1 Couple Years of Protection (CYP) as a measure of family planning uptake is one of the recently introduced PEAP indicators reflecting the importance the government and the sector stakeholders place on maternal and child health. The role unwanted pregnancies may play in this. CYP is an absolute number which is computed using routine data in the HMIS, considering the uptake of the various methods of family planning. This considers utilization of contraception.

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Annex 1I: General Hospitals’ Outputs

258 Annual Health Sector Performance Report Annex III: Efficiency scores and returns to scale for the different districts FY 2009/10 Unit name Score Scale Unit name Score Scale MASINDI 57% Decreasing returns ABIM 100% Constant IGANGA 57% Decreasing returns AMOLATAR 100% Constant RAKAI 62% Decreasing returns BUDAKA 100% Constant BUNDIBUGYO 63% Decreasing returns BUDUDA 100% Constant SSEMBABULE 66% Decreasing returns BUKEDEA 100% Constant KAMULI 67% Decreasing returns BULIISA 100% Constant ADJUMANI 67% Decreasing returns DOKOLO 100% Constant MUBENDE 68% Decreasing returns GULU 100% Constant BUGIRI 70% Decreasing returns HOIMA 100% Constant APAC 72% Decreasing returns ISINGIRO 100% Constant PALLISA 74% Decreasing returns KABALE 100% Constant KATAKWI 74% Decreasing returns KABAROLE 100% Constant AMURU 75% Decreasing returns KALANGALA 100% Constant KAPCHORWA 75% Decreasing returns KAMPALA 100% Constant KABERAMAIDO 76% Decreasing returns KAMWENGE 100% Constant AMURIA 76% Decreasing returns KIBAALE 100% Constant KASESE 77% Decreasing returns KIRUHURA 100% Constant KAABONG 78% Decreasing returns KITGUM 100% Constant PADER 79% Decreasing returns KOBOKO 100% Constant KANUNGU 80% Decreasing returns KOTIDO 100% Constant LUWERO 81% Decreasing returns KUMI 100% Constant MAYUGE 81% Decreasing returns LYANTONDE 100% Constant BUSHENYI 81% Decreasing returns MANAFWA 100% Constant KIBOGA 82% Decreasing returns MBALE 100% Constant NEBBI 82% Decreasing returns MBARARA 100% Constant NTUNGAMO 83% Decreasing returns NAKAPIRIPIRIT 100% Constant JINJA 83% Decreasing returns OYAM 100% Constant KISORO 84% Decreasing returns RUKUNGIRI 100% Constant MUKONO 85% Decreasing returns SIRONKO 100% Constant MASAKA 85% Decreasing returns SOROTI 100% Constant ARUA 89% Decreasing returns YUMBE 100% Constant KAYUNGA 89% Decreasing returns IBANDA 89% Decreasing returns BUSIA 89% Decreasing returns KALIRO 89% Increasing returns MPIGI 90% Decreasing returns BUKWO 91% Increasing returns LIRA 91% Decreasing returns MOYO 91% Decreasing returns MOROTO 92% Increasing returns NAKASEKE 93% Decreasing returns NAKASONGOLA 93% Decreasing returns KYENJOJO 93% Decreasing returns WAKISO 96% Decreasing returns BUTALEJA 96% Decreasing returns TORORO 97% Decreasing returns MITYANA 97% Decreasing returns NAMUTUMBA 98% Decreasing returns

Annual Health Sector Performance Report 259

Annex IV: Change in the efficiency score between 08/09 and 09/10 efficiency Score change in the efficiency score between District 08/09 Efficiency Score 09/10 08/09 and 09/10 ABIM 100% 100% 0% ADJUMANI 67% 76% 9% AMOLATAR 100% 100% 0% AMURIA 76% 100% 24% AMURU 75% 78% 3% APAC 72% 92% 20% ARUA 89% 99% 11% BUDAKA 100% 100% 0% BUDUDA 100% 100% 0% BUGIRI 70% 86% 16% BUKEDEA 100% 100% 0% BUKWO 91% 100% 9% BULIISA 100% 100% 0% BUNDIBUGYO 63% 85% 22% BUSHENYI 81% 95% 14% BUSIA 89% 86% -3% BUTALEJA 96% 100% 4% DOKOLO 100% 100% 0% GULU 100% 100% 0% HOIMA 100% 100% 0% IBANDA 89% 85% -4% IGANGA 57% 85% 28% ISINGIRO 100% 100% 0% JINJA 83% 95% 12% KAABONG 78% 75% -3% KABALE 100% 100% 0% KABAROLE 100% 100% 0% KABERAMAIDO 76% 76% 0% KALANGALA 100% 100% 0% KALIRO 89% 74% -15% KAMPALA 100% 100% 0% KAMULI 67% 64% -3% KAMWENGE 100% 100% 0% KANUNGU 80% 91% 12% KAPCHORWA 75% 71% -4% KASESE 77% 71% -6% KATAKWI 74% 99% 25% KAYUNGA 89% 90% 2%

260 Annual Health Sector Performance Report efficiency Score change in the efficiency score between District 08/09 Efficiency Score 09/10 08/09 and 09/10 KIBAALE 100% 60% -40% KIBOGA 82% 86% 4% KIRUHURA 100% 100% 0% KISORO 84% 76% -8% KITGUM 100% 100% 0% KOBOKO 100% 100% 0% KOTIDO 100% 100% 0% KUMI 100% 100% 0% KYENJOJO 93% 77% -16% LIRA 91% 100% 9% LUWERO 81% 87% 6% LYANTONDE 100% 100% 0% MANAFWA 100% 100% 0% MASAKA 85% 99% 14% MASINDI 57% 100% 43% MAYUGE 81% 92% 11% MBALE 100% 100% 0% MBARARA 100% 100% 0% MITYANA 97% 100% 3% MOROTO 92% 92% 0% MOYO 91% 95% 4% MPIGI 90% 91% 1% MUBENDE 68% 79% 11% MUKONO 85% 98% 14% NAKAPIRIPIRIT 100% 100% 0% NAKASEKE 93% 96% 3% NAKASONGOLA 93% 87% -6% NAMUTUMBA 98% 80% -18% NEBBI 82% 88% 6% NTUNGAMO 83% 88% 5% OYAM 100% 100% 21% PADER 79% 91% 17% PALLISA 74% 93% 31% RAKAI 62% 92% -8% RUKUNGIRI 100% 85% -15% SIRONKO 100% 100% 0% SOROTI 100% 100% 34% SSEMBABULE 66% 92% -4% TORORO 97% 95% -1% WAKISO 96% 92% -8% YUMBE 100% 100% 0%

Annual Health Sector Performance Report 261

Annex V: RESOLUTIONS OF THE 7TH NATIONAL HEALTH ASSEMBLY

These were discussed and agreed upon in the plenary. In addition , there was consensus that innovative new ways of improving performance measurement of local governments should be adopted by the sector, including performance measurement of the National Medical Stores and the central Ministry of Health Directorates and Departments;

I: Human Resources for Health i) Implement the hard-to-reach, hard-to-stay, and staff motivation strategy to increase staff retention and reduce attrition. ii) Lobby government to increase wages of health workers. iii) Districts that have not reached 60% of their wage bill should recruit. iv) Accelerate the strategy of task shifting. v) Recentralize the deployment of key health workers such as MOs. vi) Review the curriculum of Enrolled Comprehensive Nurses and Registered Comprehensive Nurses. vii)MoH to write circular to districts banning recruitment of Nursing Assistants, and to work with MoE to phase out training of Nursing Assistants. viii) DHOs should monitor and ensure that schools training nurses and midwives are registered.

II: EMHS i) Improve procurement and supply chain management of medicines by regularly updating and monitoring the procurement plan (including all development partners contributions) and monitoring the performance indicators for NMS and JMS to ensure sustainable availability of drugs and health supplies at both public and PNFP units. ii) In light of new policy shift, develop and disseminate guidelines for the supply and distribution of drugs to all stakeholders. The guidelines should include a monitoring mechanism. iii) Set up a transparent drug pricing system at NMS iv) NMS and MoH to prepare, publish and circulate a medicines and supplies price list. v) Build capacity at the user units in medicines and health supplies needs forecasting and rational drug use.

III: Community Involvement i) Mobilize funding to scale up VHTs across the country. ii) Put in place and build capacity of Health Unit Management Committees. iii) Strengthen the district partnerships with CSOs/NGOs when rolling out the VHT strategy. iv) Ban the use of professional medical titles for people who practice alternative medicine.

262 Annual Health Sector Performance Report IV: Health Financing i) Develop a sustainable strategy for financing the PNFP sector: the PNFP subsidy from GoU has reduced from 22% to 20% and user fees in the PNFP have increased. ii) Develop an evidence based health financing policy and strategy which can be used for advocacy within and outside government. iii) Lobby to increase PHC non-wage recurrent budget to support operational costs especially at HC IV level. iv) Review funding criteria of districts with peculiar needs e.g. border districts. v) Accelerate the operationalization of National Social Health Insurance Initiative.

V: Malaria Control i) Intensify efforts to roll-out proven effective malaria control interventions like IRS and ITNs. ii) GOU to specifically budget and fund Indoor Residual Spraying.

VI: MCH i) Need to address the issue of high maternal deaths by focusing on EmOC and reducing the unmet need for FP. ii) Roll out and implement the Child Survival Strategy.

VII: Health Infrastructure i) Improve the release and effective use of the development budget to improve functionality of the existing health infrastructure. ii) DHOs should regularly provide and update the infrastructure and equipment inventory. iii) Maintenance of equipment should be prioritized.

VIII: Health Sub-Districts i) Review the health sub district concept. ii) Prioritize HC IV functionality particularly funding HC IVs.

Annual Health Sector Performance Report 263 IX: Neglected Diseases/Emerging diseases

i) Pay attention to neglected tropical diseases and emerging diseases.

X: Environmental Health

i) Recommit LGs to the Kampala Declaration on Sanitation (1997) to enact and enforce bye-laws/ordinances to raise pit latrine coverage. ii) Share and promote successful district/hospital experiences. iii) Mobilize resources to address climate change issues that impact on Public Health. iv) Health units and health workers should participate in community activities that mitigate the effects of global warming such as tree planting. v) Post of Medical Superintendent should be established and institutionalized in the Ugandan Civil Service.

264 Annual Health Sector Performance Report Annex VI: PRIORITIES OF THE 15TH JOINT REVIEW MISSION FOR THE HEALTH SECTOR INFRASTRUCTURE: i) Focus and consolidate construction/ repair of existing structures before embarking on the construction of new facilities ii) Start the process of securing land titles for all health facilities. The centre should plan to support districts acquire titles for hospitals while districts acquire titles for lower level facilities. iii) Develop and implement guidelines for the operations of ambulances

HEALTH FINANCING, MEDICINES, SUPPLIES AND LOGISTICS: i) Prepare a Memorandum of Understanding to govern relationship between NMS, MoFPED, MoLG, and MoH ii) Improve business processes (business process engineering) for release of funds and procurement in GOU to avoid delays and expedite implementation of planned activities iii) In light of new policy shift, develop and disseminate guidelines for the supply and distribution of drugs to all stakeholders. The guidelines should include a monitoring mechanism.

SERVICE DELIVERY i) VHT scale up from 25 districts to cover all districts ii) Allocate additional resources to HC IVs and hospitals iii) Functionalize HUMCs iv) Fill vacant posts in hospitals to 80% by the end of the FY10/11. v) Approve the Public-Private Partnership for Health Policy

HUMAN RESOURCES FOR HEALTH i) Implement the hard-to reach and hard-to-stay strategies; and the general motivation strategies for health workers ii) Establish leadership and management positions in hospitals. iii) Make Regional Referral Hospitals efficient and effective in their operations. iv) Equip all managers with leadership and management skills. v) Review training curricula and HR development programs with intention of broadening the scope of a given cadre. vi) Prioritize training of cadres who are hard to attract and retain.

Annual Health Sector Performance Report 265 should be disseminated should be disseminated to all in time stakeholders for action to be initiated. should ensure funds were released in time. increase budgetary • reports Area Team • MoFPED and MoH • MoFPED should

quarter supervision to address specific problems specific problems quarter supervision to address th that could not be handled by the regular Area Teams. that could not be handled by the regular Area Teams. were well attendance of workshops and seminars coordinated and Health Facilities had individual accounts. and consolidate planning. harmonize their EMHS supply of March 2010 were had missed etc subsequently given their medicines. and made deliberate follow up of the issues that needed deliberate follow up of and made the previous quarterly visits. In particular attention from of the Ministry participated addition the Top management in the 4 quarter FY 2009/10. Funds for the 3rd were released late by MoFPED in the of Q4, while first month of May 2010. funds for Q4 were received in the middle of the The late release affected the implementation district workplans. (% of budgeted funds that was released). districts leading to arrears especially for utilities; instance Masindi Hospital had failed to pay electricity Apac Hospitalarrears of 15million, had electricity bill of • follow up; of as a result For instance • The Acholi Region had taken action on staff absenteeism, • region had regional planning to Districts of the Karamoja • and Masindi districts that health units in Kibale Some • districts with the shared their reports All the area teams • the PHC funding for 3rd and 4th All districts received • of the districts was 95% The average budget performance • faced by problem Underfunding for health was a major PHC RNW PHC Wage PHC Development PNFP Partners Development District Local Government Area of Focus Observations/Issues Action Point ------previous visit(s) of and completeness Timeliness schedules disbursement Reporting/Accountability status Annex VII: Area Team Reports Annex VII: Area Team 1. Follow-up of issues noted in Health Care Inputs 2. Heath System/ 2.1 Financial Resource Inputs o o

266 Annual Health Sector Performance Report and submit recruitment recruitment and submit plans as part of BFPs to MoPED, MoH and MoPS. should ensure adequate funds were available for of health recruitment workers. allocation to health allocation to Hospitals. especially to should committee quicken the procurement process. should governments support the district health sector. • prepare Districts should • MoH, MoPS, MoFPED • District contracts • District local

districts. Staffing level in most districts fell between 35- districts fell between districts. Staffing level in most 45% and yet because they had exhausted their wage bill recruit. This was the case in Butaleja, they could not Those districts Jinja, Tororo, Mayuge and Namutumba. the that had high staffing levels recruited mainly lower cadres such as Nursing Assistant and Askaris A case in point was Buliisa exhausting their wage bill. district with staffing level of 86% but had no single were that had failed to Medical Officer. Then there those the critical cadres attract both as well the lower cadres e.g. had low staffing level of only 28% region. and the districts in Karamoja 23 million and Aduku Health Centre IV had 4 million. IV had 4 million. and Aduku Health Centre 23 million and water bills of 72 million Lira RRH had accumulated was only 30 the budget provision for water this FY million. most districts e.g. Kasese, Bukwo, Busia and Sironko procedures for capital e.t.c. due to the long procurement development. financial support to the district health sector, notably Kibale and Masindi districts. • in the There has been general shortage workers of health • by only one health health units were manned Some • funds in There was low utilization of PHC Development • Very few District contributed Local Governments

rd & 3 nd , 2 st Area of Focus Observations/Issues Action Point levels/distribution at health % accommodated facility General staffing Cadres in greatest demand Staff recruitment status Payroll management Staff accommodation – no.s & Presence of duty roster ------Teams should seek for information should seek for information Teams for the FY 2009/10 1 2.2 Resources for Health Human Quarter releases; FY 2009/10 release Quarter releases; FY 2009/10 figures up to March 15, 2010 from MoFPED are available; please note if between discrepancies there are any provided by the information MoFPED and the districts; More detailed data can be captured by the tool for Financial Management available;

Annual Health Sector Performance Report 267 and motivation strategy. and motivation address remuneration of health workers. reach and hard to stay strategy. central purchase and distribution of uniforms. • the retention Implement • MoPS/MoH should • Fast track the hard to • MoH should ensure

Observations/Issues

to have generally improved. NMS had tried to supply to have generally improved. whatever was required by the districts. worker e.g. Butawata HC II in Mubende district which by one Nursing Assistant. was manned Specialists in RRHs, Medical Officers, Pharmacists, Nurses Anaesthetists, Dispensers and other paramedics, had persisted through the FY 2009/10. and midwives Arua district had recruited 143 health workers in the FY 2009/10 and all were posted to health sub districts; staffing level had risen to 63.5%. cadres. the nursing especially for affected by availability of supplies. The Lango Area likely to be found that health workers were more Team to avoid harassment medicines there are no absent when by the patients and local leaders. • country was noted The availability of EMHS across the • cadres of staff such as Failure to attract and retain critical • districts had addressed health worker shortages. Some • for health workers more There was lack of uniforms • were station and morale presence at duty Health worker Area of Focus Action Point 2.3 Medicines & Health Supplies (MHS)

268 Annual Health Sector Performance Report facilities should continue facilities should with the verification of supplies schedule, and when it is not possible should the districts inform beforehand. ensure adequate availability of ACTs. • health Districts and • NMS should follow their • MoH/NMS should

rd

procurement plans and forwarded them to NMS. plans and forwarded them procurement officials (RDCs, DISOs, done by the relevant government GISOs, Auditors, CAOs, LC Chairmen). of the districts. to some during the quarterly visits. There was severe shortage of 2nd quarter of the FY 2009/10 ACTs especially in the up to March 2010 during which that lasted for 5 months facilities e.g. Ngoleriet HC II resorted to the use of some Chloroquine and Fansidar. region during the 4th quarter supervision. e.g. health units supplied by NMS, as a result some RRH, and Masindi hospitals had no Hoima 3 catheters during the drugs, anti-sera, anaesthetic quarter leading to avoidable referrals. • their made Hospitals Regional Referral Districts and • Verification of EMHS delivery to districts was being • NMS did not follow their own EMHS delivery schedule • Shortage of ACTs was encountered in several districts • in the Lango sub Shortage of all EMHS was rampant •districts and hospitals were ordered by the Not all items Evidence of timely orders Evidence of timely Delivery lead time Delivery discrepancies of Completeness deliveries Supervision of deliveries by authorised personnel (Internal Auditors; DHO/MS representative; RDC representative); status of Presence and Stock cards Suggestions to improve MHS availability at facility level Area of Focus Observations/Issues Action Point ------General level of MHS availability General level of MHS availability & facility level at district, HSD PHC CG funds at Utilisation of district level for MHS procurement PHC CG (at NMS) Utilisation of Funds for MHS and Credit Line procurement Efforts to assess functionality of (both District & NMS system responsibilities) should be of undertaken through assessment of areas including: a number o o o o to Particular efforts should be made look at copies of MHS orders orders were district level, to confirm

Annual Health Sector Performance Report 269

for Support Supervision. Department should Department guide the revival of consultants outreach throughout programme the country reactivate and re- reactivate and In HUMCs. orientate addition MoH/QAD should ensure that the HUMC guidelines were updated. RRHs have an effective and functional board. • Districts should budget • MoH, Clinical Services • Districts should • MoH should ensure all

lower level facilities was irregular. This was aggravated facilities was irregular. lower level of transport for the DHT and by lack of reliable means late release of funds. In most districts Support supervision was last done in November 2009. Technical support supervision was however, being done regularly in those districts where there was donor support. RRH to Kikube HCIV the Hoima Specialists from sponsored by Sight Savers; and from Soroti RRH to Kaabong and Kotido districts with the support of AMREF. Specialists from Gulu RRH support Amuru district. had overstayed in office for over Mityana districts. Some 8 years e.g. in Kibale, Mubende and Bundibugyo. Board. Mubende hospital still had the old management that was operational when the hospital had not committee yet been upgraded to regional status. Hoima RRH had no and Masindi districts had Board because only Hoima for membership. nominations made done for the five Training VHTs districts in Karamoja Region. Medicine boxes/carriers introduced by UNICEF. • Supervision to HSDs and Integrated Support • Consultants’ outreaches were being done; Eye Limited • HUMC were functional in Kasese, Masaka, Masindi and • Regional Referral Hospitals had no Management Some • districts. VHTs were largely non functional in many Area of Focus Observations/Issues Action Point Service provider capacity and function Support Supervision to HSDs & – evidence of health units Reports, of Yellow Star Implementation – regularity; scores Programme Consultant’s Outreach – record of visits Programme for community Mechanism feedback – suggestion box ; HUMC? made, and when they were made. and when they were made. made, 2.4 Support Supervision & Quality of Care issues o o o o o

270 Annual Health Sector Performance Report

continuously mentor continuously mentor districts in planning and data management. Governments should Governments the district ensure that land boards assist in the acquisition of land titles. should support districts of in the implementation the VHT strategy. • The MoH should • District Local • MoH/HPE division operational plans by the end of the FY 2009/10. Some of the FY 2009/10. Some operational plans by the end MoFPED and MoH, while to had already submitted others were awaiting approval of their district councils. districts was done in time. utilization of generated data were charts, targets (graphs, available). health facilities. The districts that had made progress with health facilities. The districts that had made and surveying included Kyenjonjo, demarcation Mubende and Masindi districts). Region). HSDs PNFP (Karamoja in Moroto; – Matheniko Officers & DHO, Nursing Officer; Environment Statistician. • of their Districts were in various stages finalization in the • required of the B reporting that was form Performance • of analysis and evidence districts there was In some • There are districts with challenges of HSD Management • of the DHT is thin on ground – Kanungu lack Some Area of Focus Observations/Issues Action Point Quality of health information Quality of health in information of Utilisation planning & monitoring (presence of tables, charts etc.) for assessment Performance the FY 2009/10 Q1 & Q2 (probe and discuss using B for Form Performance district, HSD & HF levels ) of data to the Submission Resource Centre Planning process for the FY 20010/11 – is work-plan completed? o o o o o 2.5 Planning / Performance 2.5 Planning / Performance Assessment 5.0 General Observations • titles for their Most districts still had not acquired Land

Annual Health Sector Performance Report 271 building for the new districts. • Plan for capacity They generally lack qualified staff and office to system. execute duty. New districts visited included Napak and district in Karamoja region, Amudat Central region, Alebtong in Acholi sub-region etc. • established into Most new districts are struggling to get Area of Focus Observations/Issues Action Point

272 Annual Health Sector Performance Report Ranking Total Total Score HIV/AIDS HIV/AIDS Service Availability* FDS Flexibility Gain % PHC funds disbursed are that expended Proporon Proporon of PHC funds spent on drugs(at NMS and JMS)** % Pregnant % Pregnant women 2nd receiving dose Fansidar IPT for Proporon of Proporon new smear TB posive cases nofied to compared expected % Deliveries % Deliveries in Govt and NGO health facilies Pit Latrine Pit Latrine Coverage Total Total Govt and NGO OPD ulizaon per person per year % children % children <1 received 3 doses of DPT to accordig schedule 5 12.5 12.5 7.5 12.5 10 10 10 5 5 10 100 District League Table 2009/10 all 80 districts League Table District % Score % Score Score % Score % Score Score % Score % Score % Score Score % Score %District %District HMIS Outpaent returns submied mely Total Total No. of Health Units No. of 1597800 577100 200 1301800 100% 3 19 5463600 52 4 100% 58%475600 12.5 57 5 1.2 100% 3403200 12.5 5 67 3 78% 94.0 100%55200 7 92% 5 9.7 53 92% 1 11.4 2.4 111%311600 92% 1.3 12.5 12.5 5 4 67% 18 12.5 11.5 169%416600 85.0 1.2 6 85.0 63% 3 65 10 3 6 12.5 83%454800 7.9 65% 82.0 96% 81% 40 4 46% 6 75% 4 1.0171000 8.2 10.1 12.5 10 5.8 4 1.1 64 1 29% 191% 132% 92% 84.0374700 12.5 78% 12.5 78 6 10 3.7 86% 5 2.4 13 88.0 3 75% 8 8 7120400 12.5 62% 46% 10.8 52% 94% 4 1.9 51 38.0 1 100% 5.7 43% 6 3 52%981600 100% 12.5 5 11.8 5 5 95% 74% 0.9 10 5.3 97.4 7 92% 5 56% 7 67%241800 11.0 100 11.9 89% 83% 7 50% 5 1.0 77 7.0 65.0 2 10 92% 2.5 7 92 53% 11.1 5833700 12.5 8 135% 0.9 57% 66 89% 5 100% 46 6.7 58.6 9 9 100% 11.0 97 39% 10 6.6 5 4466900 11.1 44% 59% 5 6 56.0 117% 1.7 80 4.8 3 10 4 100% 91.0 56% 100% 41% 12.5 50%427200 12.5 4 6 5 1 65% 106% 5 87 0.8 2.5 100% 92 5.2 37.1 6 3 24% 92% 10.1 8.1 10 5 3 71 80 9 50% 45% 83% 67% 3.0 62.6 7.1 5 0.9 53 2.5 39 5 92% 45% 50% 10.4 8 50% 11.4 68% 5 7 76 100% 79.6 1.1 2.5 4 89% 5 5 6.2 85.0 4 25% 7.6 2 67% 12.5 7 6 59 100% 93 11.1 35% 159% 5 3.1 90.1 5.9 65% 78.4 3 0.8 100% 50% 85 7 38% 9 10 5 3 82% 10.4 2.5 79% 3 8.1 74.8 50% 8 50% 4.8 95.1 78 34% 4 1.0 37% 2.5 8 8 50% 7 100% 93 6.2 7.8 12.2 48% 5 2.5 4.2 79 100% 4 0.9 84.4 65 27% 9 7.9 5 74.1 46% 75 50% 5 6 11.4 50% 5 7.5 3.4 69 6 74.1 2.5 92.3 5 5 50% 100% 29% 5 7 60% 69% 73.5 5 2.5 50 7 7 100% 3.6 83 5.0 51% 56 6 36% 7 5 50% 5.6 65% 100% 8 73.3 2.5 4.5 5 5 94 50% 8 31% 73.0 7 79 93% 2.5 9 100% 89 9 7.9 50% 3 5 90 9 2.5 37% 9 9.0 72.6 70 100% 88 50% 10 4 5 36% 7.0 72.3 2.5 100% 9 11 5 90 72.3 4 95 50% 9.0 11 2.5 100% 9 50% 97 5 87 72.2 2.5 8.7 13 10 64 100% 50% 5 6.4 72.0 2.5 100% 14 5 75 71.9 50% 7.5 15 2.5 50% 83 70.3 2.5 8.3 16 76 7.6 70.2 17 70.0 18 Popul- aon KAMPALA LYANTONDE MITYANA TORORO JINJA KABAROLE ABIM RUKUNGIRI MBALE MPIGI DOKOLO GULU AMOLATAR MUKONO KANUNGU MASAKA RAKAI 2 3 4 5 5 7 8 9 10 11 11 13 14 15 16 17 18 1 Ranking

Annual Health Sector Performance Report 273 Ranking Total Total Score HIV/AIDS HIV/AIDS Service Availability* FDS Flexibility Gain % PHC funds disbursed are that expended Proporon Proporon of PHC funds spent on drugs(at NMS and JMS)** % Pregnant % Pregnant women 2nd receiving dose Fansidar IPT for Proporon of Proporon new smear TB posive cases nofied to compared expected % Deliveries % Deliveries in Govt and NGO health facilies Pit Latrine Pit Latrine Coverage Total Total Govt and NGO OPD ulizaon per person per year % children % children <1 received 3 doses of DPT to accordig schedule 5 12.5 12.5 7.5 12.5 10 10 10 5 5 10 100 District League Table 2009/10 all 80 districts League Table District % Score % Score Score % Score % Score Score % Score % Score % Score Score % Score %District %District HMIS Outpaent returns submied mely Total Total No. of Health Units 218 1510 84% 4 76% 9.5 0.9 11.5 70 5 33% 4.1 56% 6 47% 5 78 8 100% 5 50% 2.5 78 7.8 67.9 No. of 343000 2490000 7 22206200 100% 100 1387100 5 92% 123% 2 23 15.3 5 100% 0.6 35481800 83% 10.4 5 6.9 92% 73.0 2 1.4858600 90% 11.3 12.5 5 5 91.0 7 1.3 55178600 71% 18% 12.5 100% 7 110 75.0 2 8.9167000 2.3 1.2 25% 5 50% 6 46% 1 12.5 21377900 3.1 74% 38.0 42% 3 100% 9.2 35% 5 2 12220400 5.2 95% 3 1.0 11.9 5 100% 12.5 59% 39% 23% 3 2 0.8 26242800 29.0 57% 4.8 5 10.3 6 7.1 34% 75% 89.0 147% 2 2 2 35396700 1.1 12.5 56% 92 32% 3 4 7 12.5 54% 1.1 42% 3 37695500 82.9 4.0 76% 12.5 6 30% 89 9 58.0 5 2 83% 100% 4 9.4 6 52207200 3.7 70% 78% 68% 1.0 89 4 9 49% 4 67% 5 100% 51% 1 8.5 12.5 88 7 8 24% 56.0 50% 6.2 81% 1.3 9 10.1 3 50% 5 2.5 2.9 100% 63 5 12.5 53% 33 51% 4 0.9 34.6 50% 61 82% 30% 10.3 3 11.5 26% 92% 5 2.5 52% 5 6 88.9 6.1 5 3 1.1 50% 77 96% 100% 68.4 6.6 65 3 3 12.0 5 12.5 2.5 26% 7 58% 78.0 7.7 0.7 5 45 87% 25% 26 99 68.3 3.3 40% 31% 50% 10.9 7 6 6 9.1 100% 4.5 0.8 74.0 2.5 3.9 82% 10 3 28 68.2 4 29% 100% 70 73 10.1 5 51.0 56% 6 51% 82 3.7 8 29 50% 7.3 5 7 43% 68.1 4 50% 2.5 100% 39% 6 5 50% 8 85 5.3 2.5 30% 100% 30 89 20% 5 71 4 5 3.7 8.5 28% 50% 5 67.7 7.1 65 2 9 49% 50% 2.5 27% 67.2 100% 3 45 2.5 31 94 5 7 66 3 54% 32 5 100% 4.5 95 50% 66.9 9 6.6 37% 100% 5 5 2.5 66.5 33 50% 53 9 81 4 5 100% 34 2.5 50% 5.3 88 93 65.7 8 5 2.5 100% 50% 44 9.3 9 35 65.5 2.5 100% 5 4.4 39 50% 65.4 36 5 2.5 3.9 50% 37 65.3 70 2.5 92 7.0 38 65.3 9.2 65.0 38 40 1260900 7 99 100% 5 85% 10.6 0.7 8.9 83.5 6 26% 3.3 43% 4 43% 4 72 7 100% 5 50% 2.5 72 7.2 64.6 41 31783300 344600 3281100 23 2 27 92% 5 100% 5 78% 9.7 96% 0.9 12.1 11.3 0.8 75.0 9.5 6 72.8 5 36% 4.5 29% 42% 3.6 58% 4 6 46% 40% 5 4 83 8 81 8 100% 5 100% 5 50% 2.5 50% 86 2.5 8.6 77 7.7 69.0 21 68.7 23 Popul- aon KAYUNGA BUSIA MANAFWA KABALE BUTALEJA KITGUM Naonal Average PADER BUSHENYI NAKASEKE BUDUDA KUMI AMURU IBANDA ISINGIRO KASESE NAMUTUMBA WAKISO District 31 26 28 29 30 32 33 34 35 36 37 38 38 40 41 23 21 Ranking

274 Annual Health Sector Performance Report Ranking Total Total Score HIV/AIDS HIV/AIDS Service Availability* FDS Flexibility Gain % PHC funds disbursed are that expended Proporon Proporon of PHC funds spent on drugs(at NMS and JMS)** % Pregnant % Pregnant women 2nd receiving dose Fansidar IPT for Proporon of Proporon new smear TB posive cases nofied to compared expected % Deliveries % Deliveries in Govt and NGO health facilies Pit Latrine Pit Latrine Coverage Total Total Govt and NGO OPD ulizaon per person per year % children % children <1 received 3 doses of DPT to accordig schedule 5 12.5 12.5 7.5 12.5 10 10 10 5 5 10 100 District League Table 2009/10 all 80 districts League Table District % Score % Score Score % Score % Score Score % Score % Score % Score Score % Score %District %District HMIS Outpaent returns submied mely Total Total No. of Health Units No. of 247300 3199200 2 31543200 92% 3 31210900 5 92% 2 39 74%613300 5 92% 9.3 3 23 61%150000 1.6 5 12.5 92% 7.6 1 73.8 44 63%163000 1.2 5 12.5 83% 7.8 6 1 57.9 30 80%183000 0.7 45% 100% 10.0 4 4 8.5 2 0.9 18 5.6 47%709400 69.0 5 23% 10.7 83% 5.9 60.0 35% 71% 4 5 20 2.9504700 0.9 8.9 4 5 27% 10.8 67% 3 20% 3 1.3 68.0 81 80%204600 15% 3.4 12.5 10.0 14% 3 92% 73.0 2 5 1.9 1 0.8 40 56% 71%169200 21% 1 52% 5 5 49% 9.7 75% 8.9 1 49.3 6 18 2.7 70%599000 0.9 87 31% 5 100% 4 5 11.3 8.7 46% 4 59% 3.9 3 49.0 15 71%506900 0.6 9 86 20% 5 24% 100% 51% 5 83% 8.8 104% 6 4 7.0 3 71 3.0 12.5202200 0.8 66.0 9 2 61 5 22% 100% 0.9 66% 4 5 10.3 83% 50% 37% 1 62.0 80 5 40 2.7 11.3 96%280200 2.5 6 35% 5 7 12.0 6.7 4 30% 100% 75% 38 4 5 50% 29% 2 0.8 8 17 82%429300 85 3.7 3 100% 2.5 1 23% 10.0 10.3 3.8 48% 4 5 92% 60.0 69 3 62.4 3 0.5 23 50% 42% 16% 2.8 63% 9 8 5 5 100% 6.9 2.5 46% 5 5 50% 6.5 2.0 7.8 45 34% 62.1 83% 78.7 88 2 4 38 84% 0.5 2.5 86 40% 100% 5 31% 5 10.5 78 75% 8.8 25% 4 3 46 6 50% 5.7 5.0 0.4 61.9 67.9 9 85 5 74% 7.8 2.5 3 16% 100% 28% 4 50% 14% 3 5.3 61.9 45 9.3 81.0 47 5 2.0 60% 2.5 9 70% 0.9 94 5 3 100% 4.5 75 1 47 30% 7.5 6 50% 29% 11.5 61.7 7 0.5 83.0 89 3.8 7.5 2.5 9 54% 5 23% 61.5 100% 63 3 58 49 50% 6.0 6 36% 2.9 62.0 9 5 2.5 100% 6.3 42% 50 5 11% 78 6 25% 61.5 4 38 5 50% 100% 1.4 5 4 7.8 2.5 23% 55% 3 50 50% 61.3 85 4 5 27% 89 2.9 100% 2.5 50% 30% 5 8.5 76 52 2.5 3 49% 61.1 9 5 53 89 3 100% 7.6 50% 23% 60.6 5 53 5.3 2.5 73 9 5 60.0 62 2 100% 44% 54 50% 7 6.2 2.5 92 55 100% 5 4 59.9 72 50% 9 78 5 7.2 2.5 56 100% 50% 59.5 75 2.5 8 5 100% 7.5 88 57 50% 59.1 8.8 2.5 5 58.5 42 58 50% 2.5 4.2 59 89 58.5 8.9 59 58.4 61 Popul- aon KISORO KAPCHORWA APAC SSEMBABULE KIBAALE NAKASONGOLA KATAKWI KABERAMAIDO IGANGA KYENJOJO KOTIDO BUDAKA BUGIRI PALLISA KALIRO KIRUHURA 45 46 47 47 49 50 50 52 53 54 55 56 57 58 59 59 61 Ranking

Annual Health Sector Performance Report 275 Ranking Total Total Score HIV/AIDS HIV/AIDS Service Availability* FDS Flexibility Gain % PHC funds disbursed are that expended 2002 Proporon Proporon of PHC funds spent on drugs(at NMS and JMS)** % Pregnant % Pregnant women 2nd receiving dose Fansidar IPT for Proporon of Proporon new smear TB posive cases nofied to compared expected % Deliveries % Deliveries in Govt and NGO health facilies Pit Latrine Pit Latrine Coverage Total Total Govt and NGO OPD ulizaon per person per year % children % children <1 received 3 doses of DPT to accordig schedule 5 12.5 12.5 7.5 12.5 10 10 10 5 5 10 100 District League Table 2009/10 all 80 districts League Table District % Score % Score Score % Score % Score Score % Score % Score % Score Score % Score %District %District HMIS Outpaent returns submied mely Total Total No. of Health Units No. of 67500 1 12 100%76900 5 1 98% 12.2 1.0 9 12.5 60.0 73% 5 4 17% 63% 2.1 7.8 0.6 13% 7.3 49.0 1 4 50% 14% 5 1.8 27 27% 3 100% 3 52% 5 50% 5 2.5 25 71 2.5 55.3 7 100% 72 5 50% 2.5 75 7.5 54.2 75 554900 4297800 3 44312500 25% 3 19466400 1 50% 1 28354300 43% 3 83% 5.4 2 17499100 74% 0.7 100% 4 9.3 2 9.1 37566600 64% 0.8 70.0 5 100% 8.0 3 9.4 52% 23 5 0.7 5 5.7 6.5 67% 30% 8.7 27% 56 0.5244900 68.0 0 3.8 3.4 3 92% 6.7 3 12% 0.9 75.0716700 5 34% 39% 11.0 1.5 5 4.9 27% 78.4 6 4 15 3 50% 0.6 93% 3.4 26% 6 83% 6.2 8.1 81% 71388200 31% 3.2 0.5 72.0 9 17% 4 92% 8 2 6.2 10% 2.1602100 5 3 52% 71% 76.0 79 5 23% 8.9 29% 3 1 27% 31 5331600 6 79% 0.7 3.7 8 58% 2 67% 9.8 13% 64 3 1 8.6 100% 51344200 50% 0.6 1.7 2.0 75% 81 3 7 67% 6 5 2 7.3 32345300 5 100% 42% 56% 82.0 50% 0 69 7 8 3 33% 7.0 2.5 2 35% 100% 23 5 6 4 41% 7% 64 0.8 64 7 50% 2 67% 10.6 100% 5.1 26% 0.8 3 5 44% 27 6.4 2.5 57.0 33% 6 0.4 50% 3.2 58.0 56 100% 37% 82 3 5 92% 4.1 2.5 4 4 4.4 50% 23% 55% 0.7 5.6 68.2 59 65 5 4 28% 73 8 57.2 5 2.5 6.9 50% 9.1 100% 5.9 75 5 2 44% 3.6 0.6 67.0 67% 56.7 2.5 66 7 5.5 15% 7.5 55 5 7.6 29% 100% 14% 5 56.7 0.6 21.0 7 50% 67 1.9 5.5 19% 2.5 3 5 1 7.7 72 56.6 2 67 52% 14.1 65 50% 2.4 30 61% 21% 2.5 69 7 6.5 1 5 31% 77 100% 2.6 56.0 3 6 43% 100% 5% 7.7 3 23% 5 70 62 55.4 0.6 50% 4 5 50% 2 2.5 50% 71 12% 6 87 75 100% 2.5 5 49% 84 1 7.5 65 9 5 55.2 5 100% 8.4 50% 62% 55.1 86 6 2.5 73 5 100% 42 6 50% 74 9 81 4.2 2.5 5 100% 53.7 68 50% 8 2.5 5 6.8 76 100% 50 50% 52.4 2.5 5.0 5 30 77 49.5 50% 3.0 2.5 78 48.3 50 5.0 79 47.6 80 Popul- aon SOROTI MOROTO BUNDIBUGYO YUMBE MOYO HOIMA MUBENDE BUKWO NAKAPIRIPIRIT KAMULI BULIISA NYADRI MASINDI ADJUMANI AMURIA 73 76 65 66 67 67 69 70 71 72 74 75 77 78 79 80 *Populaon figures based on the 2010 mid term populaon projecons from the UBOS which were derived census of figures based on the 2010 mid term *Populaon Note: Monthly HMIS reports used to derive all indicators HMIS reports used to Monthly Note: Ranking

276 Annual Health Sector Performance Report Ranking

Total Total Score expected compared to to compared smear posive smear posive TB cases nofied TB cases Proporon of new Proporon 12.5 10 10 100 2002 Govt and NGO % Deliveries in % Deliveries health facilies % Score Score Score 7.5 34 56%5 24% 7.0 25% 3.0 135% 3.16 68% 105 79% 7 7.5 42% 8 33% 5.2 73.54 9.0 4.13 23% 3 9.0 72.3 24%7 56% 72.2 2 26% 4 2.96 6 31% 5 3.3 30% 4.5 29% 3.95 82% 7.8 68.2 3 3.76 56% 67.9 8 40% 8 39% 6.6 6 23% 5.05 9.3 66.5 4 2.9 14% 4.4 65.5 23% 10 5 25% 3.9 65.4 1 11 2.94 65.3 3 17% 12 22% 6.2 14% 13 2.12 8.8 59.9 2 1.81 13% 58.5 21% 15 27% 7.1 1 5% 16 2.6 58.2 3 23% 0.6 2.5 18 12% 7.5 55.3 2 54.2 20 1 3.0 21 48.3 5.0 23 47.6 24 Coverage Pit Latrine Pit Latrine 38.0 56.0 62.6 75.0 70 58.0 34.6 88.9 78.0 60.0 81.0 65.0 60.0 49.0 21.0 14.1 %Score year Total Govt Total person per person 2.4 12.51.3 12.52.4 85.0 12.5 0.9 6 85.0 11.0 0.8 6 10.1 0.5 65% 6.60.6 46% 8.2 6.91.3 5.8 132% 68.6 12.5 0.9 78% 5 73.0 10 11.5 1.1 5 12.5 8 7.11.1 32% 12.5 1.3 79.6 82.9 18% 4.0 7.6 12.5 0.9 6 1 2.3 68% 78.4 11.5 1.1 46% 12.5 0.8 49% 2 7 10.10.8 6.2 5 10.0 0.4 9.3 51.0 51% 5.3 0.9 6.1 4 69.1 11.5 50.7 68.4 6 8.3 0.5 30% 83.0 7 4.5 6.81.0 3.7 6 66.9 12.5 0.6 27% 64.0 7.3 0.8 11% 9 5 10.6 30.6 1.4 7.6 0.6 57.0 27% 22% 9.2 7.7 4 2.7 65.0 3 31% 28% 14 4.2 3.6 3 58.5 14% 16 7.9 1 58.2 18 4.2 53.7 22 ulizaon per ulizaon and NGO OPD 9.7 11.4 12.5 11.1 12.5 11.8 15.3 11.3 9.5 7.1 12.5 8.5 10.1 10.3 10.9 12.0 10.5 9.3 8.1 11.3 12.2 7.8 7.0 6.9 5.5 schedule % children % children accordig to to accordig doses of DPT <1 received 3 <1 received 5 12.5 12.5 returns returns Outpaent Outpaent %District HMIS %District submied mely submied % Score % Score Score Units Total No. Total of Health HSDs No. of 13 191 521 18 58%1 3 13 100%2 5 10 83%2 4 17 100%1 78% 5 92% 22 92%218 5 23 100%2 379 191% 5 89% 100%1 5 84% 21 100%2 117% 5 4 94% 122 123% 35 100%3 5 90% 37 100%1 76% 5 52 42%1 2 57% 33 83%1 4 147% 15 67%2 3 17 92%1 68% 5 8 83%1 81% 4 11 92%1 82% 5 101 87% 83% 12 67%2 4 96% 3 9 100%2 84% 5 31 100%2 5 74% 23 65% 73% 90% 27 58% 4 3 98% 67% 3 92% 63% 5 56% 55% 44% League Table 2009/10 for new districts that started FY 2005/06 and above FY 2005/06 and above started that new districts 2009/10 for League Table LYANTONDEMITYANAABIM 77100 DOKOLOAMOLATAR 301800 OYAMMANAFWABUTALEJA 171000 55200 120400 AverageNaonal NAKASEKE 31783300 343000 353700 BUDUDA 206200 AMURUIBANDA 178600 ISINGIRO 167000 NAMUTUMBABUDAKA 220400 KALIRO 207200 242800 396700 KIRUHURABUKEDEAKOBOKO 169200 BUKWO 280200 202200 BULIISA 171000 NYADRI 209600 AMURIAKAABONG 67500 76900 388200 344200 345300 4 5 6 9 11 12 13 14 16 16 18 21 22 24 2 3 7 8 10 15 18 20 23 1 *Populaon figures based on the 2010 mid term populaon projecons from the UBOS which were derived census of figures based on the 2010 mid term *Populaon Note: Monthly HMIS reports used to derive all indicators HMIS reports used to Monthly Note: Ranking District Populaon

Annual Health Sector Performance Report 277 Rank- ing Total Total Score Service HIV/AIDS HIV/AIDS Availability* 5 10 100 FDS Gain Flexibility Flexibility 5 that are are that disbursed disbursed expended % PHC funds of PHC JMS)** NMS and Proporon Proporon on drugs(at on drugs(at funds spent funds spent 2002 for IPT for women women % Pregnant % Pregnant receiving 2nd receiving dose Fansidar dose Fansidar expected posive TB posive new smear compared to to compared Proporon of Proporon cases nofied 12.5 10 10 10 facilies in Govt and NGO health % Deliveries % Deliveries 7.5 Coverage Pit Latrine Pit Latrine Total Total per year Govt and NGO OPD ulizaon ulizaon per person per person schedule % children % children accordig to to accordig doses of DPT <1 received 3 <1 received 5 12.5 12.5 HMIS mely returns returns %District %District submied submied Outpaent Outpaent % Score % Score Score % Score % Score Score % Score % Score % Score Score% Score Total Total Units No. of Health League Table 2009/10 for Hard-To-Reach districts districts Hard-To-Reach 2009/10 for League Table HSDs No. of aon Popul- Naonal AverageNaonal 31783300 218 106 84% 4 76% 9.5 0.9 11.5 70 5 33% 4.1 56% 6 47% 5 78 8 100% 5 50% 2.5 78 7.8 67.9 12 ABIM3 GULU4 KANUNGU KITGUM56 55200 PADER 241800 3747007 1 AMURU 2 38 387100 18 KALANGALA9 83% 46 51 2 100% KISORO 92%10 4 35 481800 5 KOTIDO 191% 511 92% 220400 MOROTO 83% 12.5 58100 2 89%12 2.4 10.4 5 2 BUNDIBUGYO 11.1 1.1 2 55 12.513 1.7 38.0 71% 100% 247300 BUKWO 12.5 35 12.5 90.114 11 37.1 8.9 42% 3 204600 100% NAKAPIRIPIRIT 5 3 297800 1.2 312500 715 56% 3 74% ADJUMANI 2 1 12.5 5 31 34% 38.0 3 7.0 3 50% 175% 9.2 68% 92% KAABONG 4.2 135% 18 244900 1.0 6.2 12.5 3 100% 19 28 8.5 67500 0.9 5 50% 159% 12.5 50% 10 83% 39% 3 1.3 29.0 5 11.6 56% 331600 74% 1 56.0 4.8 12.5 10 104% 3 5 34.6 4 15 2 37% 9.3 51% 12.5 1 56% 345300 6 12 83% 4 74% 64% 32% 1.6 100% 3 39 0.9 12% 4 4.0 9.3 2 12.5 32 8.0 5 4 26% 6 11.3 73.8 69 5 89 1.5 0.8 0.7 33% 4 6.7 78% 70% 3.3 71% 100% 27 98% 6 49% 9.4 7 8.7 1 92% 2 82% 9 8.9 100% 68.0 12.2 8 5 5.7 100% 45% 7 50% 0.7 63 1.0 16% 33% 5 53% 5.6 5 5 5 2.5 8 0 5 50% 12.5 2.0 31% 8.6 75 50% 4.1 60.0 50% 44% 27% 6 35% 12% 2.0 2.5 5 100% 0.7 2.5 31% 70 65 7.5 3.4 3 5 64 5.5 1.5 73.5 5 0 78 9.1 5 3 0.6 67.0 65 17% 7.0 50% 31% 3 93% 6.4 14% 1 7 72.3 100% 71.9 7% 2.5 70% 2.1 7.7 8 5 14.1 73 100% 2 7 3 0.8 3 9 1 100% 5 13% 19% 27% 7 87 50% 52% 1 7.3 5 37% 58 68.1 2.4 50% 5 2.5 50% 1 85 3 5% 2.5 9 5 4 31% 50% 100% 81 4 2.5 6 50 64 0.6 100% 93 8.5 67% 67.7 5 5.0 3 5 12% 8 50% 5 6 9.3 63.1 100% 27 100% 50% 5 50% 7 65.5 2.5 72 7 2.5 38 1 5 6 5 53 3 50% 5 50% 62% 100% 65 3.8 7 2.5 2.5 100% 62.4 5.3 59 56 60.0 5 6 50% 8 6 81 5 100% 5.9 9 50% 5.6 2.5 56.7 57.2 25 2.5 11 5 8 10 75 100% 50% 2.5 2.5 55.3 7.5 5 50 12 55.2 50% 13 2.5 5.0 50 49.5 14 5.0 47.6 15 Ranking District *Populaon figures based on the 2010 mid term populaon projecons from the UBOS which were derived from the populaon census of populaon projecons from the UBOS which were derived census figures based on the 2010 mid term *Populaon Note: Monthly HMIS reports used to derive all indicators HMIS reports used to Monthly Note: 278 Annual Health Sector Performance Report