THE REPUBLIC OF UGANDA
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 Execu ve Summary ...... xvii Chapter One: Introduc on ...... 1 1.1 Background ...... 1 1.2 The framework for achieving sector goals & objec ves ...... 1 1.3 The Annual Health Sector Performance Report FY 2009/10 ...... 1 1.4 The dra ing process ...... 2 1.5 Sources of Informa on ...... 2 1.6 Outline of the Report ...... 3
Chapter Two: Overview of Health Sector Performance (Summa ve Evalua on 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 Na onal Minimum Health Care Package ...... 21 3.1 Health promo on, disease preven on and community health ini a ves ...... 21 3.2 Maternal and child health ...... 50 3.3 Preven on and control of communicable diseases ...... 69 3.4 Non-communicable diseases/condi ons 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 Essen al Medicines and Supplies ...... 172 4.5 Diagnos c and Blood transfusion services ...... 187 4.6 Informa on 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: Implementa on 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 Func onality 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 BUTABIKA 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 RESOURCE MANAGEMENT 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 BUTABIKA HOSPITAL 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: AMURU DISTRICT, 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 National Drug Authority 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-laws. 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 Butaleja 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 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. 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