St Kizito Hospital Matany Moroto Diocese-Karamoja P.O. Box 46, Moroto - UGANDA-

Annual Analytical Report Financial Year 2014/15

St Kizito Hospital Matany th 15 December 2015

Endorsement of Report

This annual analytical report for St. Kizito Hospital Matany covering the period from 1st July 2014 to 301h June 2015 has been prepared by the management of St. Kizito Hospital Matany. I endorse that it represents management's views on the position of the Hospital in the period under report.

Br. Giinther NAHRIC

This is to acknowledge that I have received this annual analytical report for St. Kizito Hospital Matany covering the period from 1st July 2014 to 30th June 2015 . I have read it and endorse its authenticity and representativeness of the position of the Hospital in the year under report

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2 of 100 TABLE OF CONTENTS

LIST OF ABBREVIATIONS AND ACRONYMS 4 ACKNOWLEDGMENT / APPRECIATIONS 5 IMPORTANT INDICATORS AND DEFINITIONS 8 EXECUTIVE SUMMARY 9 CHAPTER ONE, INTRODUCTION 11 THE HOSPITAL AND ITS ENVIRONMENT 11 THE COMMUNITY AND HEALTH STATUS 12 CHAPTER TWO, PRIMARY HEATLH CARE DEPARTMENT 16 A) CATCHMENT AREA 16 B) PERSONNEL STAFFING 17 C) ACTIVITIES / ACHIEVEMENTS 18 CHAPTER THREE, GOVERNANCE AND MANAGEMENT 24 ORGANOGRAM 24 THE BOARD OF GOVERNORS 25 MANAGEMENT 28 CHAPTER FOUR, HOSPITAL HUMAN RESOURCES 31 CHAPTER FIVE, HOSPITAL FINANCES 36 INCOME 36 EXPENDITURE 38 CHAPTER SIX, HOSPITAL SERVICES 45 A: OUT PATIENT DEPARTMENT 45 SPECIAL OPD CLINICS 48 HIV AND AIDS SERVICES 49 B: INPATIENT WARDS 56 ORGANISATION AND MANAGEMENT 56 MATERNITY WARD 59 C: OPERATING THEATRE 63 D: DIAGNOSTIC SERVICES 64 LABORATORY 64 IMAGING SERVICES 66 PHARMACY 68 CHAPTER SEVEN, HOSPITAL SUPPORT SERVICES 69 CHAPTER EIGHT, QUALITY AND PATIENT SAFETY 72 CHAPTER NINE, HEALTH TRAINING INSTITUTION 80 CHAPTER TEN, SUMMARY, CONCLUSION, RECOMMENDATION 89 FAITHFULNESS TO THE MISSION 89 ANNEX 1 - NAPAK DISTRICT WITH HEALTH UNITS (Map) 96 ANNEX 2 - MEMEBERS OF BoG, HMT and NMTS STAT. COMMITTEE 97 ANNEX 3 - MATANY HOSPITAL ANNUAL FINANCIAL REPORT 98

Page 3 of 100 LIST OF ABBREVIATIONS AND ACRONYMS

AIDS Acquired Immunodeficiency Syndrome ALOS Average Length of Stay ANC Antenatal Care ARV Anti Retroviral ART Anti Retro Viral Therapy BoG Board of Governor BOR Bed Occupancy rate CBOs Community Based Organisations CVD Cardio Vascular Disorder DHC District Health Committee DHO District Health Officer DHMT District Health Management Team DHT District Health Team DOTs Directly Observed Therapy EMOC Emergency Obstetric care EMTCT Elimination of Mother To Child Transmission ENT Ear Nose and Throat EPI Expanded Programme on Immunization FHW Field Health Worker FY Financial Year (July of previous year to June of the current year) GoU Government of Uganda GSM General Staff Meeting HBC Home Based Care HC Health Centre HCT HIV Counselling and Testing HIV Human Immunodeficiency Virus HMIS Health Management Information System HR Human Resources HSD Health Sub-District ICT Information and Communication Technology IGAs Income Generating Activities IMCI Integrated Management of Childhood Illnesses MCH/FP Maternal and Child Health Care/ Family Planning MDG Millennium Development Goal MH Matany Hospital MoU Memorandum of understanding MS Medical Superintendent NGO Non-Governmental Organisation NMTS Nursing and Midwifery Training School NSSF National Social Security Fund OPD Out Patient Department PEAP Poverty Eradication Action Plan PHC Primary Health Care PLWA People Living with HIV and AIDS SUO Standard Unit of Output SWOT Strengthen Weakness Opportunities and Threats TASO The AIDS Support Organization TB Tuberculosis UCMB Uganda Catholic Medical Bureau UDHS Uganda Demographic Health Survey UHSSP Uganda Health Sector Support Programme UNICEF United Nation Children Education Fund UNMHCP Uganda National Minimum Health Care Package VCT Voluntary Counselling and Testing VHT Village Health Team

Page 4 of 100 ACKNOWLEDGMENT / APPRECIATIONS

The Hospital Management Team on behalf of the Board of Governors of St. Kizito Hospital Matany wishes first of all to thank all the Hospital employees for the demanding and often unrewarding work without which all what was achieved and described in this report would have not been possible.

ADMINISTRATION Lowanyang Lucy Reg. Nurse /Midwife Br. Günther Nährich Administrator / CEO Ekobu Joseph Registered Nurse Lokongo Santine Accounts Assistant Amulen Rebecca Registered Nurse Ogwango Samuelle Accountant Nabukwasi Sofia Registered Nurse Zoe Martin Internal Cashier Among Mary Reg. Nurse Ariam Juliana Assist Cashier Br. José Eduardo DN, I/C Pharmacy Ngorok Magdalen Cashier Ameo Jesca Diploma Nurse Otim David A/C Assistant / Cashier Menya Joseph Diploma Nurse Naigaga Lydia Secretary / NMTS Achilla Lilly Diploma Nurse Nakiru Magdalen Secretary Tunyany Jacinta Enrolled Nurse Sr. Palma Bako Pastoral Care Giver Chemmelly Nelly Enrolled Nurse Lokol Thomas ICT Officer Aluko Grace Enrolled Nurse Engelbrecht Einhard Tec. Advisor, ICT Officer Abucho Babrah Enrolled Nurse Akiteng Naome Office Attendant Agan Adam Enrolled Nurse Amei Damiano HMIS/Data Mgt. Assist Tino Peace Enrolled Nurse MEDICAL OFFICERS Ogwang Alex Enrolled Nurse Dr. John Bosco Nsubuga Gynaecologist Loukae Gabriel Enrolled Nurse Dr. Borghi Emanuela Senior Medical Officer Isone Mary Enrolled Nurse Sr. Sebastiano Cipriano Surgeon Okudet Paula Enrolled Nurse Dr. Deusdedit Kateregga Medical Officer Achia Esther Enrolled Nurse Dr. Paul Kasalirwe Medical Officer Apio Rebecca Enrolled Nurse Dr. John Ssembuusi Medical Officer Okot Kennedy Enrolled Nurse Dr. Patrick Sali Medical Officer Asege Sarah Certificate Nurse PARAMEDICALS Irusi Daniel Cert.Compr.Nurse Oyaya Samuel Ochieng Clinical Officer Lochoro Hellen J. Enrolled Midwife Opio Moses Clinical Officer Akech Martha Enrolled Midwife Otim Tonny Clinical Officer Aguti Victoria Enrolled Midwife Maraka Aloysius Clinical Officer Asekenye Peace Enrolled Midwife Amei Simon Peter Laboratory Technician Amongin Celine Enrolled Midwife Lopuwa Albino Laboratory Assistant Napeyok Mary Enrolled Midwife Lokawa Paul Laboratory Assistant Adongo Sarah Enrolled Midwife Kodet Christine Laboratory Assistant Atero Lucy Enrolled Midwife Egwapu Anthony Laboratory Assistant Achia Agatha Enrolled Midwife Locham Augustine Ophthalm. Assistant Loilik Benardette Enrolled Midwife Awas Patrick Othopedic Officer Alungo Salome Enrolled Midwife Apono Mark Physiotherapist Akello Hellen Enrolled Midwife Keem Jackson Anaesthetic Officer Aliat Esther Enrolled Midwife Ayepa Alfonse Anaesthetic Attendant Lotukei Anna Grace Enrolled Midwife NURSING STAFF Loteng Veronica Enrolled Midwife Sr Rosario Marinho Principal Nursing Officer Logwee James ECN Atekit Helen Deputy PNO Lomilo Paul Dental Attendant Sr Nataline Mowo Principal Tutor Adiaka Rosemary Nursing Assistant Sr Gladys Licoru A. Deputy Principal Tutor Agaro Sylvia Nursing Assistant Sr. Anita Conception Tutor Akinyi Jennifer Nursing Assistant

Page 5 of 100 Akol Lucy Nursing Assistant Napeyok Lucy Cleaner Akumu Lucy Senior Nursing Aid Neno Betty Cleaner Awas Mary Goretti Nursing Assistant Ngole Jacinta Cook Chila Agnes Nursing Assistant Pulkol John Laundry Attendant Jaka Valentine Nursing Assistant Santina Yeno Cleaner Karane Josephine Nursing Assistant Apuun Lucy Cook Keem John Senior Nursing Aid Abura Alice Watchwoman Lochoro Hellen Nursing Assistant Angolere Mario Watchman Lotukei Anjello Dark Room Att. Lochoro Daniel Watchman Nachuwa Mary Senior Nursing Aid Losur Stephen Watchman Namoe Rachel Nursing Assistant Koryang Isaac Watchman Otyang Charles Nangiro Dark Room Att. Omuke Stephen Watchman Sagal Florence Nursing Assistant Lomeri John Compound Yeno Maria Senior Nursing Aid Ichumar Peter Mortury Attendant Angella Molly Nurse/Aid, SW Teko Peter Compound Anero Betty Nurse/Aid, TB Ward Akol Alice Cleaner Achuka Angelina Nurse/Aid TB Ward Lomongin Clement. Cleaner Kodet Jenifer Nurse/Aid, OPD Agilu Evalyn Cleaner Namoe Margaret Nurse/Aid, TB Ward Akung Betty Cleaner Amodoi Josephine Nurse/Aid, CHW Longoli Maria Cleaner Sagal Anna Theatre Attendant Amuron Hellen Cook Aleper Agnes Theatre Attendant Angella Magdalen Cook / Caterer Lokwi Florence Theatre Attendant Lochoro Rose Cook Dengel Margret Nurse/Aid, Mat Lokoel Agnes Cook Ikiror Rose Nurse/Aid, TBW Nake Cecilia Cook SUPPORT STAFF Aleper Dina Cook Sr. Ruaro Giovanna Domestic Officer Nauga Cecilia Cook Atim Magdalen Assist Store Keeper, GS Longok Valentine Cook Aisu Anna Assist Store Keeper, GS Ojao Angelline Cook Namoe Rose Assist Store Keeper, GS Lodungokol Marco Compound Alumo Luigina Assist Store Keeper, GS Achia Anna Tailor Adupa Janet Cleaner Lolem Lucy Tailor Aboka Agnes Cleaner Nakong Lucy Assist Tailor Lomongin Hellen Cook Loma Alice Tailor Achia Giovanna Cook Aleper Emanuel Incinerator Attendant Chero Anna Cleaner PUBLIC HEALTH DEPARTMENT Ngorok Scola Cleaner Longole Mary Diploma Midwife Kiyonga Agnes Cleaner Lokwang Anthony Health Inspector Alinga Amalia Cook Imalany Ambrose H’Information Assist. Koryang Angellina Cleaner TECHNICAL DEPARTMENT Lobur Joseph Mortury Attendant Gruska Peter Incharge, TD Akello Beatrice Cook Achilla Matthias Carpenter Logiel Agnes Cook Lokwii Joseph Carpenter Lochan Matteo Compound Sagal Michael Carpenter Lokol Enok Compound Eliau Julius Electrician / Driver Lokiru Raphael Laundry Attendant Maruk Augustine A. Electrician Lokoryo Dorothy Cleaner Otyang Paul Electr./Metal Worker Lokut Marko Compound Logiel Thomas Mason Longole Theresia Cleaner Lokiru Mark Mason Longoli Simon Compound Mubakye Patrick W Mason Lopwanya Veronica Cleaner Lajul Robert Mason Lotukei Agnes A. Cleaner Onyait Christopher Mason

Page 6 of 100 Edieru Peter Mechanic / Driver Amei Domenic Casual Worker Iriama Philip Mechanic / Driver Loli John Casual Worker Koryang Paul Mechanic / Driver Lomongo Pau Casual Worker Loram Paul Mechanic / Driver Loteng Philip Casual Worker Lokiyo James Metal worker Lotukei Michael Casual Worker Lokut Matthew Metal worker / Driver Logiel Pasquale Store Keeper Aleper Gabriel Plumber / Mason Lochen Sisto Support Staff Okidi Martin Plumber Iiko Michael Support Staff Lokiru Peter Porter Lowakori Marko Support Staff Loburo Peter Porter Ngorok J.B Support Staff Ngorok Eliya Porter Moru Paul Support Staff Okure Simon Porter

We would also like to remember all those who support us from near and far (our benefactors) with spiritual and material resources. In particular we thank the two Italian Matany support groups: Gruppo di Appoggio dell’Ospedale di Matany-ONLUS, Milano and Associazione Toyai – Onlus, Pavia. We further thank CUAMM; The Italian Cooperation; Insieme Si Puo; ‘IDEA Onlus’ Torino; PMK Aachen, Dreikönigsaktion Wien, MIVA/BBM Austria, Horizont 3000, STACC Scotland, USAID/Sustain, Dr. Keith with Eye Team; the Comboni Missionaries and Comboni Sisters, Dr. Friedrich Ullrich and SES Bonn, and so many not mentioned but surely valuable supporters, who have helped Matany a lot in different ways.

We thank those involved in making policy decisions in favour of the smooth running of our Institution. A special thanks to the Uganda Catholic Medical Bureau, for all its support and encouragement over the past years.

We exercise our services under the mandate of the Ugandan Government and in particular the Ministry of Health for the Hospital, Ministry of Education for the training school, professional bodies, Uganda Catholic Medical Bureau, Moroto Diocesan Health Office and other statutory bodies.

And once again a special vote of gratitude to the numerous patients who have availed us with an opportunity to follow in the footsteps of Christ, to bring healing to the sick and suffering. We thank all our staff, our students, our expatriates and all the Ugandans who continue to make St. Kizito Hospital a model for others to follow.

Page 7 of 100 IMPORTANT INDICATORS AND DEFINITIONS

1. Inpatient Day / Nursing Day / Bed days = days spent by patients admitted to the health facility wards. 2. Average Length of stay (ALOS) = Sum of days spent by all patients/number of patients = Average length of days each in-patient during each admission. The actual individual days vary. 3. Bed Occupancy Rate expressed as % = used bed days/available bed days = Sum of days spent by all patients/365 x No. of beds =ALOS x No. of patients/365 x No. of Beds 4. Throughput =Average number of patients utilising one bed in a year =Number of patients/no. of beds 5. Turn over interval =Number of days between patients = (365 x no. of beds)-Occupied bed days/no. of patients 6. FSB (Fresh Still Birth): This is a baby born with the skin not pealing / not mercerated. The foetal death is thought to have occurred within the 24 hrs before delivery. However it is important for us to know the trend of deaths of foetuses actually occurring in mothers who have arrived already in the hospital (Foetal heart sound heard on arrival). For this purpose we shall monitor FSB in total as well as FSB of fetuses who died in hospital. They have been separated in the table. The hospital should try to provide space to collect this information from the maternity ward / delivery room. 7. Post C/S Infection Rate: = (No. mothers with C/S wounds infected / Total No. of mother who had C/S operations in the hospital) x 100. = The rate if caesarean section wounds getting infected. It is an indicator of the quality of post-op wound care as well as pre-op preparations. 8. Recovery Rate: = % of patients admitted who are discharged while classified as “Recovered” on the discharge form or register. = (No. of patients discharged as “Recovered” / Total patients who passed through the hospital) x 100 9. Maternal Mortality Rate (for the hospital): = Rate of mothers admitted for delivery and die due to causes related to the delivery = (Total deaths of mothers related to delivery / Total number of live deliveries) x 100 10. SUO = Standard Unit of Output. This is where all outputs are expressed into a given equivalent so that there is a standard for measurement of the hospital output. It combines Outpatients, Inpatients, Immunisations, deliveries, etc which have different weights in terms of cost to produce each of the individual categories. They are then expressed into one equivalent. As the formula is improved in future it may be possible to include Out-patients equivalence of other activities that may not clearly fall in any of the currently included output categories. 11. SUOop = SUO calculated with inpatients, immunizations, deliveries, antenatal attendance, and outpatients all expressed into their outpatient equivalents. In other words, what would be the equivalent in terms of managing one outpatient when you manage e.g. one inpatient from admission to discharge? SUO-OP = (15 x no. IP) + (no. OP) + (5 x no. deliveries) + (0,2 x no. of immunizations given) + ( 0,5 x ANC visits) 12. TB case notification rate = total cases of TB notified compared with the expected number for the population in one year =Total cases of TB Notified / Total population x 0.003. 13. OPD Utilisation = Total OPD New attendance in the year / Total population of the area.

Page 8 of 100 EXECUTIVE SUMMARY

Description of the Hospital and its environment

St. Kizito Hospital Matany is located within Napak District in North-Eastern Uganda, bordering Moroto District the East side, Katakwi and Amuria, districts to the West side, Nakapiripirit to the South side; Kotido and Abim Districts to the north side.

Due to the periodic drought the entire Karamoja Region is always at risk of famine. The major challenges for health care delivery are: very poor health seeking behaviour, the poor road network, hard to reach settlements and the irregular telephone network coverage Functionally the Hospital is a de facto regional referral health facility for the entire Karamoja Region including the neighbouring Districts of Teso (Amuria, Katakwi, Soroti), and deals with an average annual admissions of about 10,000 inpatients and 30,000 outpatient consultations.

The Hospital holds a significant public health influence in the catchment’s population and is linked to thirteen peripheral Health Units in Bokora Health Sub-District; serves as an administrative headquarters where planning, implementation, monitoring and evaluation of all PHC activities are done. The socio-economic impact of the Hospital to the immediate surrounding community is quite evident by a fast growing and busy Matany Trading Centre which is a town board.

The Hospital entirely depends on the inhabitants of this Trading Centre for its support staff and a few skilled labourers, thus not only providing employment opportunity to the community but also creates a symbiotic co-existence between the Hospital and its neighbourhood as well as a sense of ownership of the Hospital facility and its services by the community.

The functionality of Matany Hospital is in accordance with the National Hospital policy of the Republic of Uganda with technical guidance from the Uganda Catholic Medical Bureau (UCMB) as well as Napak District Health Office, local authorities, and other partners in the Health sector (including the service beneficiaries).

The Hospital capacity constitutes 250 beds distributed through Obstetrics/Gynaecology, Internal Medicine, Tuberculosis, Paediatrics and Surgery Departments. Other services provided by the Hospital include: Diagnostic Laboratory, diagnostic imaging, General surgery, Orthopaedic and Physiotherapy, Counselling, HIV/AIDS Clinic, Antenatal Clinic and Prevention of Mother to Child Transmission, human resource development to meet the Hospital needs. Annexed to the Hospital are a Health Training Institution, a Human Resource Development Centre and an Airstrip.

The Nursing and Midwifery Training School has an annual intake of 15 UCN students and 20 UCM students with slight variations.

A well established Technical Department with construction department for general repairs and maintenance of the Hospital’s equipments, plants and infrastructures is another important element of the Hospital, generating also income through service to the public.

The Hospital for its effectiveness in administration and daily operation developed key documents to guide the management in the day to day running of the institution. Human resource and finance manuals were developed and are currently in use. Other aspects in the health professional development involves nursing students, midwives, clinical officers, internship training for paramedical students, pharmacist, medical technologists and others, are conducted within the hospital. The hospital is contributing to the health manpower development in Uganda.

Page 9 of 100 Achievements / improvements that have been made in FY 2014/15

Key planned activities Status of achievement Develop information and communication This is still a task which has to be guidelines accomplished Mother and Baby Care packets have been Provision of Mother and baby care package received by UNICEF during FY 2014/15 Formulation and use of Hospital clinical protocols Some protocols especially for maternity are and guidelines in place Start the process of accreditation of the Baseline line assessment, first training and Laboratory into SLAMTA first assessment done Intensify quality assurance activities Departmental quality assessments done Hold the Diocesan Health assembly Held in February 2015 Rehabilitation of patients/attendants kitchen Not yet achieved due to lack of funds Maternal deaths and Fresh still births Improve on Mother and Child Health, mainly reduced (chapter six). Major Challenge: late maternal deaths and fresh still births. referrals Conduct maternal and perinatal death audits Committee in place and audits done Start MDR diagnosis with the GeneXpert Started in October 2014 As funding was not forthcoming it is hoped Modernisation of X-Ray equipment, phase 2 to have a new X-Ray machine within FY 2015/16 Was completed by the end of 2014 and old Extension of Administration Block Admin Block renovated Improvement on medical forms like consent, Already in place anaesthetic forms and documentation Increase outreaches to hard to reach areas Ongoing Renovation of some buildings in NMTS Some finished but work still in progress Digitalising the NMTS Library Completed Standardising the application forms for the NMTS Completed Employ a Human Resource Officer Will be done during FY 2015/16 This activity started in October 2014 and will Extension of Laboratory be completed in October 2015 The transformer with stabiliser could not be Construction of a transformer building in view of installed due to technical fault. The connecting to the main electricity grid connection to the national electricity grid is foreseen in October 2015. top layers replaced, piping reconditioned, Resurfacing the waste water treatment plant new Napier grass planted

Challenges encountered are: limited financial resources and manpower which did not allow to achieve all the planned activities. The Hospital Administration is very slim and functions like for Personnel Officer, Procurement Officer, Communications Officer, etc. have to be met by other cadres as to keep the employment costs as low as possible.

Important recommendations/plans for the coming year 2015/16

 Complete the accreditation process the laboratory into SLAMTA  Send some staff for training like Hospital management, records management, surgery  Intensify activities of the quality assurance committee  Continue with MPDR audits  Start the Electronic Patients’ Records Management System  Major renovation of NMTS if funds are available  Modernisation of X-Ray equipment, phase 2 – new equipment is hoped to arrive in 2015/16  Rehabilitation of patients/attendants kitchen (once funds are available)  Complete Extension of Laboratory in October 2015  Complete “Oxygen generating room”, and start oxygen production with piping system to the various wards.

Page 10 of 100 CHAPTER ONE

INTRODUCTION

The Hospital and its environment

St Kizito Hospital Matany is a Private Not-For-Profit (PNFP) institution with social and spiritual objectives, belonging to the Catholic Diocese of Moroto (North-Eastern Uganda). It was built at the beginning of the 70’s with the help of MISEREOR (a German Church Organisation) on request of the Comboni Missionaries in Uganda, and has since then provided a very essential comprehensive package of health services to the population of the Karamoja region, an extremely remote and underdeveloped region of the Country characterised by very poor health indicators. By its functional profile, Matany is a General Hospital with a bed capacity of 250 distributed through Obstetrics/Gynaecology, Internal Medicine, Tuberculosis, Paediatrics and general Surgery Departments. ` Other services provided by the Hospital include: Diagnostic Laboratory, diagnostic imaging, General surgery, Orthopaedic and Physiotherapy, Counselling, HIV/AIDS Clinic, Antenatal Clinic, Prevention of Mother to Child Transmission (PMTCT) and human resource development to meet the Hospital needs. Annexed to the Hospital is a Nursing and Midwifery Training Institution, a Human Resource Development Centre and an Air Strip. Although Ministry of Health has upgraded Moroto Hospital into a regional referral hospital, Matany Hospital still shoulders the burden of heavy workload due to patients’ preference to seek its services. Also, due to its relatively well developed and maintained infrastructure and above average quality and affordable services provided by committed staff, Matany Hospital still serves as a referral health facility for the entire Karamoja Region including the neighbouring Districts of Teso (Amuria, Katakwi, Soroti). The total number of admissions for the year under review was 9,556 In-patients with an increase of 2.9% from the previous year, and the total new and re-attendant outpatient consultations during the FY were 32,011 showing a decrease of 3.2% as compared to the previous year. In the special Clinics of the Hospital 46,164 patients were seen and thus the total of all out patient contacts was 78,175 compared to 57,866 which constitutes an increase of 36.9%. Deliveries in the Hospital have increased by 103 (9.7%), while antenatal attendance has slightly decreased by 25 (0.7%), with more staff allocated to the clinic and increased health education. More men accompany nowadays their wives for this service. Total immunisations has greatly increased by 5,783 (16.1%) which is the highest indicator compared to the last five years. The Public Health demands on the Hospital are becoming more challenging and costly. Although the government gives subsidy to the Hospital in form of delegated PHC funding, less attention has been taken on the sky-rocketing market prices of medicines and supplies! The number of peripheral health units for support supervision has increased to 14 and the District Local Government has recommended the establishment of more lower level health units. As much as Matany Hospital would wish to play a significant public health role in the catchment’s population, the cost implications of this task need to be taken into consideration. The PHC Department serves as an administrative headquarters for Bokora Health Sub- District (HSD) where planning, implementation, monitoring and evaluation of all PHC activities are done. The socio-economic impact of the Hospital to the immediate surrounding community is quite evident by a fast growing Matany town. This lively economic focus in our Health Sub District is a daily convergence point of the community with great influence on the economic and social aspects in Bokora. It caters for all needs of the residents, patients, attendants and visitors.

Page 11 of 100 Due to financial constraints and with the introduction of the VHTs the Hospital Administration had to depart from its Field Health Workers, after informing the District Health Office, by 31st December 2014. The impact of their missing services, especially immunisations, will have to be evaluated in due course. The Hospital entirely depends on the inhabitants of this Trading Centre for its support staff and a good number of skilled labourers, thus not only providing employment opportunity to the community but also creates a symbiotic co-existence between the Hospital and its neighbourhood as well as a sense of ownership of the Hospital facility and its services by the community. The role played by the Hospital in the socio-economic transformation of the surrounding residents cannot be under-estimated. This contribution is done through salary payments to the staff, vocational training to the youth and scholarship/bursary support to students. The functionality of Matany Hospital is in accordance with the National Health policy of the Republic of Uganda with technical guidance from the Uganda Catholic Medical Bureau (UCMB) as well as Napak District Health Office, Board of Governors, and other partners in the Health Sector (including the service beneficiaries). The current Board of Governors underwent an induction exercise in 2011 by UCMB on the statutory role of overseeing functionality of the Hospital.

The geographical location of Napak District with Health Units is found in the Annex 1

The community and health status

Napak District is inhabited by the Bokora sub ethnic group of the Karimojong tribe. The other groups i.e; Matheniko, Jie, Dodoth, Pokot, Pian, Ik and Kadam comprise the inhabitants of the rest of the other six Districts of Karamoja Region. The socio-economic organisation of the community has significant influence on the health status and indicators. The people live in homestead clusters called "ere" (Karimojong- homestead), comprising of relatives, friends and kinsmen. For security reasons each ere has a thorn fence with residential family clusters living all around. A central place right in the centre of every homestead is the kraal. This is the most protected part of the homestead where cows, goats, sheep and donkeys live. A village may have up to 400 inhabitants.

People live in small and short round huts with mud walls and grass thatched roofs. The huts are used mainly for sleeping and during the night up to 10 people can fill it. The average sleeping arrangement for each family is in three groups (i.e. adults/parents, adolescents and children) sharing a small hut. Such practices coupled with poor ventilation, lack of sanitation facilities, limited access to clean and safe water, living in close proximity to livestock and general poor health seeking behaviour of the community makes it easier for the spread of communicable and hygiene related diseases like scabies, diarrhoeas, eye infections, TB, other RTIs, and zoonotic diseases etc.

The Karimojong socio-economic organization is mainly agro-pastoralists. There exist some agricultural potentialities, especially around Iriri, Apeitolim, Nakapiripirit and Abim where the land is fertile and the rainfall pattern fairly reliable. The main crop cultivated is sorghum and few other cereals. The Karimojong population lives in both static and nomadic communities, the elderly stay in the villages while the youth roam the plains in search of pasture and water for the livestock, both communities reunite in the rainy season lasting March to September, the rain pattern in the region is significantly changing and becoming more unpredictable, with prolonged draught spells subjecting the community to chronic famine and high levels of malnutrition among the under 5. This nomadic lifestyle makes health services and other social services delivery quite difficult especially for the mobile proportion of the population.

Page 12 of 100 Although polygamous lifestyle is not a cultural norm among the Karimojong tribe, this practice is quite common and has its importance rooted onto the prestige associated with large family size. Rural-urban migration has overwhelmingly contributed to the rising HIV/AIDS prevalence in the region though relatively low compared to other regions in the country. Participation of men in socio economic welfare of their families still leaves a lot to be desired. Women play a very significant role in family up-keep and welfare; moreover men control family resources and are the decision makers! This makes women and children more vulnerable to domestic violence and neglect.

Small arms proliferation with associated insecurity in the region over the last three decades has had a negative impact on the peace and development programmes in Karamoja. However; the disarmament programme initiated by Government some years back has restored peace and rule of law in the region. It is now possible to travel for medical outreaches to distant places without carrying military escorts.

Napak District has one Health Sub District: Bokora HSD, which is designated under the Hospital support supervision. Matany Hospital is heading Bokora Heath Sub District which has seven Sub-Counties and a total of 42 parishes with 250 villages. The recent Census revealed a much lower population than projected in previous years.

Table 1.1: Demographic data for the catchment area compared to HSD and District

Catchment Area Population Group Formulae Matany Sub- HSD District County Total population (projected A 22,810 145,219 145,219 for the year under report) Total expected deliveries B (5/100) * A 1,141 7,261 7,261 (5% of population) Total Assisted deliveries in C 1,164 4,873 4,873 Health Facilities Tot. Assisted deliveries as D (C/B)* 100 102% 67.1% 67.1% % of expected deliveries E Children <1 year (4.3%) (4.3/100) * A 981 6,244 6,244 F Children < 5 years (20.2%) (20.2/100) * A 4,608 29,334 29,334 Women in child - bearing G (20.2/100) * A 4,608 29,334 29,334 age (20.2%) H Children < 15 years (46%) (46/100) * A 10,493 66,801 66,801 I Orphans (10%) (10/100) * A 2,281 14,522 14,522 Suspected tuberculosis in J (A) * 0.003 68 436 436 the service area

Table 1.2 TOP TEN CAUSES OF OPD ATTENDANCES IN BOKORA HSD FY 2012/13 FY 2013/14 FY 2014/15 Malaria 94,065 Malaria 85,132 Malaria 59,397 RTI 45,567 RTI 43,647 RTI 40,477 Diarrhoeal D'ses 12,983 Diarrheal D'ses 11,360 GID Diseases 5,528 Eye conditions 9,379 Eye conditions 7,965 Diarrheal D'ses 5,283 Intest. Worms 7,148 GID Diseases 6,141 Skin Diseases 4,808 GID Diseases 6,363 Skin Diseases 6,107 Pneumonia 2,850 Skin Diseases 5,307 Intest. Worms 4,759 Intest. Worms 2,711 ENT 4,267 Pneumonia 4,690 ENT 2,694 Pneumonia 4,205 UTI 4,204 Injuries 2,144 Injuries 3,842 ENT 3,263 UTI 1,128

Page 13 of 100 Graph 1.1: Top 10 diseases in Bokora Health Sub District during FY 2014/15

TOP TEN CAUSES FOR OPD ATTENDANCES IN BOKORA HSD FY 2014/15 Intest. ENT Injuries Pneumonia Worm s 2% 2% UTI 2% 2% Skin 1% Diseases Malaria 4% 47%

Diar r he al D's e s GID 4% Diseases 4% RTI 32%

Malaria is still the leading cause of OPD attendance over the years. However numbers of out patients has generally decreased over this FY which we attribute to increased work done by the VHTs to treat common illnesses like diarrhoea, fever and cough. As there are more small private clinics and drug shops opened it is presumed that patients also seek services from there. The migration of the communities to the fertile areas resulting in limited accessibility to the Hospital.

Public health surveillance is the mechanism that Matany Hospital PHC department uses to monitor the health status of the catchment communities. Its purpose is to provide a factual basis from which the Hospital can appropriately set priorities, plan programs, and take actions to promote and protect the public’s health.

Given the public health role played by Matany Hospital in management of health services at the HSD, disease surveillance is a routine exercise both at the community and health facility level. The Ministry of Health Case definitions for each of the epidemic prone diseases are strictly observed for disease detection. Also the procedures for notification of such diseases to the District and Ministry of Health are followed in case of any notifiable events. Weekly surveillance reports are submitted to the District Health Office, MoH and WHO field office in Moroto, using the HMIS form 033b. Common diseases epidemic events reported in the weekly surveillance reports include; malaria and dysentery. Occasionally there are challenges in timeliness and completeness of the surveillance reports from lower level health facilities and efforts are being made to ensure that this problem is overcome by frequent submission reminder to the Health Unit in charges and weekly movement of the surveillance focal person to collect these reports.

Page 14 of 100 Graph 1.2: Distribution of malnourished children admitted in Matany Hospital ITFC (July 2014 – Jun 2015)

Distribution of Cases admitted to Matany Hospital ITFC per Health Center FY 2014/15

Matany 2.2% 1.8% 0.4% Lokopo 2.9% Iriiri 4.3% 32.4% 4.7% Ngoleriet 4.7% Lopeei 6.1% Lorengechora Lotome Kotido 6.5% Moroto Katakwii 13.7% 20.5% Nakapiripirit Amudat Total admitted Children: 278

Matany Hospital has the only intensive therapeutic feeding centre in the District. Severe acute Malnutrition is still a big challenge in the community and it is among the top ten causes of admissions. It was projected that the situation could possibly worsen given the fact that harvest season for 2015 was delayed like in the previous year as a result of too little rains and practically no harvest. The considerable deterioration of food reserves in the community has resulted into most people migrating to neighbouring districts of Teso and other towns, as a coping mechanism for survival.

Several factors appear to play a role: persistent low harvest, increasing levels of poverty, and food insecurity. Also the rainy seasons are characterized by a number of epidemics. Diarrhoeal diseases have also contributed to the high levels of malnutrition. The overall population strata are affected but the under-five age bracket is most affected.

Other factors influencing the health status of the community include, high levels of illiteracy, poverty and poor health seeking behaviour of the community. Over time, there has been some observed improvement in the general health status of the community, including the immunisation coverage.

Reproductive Health (RH) indicators are still quite poor in Karamoja and are characterised by: low 4th ANC attendance, low supervised deliveries and low TT coverage for WCBA. There are continued efforts through community dialogue and health education to improve RH indicators in the HSD.

Page 15 of 100 CHAPTER TWO

HEALTH POLICY AND DISTRICT HEALTH SERVICES

PRIMARY HEALTH CARE DEPARTMENT (PHC)

A) Catchment area

The community health department of Matany Hospital doubles as Bokora Health Sub- District office as well and is implementing health activities in accordance to the health sector strategic plan set by the Ministry of Health with a purpose of achieving improved health for all in the HSD.

Bokora Health Sub-District comprises of 7 Sub-Counties (i.e. Matany, Iriri, Lokopo, Lopei, Ngoleriet, Lotome, and Lorengecora including one town council. It was in July 2010 that Napak District was curved out of Moroto District which covers the area of Bokora HSD. There are 13 Health Units, 1 Hospital (Matany), 6 health centre IIIs (Iriiri, Lorengechora, Lopeei, Lokopo, Kangole and Lotome) and 7 health centre IIs (Amedek, Nabwal, Morulinga, Ngoleriet, Namendera, Nakicumet and Apeitolim) are starting to contribute to improved health services to the communities.

Matany Hospital and Kangole Health centre are Private Not for Profit health units under UCMB which offer services at highly subsidised prices compared to other PNFPs in the country.

There is evident presence of good health care but other factors such as high illiteracy rate, lack of business and working opportunities, poverty, poor climatic conditions and long distances walked to receive health care still remain a challenge in Health care provision and a setback in achieving the health related millennium development goals.

Table 2.1: Health Centres for support supervision by Matany Hospital in Bokora HSD

Sub Distance from Catchment Health Units Counties Matany Hospital Population 1. Matany Hospital Matany 2. Morulinga HC II 8 km 22,810 3. Nakicumet HC II 18 km 10 km ( 21 Km during 1. Lokopo HCIII the rainy season) Lokopo 21,311 80 km (120 km during 2. Apeitolim HC II the rainy season) 1. Nawaikorot HC II 15 km Ngoleriet 17,807 2. Kangole HC III 10 km 17 km (50 km during Lotome Lotome HC III 11,589 the rainy season) 1. Iriri HC III 45 km 2. Nabwal HCII 70 km Iriiri 41,932 3. Amedek HC II 53 km 4. Namendera HC II 78 km 11 km (37 km during Lopeei Lopeei HC III 13,393 the rainy season) Lorengecora 1. Lorengecora HC III 37 km 11,099 Lorengecora T.C 37 km 5,278 Total Bokora HSD 145,219

Page 16 of 100 Table 2.2: Population figures for year 2014/2015: (Bokora HSD population from Census 2014, total population NAPAK DISTRICT = Bokora Health Sub-District = 145,219)

% of the Age group Target Population Remarks population For DPT-HEP B + Hib, Infants < 1 Yr. 4.3% 6,244 measles, polio coverage Children < 5 Yrs 20% 29,044 For Polio campaign (NIDs) Women 15 to 49 Yrs 23% 33,400 For TT coverage Pregnant Women 5% 7,261 For TT coverage >6 months to <5 years 19.2% 27,882 For Child days 1 – 15 years 48.4% 70,286 For child days

B) Personnel/Staffing

Matany Hospital Primary Health Care Department

The Primary Health Care Department (PHC) comprises a team of eight established staff at the HSD office: 1 Medical Officer (the in charge of the HSD), 1 Diploma Midwife, 1 Health Educator, 1 Health Inspector, 1 Health Information Assistant, 1 Ophthalmic Assistant, 1 Nursing Assistant and 2 Counsellors (two Registered Nurses). At the community level there were up to 31st December 2015 Field Health Workers (FHWs) that assisted the health workers carry out immunisations. In Matany Sub-County are 108 VHTs and one Leprosy Assistant who are supervised by the PHC team.

The national health policy developed operational responsibility for delivery of the minimum health package to the HSD and it is expected to provide overall day to day management of the health units and community level health activities under its jurisdiction. Its specific functions include:

1. Leadership in planning and management of health services within the HSD including supervision and quality assurance. This is quarterly followed up through meetings with the HU in charges.

2. Provision of technical, logistical and capacity development support to the lower health units and communities. This HSD is relevant in contributing to progress in service delivery and the below narrative report is evidence of the activities carried out.

3. Coordinating community health department in conjunction with the HIV clinic has carried out outreach activities to Apeitolim, Lotome, and Kangole Health unit to offer integrated HIV care services which include; HCT, EID,CD4 testing and TB/HIV co management. These are distant and hard to reach areas and yet there are high numbers of HIV clients. Since MoH accredited HC IIIs to run HIV Clinics, Matany Hospital has gradually transferred clients to Iriiri HC and Kangole HC as a strategy to minimise poor adherence to treatment. However Matany Hospital still gives assistance to these health centres in caring for HIV patients.

4. Monthly support supervision of peripheral health units integrated with eye care, health education on common diseases and TBA meetings.

5. Through the FHWs and VHTs, guinea worm eradication activities, TB case finding and contact tracing, malnutrition screening, patient referral and follow up, identification of people with disabilities, surveillance of epidemic out breaks and case finding; and follow up of chronically ill patients.

Page 17 of 100 Peripheral Health Units and staffing levels

Table 2.3: Personnel by qualification in Bokora HSD Peripheral Health Units as 30/06/2015

HEALTH UNIT Lab. Lab. Lab. S.N.O Nurse Nurse Nurse Health Officer Officer TOTAL Clinical Midwife Midwife Assistant ssionnals ssionnals Dispenser Certificate Certificate Assistants Assistants Registered Registered % of profe- Ophthalmic Ophthalmic

(OWNER-SHIP) Info Asstant Technicians 1 HC III standard + 1 1 1 1 3 2 1 0 3 1 1 1 0 15 100% by Government SCO 1 + 1 IRIIRI HC III 2 1 2 1 2 3 1 3 1 1 0 1 20 133% (Govt) Th

KANGOLE HC III 0 0 1 1 2 0 1 0 3 1 1 1 0 11 73% (Cath.Church)

LOKOPO HC III 0 0 1 0 1 2 1 0 2 1 0 1 0 9 60% (Govt)

LOPEI HC III 0 0 0 1 1 2 2 0 3 1 1 0 0 11 73% (Govt) 1 LORENGECORA 0 1 1 2 1 1 0 3 1 0 1 0 12 80% HC III (Govt) SCO LOTOME HC III 1 0 1 0 2 4 1 0 4 1 1 1 0 16 107% (Govt) SCO

HC II standard by 0 0 0 0 1 1 1 0 2 0 0 0 0 5 100% Government Nawaikorot 0 0 2 0 5 1 0 0 5 1 0 0 0 14 280% HC II (Govt) Amedek HC II 0 0 1 0 2 0 0 0 0 0 0 0 0 3 60% (Govt) Morulinga HC II 0 0 1 0 3 0 0 0 3 0 0 1 0 8 160% (Govt) Apeitolim 0 0 0 0 1 2 1 0 1 1 0 0 0 6 120% HC II (Govt.) Nabwal HC II 0 0 0 2 1 0 0 1 0 0 0 0 4 80% (Govt.) Nakichumet HC 0 0 1 0 1 0 0 0 1 0 0 0 0 3 60% II (Gov’t) Namendera 0 0 0 0 1 0 0 0 1 0 0 0 0 2 40% HC II (Gov’t) TOTAL (current 4 1 11 4 25 14 9 1 30 8 4 5 1 117 89% staff) Qualified 2 5 -5 2 0 5 4 -1 2 -2 2 1 -1 14 11% Staffing Gap Total (ideal 6 6 6 6 25 19 13 0 32 6 6 6 0 131 100% staffing)

In above staffing table for HC III and II, 2 support staff and 2 guards are not recorded, but part of the staff establishment. Only nursing and clinical staff are listed.

C) Activities/Achievements

The PHC Department conducted regular supervision for the thirteen peripheral health units of Bokora Health Sub District and offers a package of services to the community. Community activities offered are in line with the concept of PHC: MCH/FP/, UNEPI, TBLCP, GWEP, CBR, EDMP, school health, dental care and primary eye care activities. Integration, community participation and multidisciplinary approach are the basis of PHC team activities. ART service has been incorporated as a new component in these integrated outreaches. These ART outreaches are to three health centres in the HSD. This has led to an increase in accessibility to HIV care and improvement on adherence to treatment by clients.

Page 18 of 100 Together with the counsellors, it follows up mothers on Option B+ and their babies in the catchment area. The HSD has been involved in training health workers in ‘helping mothers survive and helping babies breathe’ activities. These trainings were facilitated by Jhpiego. The HSD planned and participated in training of 50 new VHTs in April for the district.

Activity areas include the following:

 Support supervision to peripheral health units (Govt. & Non Govt.) and supply of logistics

The PHC Supervisor and team in FY 2014/15 visited each of the thirteen units monthly. The Support supervision was conducted with the aim of ensuring correct patient management and continuous quality assurance improvement. The activities supervised include clinical assessments and prescription habits to ensure rational drug use (EDMP), HMIS monitoring, UNEPI cold chain maintenance, supervision of Maternal and Child health related activities and generally quality of services offered at the health units. Problems identified by the unit staffs or the supervisor were discussed at the end of the working day and possible solutions (which form the basis for subsequent supervision) were suggested and agreed upon for implementation. A report is compiled and annually submitted to the District Health Officer (DHO).

Table 2.4: Support supervision visits to peripheral health units in Bokora Health Sub-District (including Matany Hospital OPD) Health Units’ 2005 2006 2007 2008 2009 2010/ 201 2012 2013 2014 Target Supervision /06 /07 /08 /09 /10 11 1/12 /13 /14 /15 2014/15 No. of visits to 84 84 96 96 96 96 100 120 117 112 144 Government units No. of visits to 12 12 12 12 12 12 11 12 12 12 12 Diocesan units Total visits to all 96 96 108 108 108 108 111 132 129 124 156 units Total no. of the units 9 9 9 9 9 9 11 11 11 13 13 Average visits per 11 12 12 12 12 12 12 12 11.7 9.5 12 unit

 Provision of Health Care in Hard to Reach Areas

Bokora Health Sub District continues to experience an exodus of the local population to other places outside the HSD including as far as Kampala streets. Some have shifted from their original catchment areas to new settlements along the border with Nakapiripirit, Katakwi and Amuria districts stretching the increased demand for outreaches to provide health care and other social services yet the budget for responding to these unique challenges is not catered for. However, The department with support from CUAMM extended the outreaches further to hard to reach areas in the district in order to reach the vulnerable communities to health services this was effected in the last quarter of the year and they managed to immunise 472 children people screened and given treatment for eye infection were 64, mothers attended during ANC were 93 and patients seen with various diseases were 735. More settlements have cropped up even in the plain areas of Matany and Lokopo sub counties; Namoruakwangan, Lomongakwangan and Natirae.

 Maternal and Child Health

A double trained registered nurse (URM/URN/TBA trainer), supervised by a Medical Officer, is responsible for the “training and supervision” of TBAs and the delivery of ANC activities in the zone. All the sub-counties have trained TBAs of whom 104 are active. They are supervised once every month at Sub-County level. The role of TBAs is to refer and escort mothers for ANC and delivery services to the nearest health unit. ANC services are conducted in all HC IIIs daily and in the Hospital from Monday to Friday. The HSD had 6,318 first antenatal visits which was an increase of 9.9% compared to last year (5,700 first

Page 19 of 100 visits). Facility deliveries increased by 105% from 2,369 in 2013/14 to 4,873 deliveries in 2014/15. The increase in maternal health services has been a combined effort of the district and implementing partners. CUAMM has started to pay from the second half of FY 2013/14 for the transport of mothers in labour to the nearest health unit through a voucher system. With this system any transporter who takes a mother to a health unit is given a voucher which is paid on a later date by CUAMM. This system is intended to minimise on the ‘second delay’ to access delivery services to mothers in labour.

 Uganda National Expanded Programme on Immunizations (UNEPI)

Bokora County has thirteen static units (corresponding to the number of health units supervised by the Primary Health Care Department) and 84 outreach posts distributed all over the county. The four hard to reach areas are also reached monthly giving a total of 124 outreaches. Each sub-county has an average 8 outreach posts run by the field health workers and health unit staff attached to Matany Hospital and Peripheral Health Units respectively.

Table 2.5: Immunisation coverage by antigen for the six killer diseases in Bokora Health Sub- District over the last six years

Coverage Coverage Coverage Coverage Coverage Coverage National Antigen 2009/2010 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 Target BCG 73% 89% 97% 100% 98% 109% 100% DPT3 92% 113% 119% 100% 100% 118% 85% MEASLES 83% 104% 115% 100% 100% 100% 95%

TT2+ P 78% 87% 124% 50% 50% 57% 50%

TT2+ NP 27% 23% 53% 27% 50% 45% 50%

Generally immunisations output targets have been met and surpassed except for TT to non- pregnant women. The high number of immunisations among children is attributed to the mobilisation and vaccinations done by the outreach team when they go to hard to reach areas. These settlements have high numbers of children of immigrants from Nakapiripirit and Amuria districts who have settled in Nabwal, Nakayot and Apeitolim. Tetanus vaccination among pregnant women has improved as also reflected in the increased ANC attendance in the HSD. TT to non pregnant women is low because of the inactive school health programs. CUAMM and CONCERN are supporting immunisation and outreaches in lower level health units in the HSD. Most important to note is the mobilisation by the Field Health Workers, TBAs attached to the community health department and VHTs who did a good job in educating the community on the importance of child immunization and there has always been positive response which was reinforced with food supply to children under two years and pregnant women under the MCHN program.

The contribution of the Hospital and its community health department to the National development plan and Millennium development goals of reducing infant and maternal mortality, tuberculosis HIV/AIDS and malaria showed significant improvements. Ambulance service from Matany Hospital to reach every mother in need of hospital services is readily available 24 hours and maternal audits are being conducted in the HSD. The Maternal mortality rate is 83/100,000 live births for mothers who deliver in health facilities in the HSD.

ANC care has also improved with mothers receiving mosquito nets and other antenatal services. Expanded programme on immunisation is steadily making progress especially among the children. The Hospital had an increase of 32.9% (11,854) vaccinations compared to last year. The HSD achieved good output targets in immunisation. (see Table 2.5). Matany Hospital has an ART clinic, provides malaria and TB treatment. Last Year 512 TB

Page 20 of 100 cases were managed in the Hospital. All these outputs contributed to achievement of the Millennium development goals.

The department has frontline health workers in form of Village health teams, Field health workers (FHw) and TBAs. The establishment of Village Health Teams was done in 2010 with support from UNICEF as strategy to reach communities and households in the HSD. The HSD has 608 village health team members, male and female per village. They implement integrated management of fever, diarrhoea and pneumonia for under five children (ICCM) with very good results as indicated by the reduced load of OPD attendance of children in all health facilities. They have also been trained in screening of malnourished children, TB case finding, maternal and child health services. The 33 field health workers participated in immunization, health education, follow up of patients and mobilisation for health services, and 104 active traditional birth attendants whose role has been shifted to mobilisation of pregnant women for antenatal care, health education, sending women to deliver in health facilities and conduct delivery only in unavoidable circumstances. Due to financial constraints the Hospital had unfortunately to depart from the 33 FHw by the end of 2014 after having informed the District Health Office. The community health department is making little progress in reducing fertility, malnutrition, and the burden of HIV/AIDs is not effectively controlled since the prevalence in Karamoja is rising from 1.7% in 2005 to current 5.3%.

 PELF (Programme of Eradication of Lymphatic Filariasis)

Lymphatic Filariasis, one of the neglected tropical diseases, is a disease caused by a filarial worm called Wuchereria Bancrofti. These worms are widely distributed in Karamoja (prevalence: 2-9%, survey done in 2002). Only two species of mosquitoes, known as Anopheles Gambia and Funestura, can spread the disease to human beings. The inoculated worms develop in the lymphatic vessels of a human being and once the above mentioned mosquitoes pick them from the blood of the affected person, the worms become adults and ready to infect others human beings. A mass distribution campaign of ivermectin/ albendazole to all people older than 5 years was carried out in December 2007. This eradication programme is still going on. 87% of the population at risk were given this prophylaxis during FY 2013/14. In October 2014 a mass drug distribution, it was the 5th round so far, expecting to have a significant impact on the drop of all the neglected tropical diseases and intestinal worm infestation in communities of Napak. The disease burden is at 3.4% in the district. However the programme coverage in the District was as follows: 1. Lymphatic filariasis = 82% 2. Trachoma= 72%

 PRIMARY EYE CARE

The PHC Department has a Primary Ophthalmic Assistant who conducts health education on primary prevention of eye problems and carries out treatment and simple surgery of simple eye problems on daily basis. Complicated eye cases are referred or booked for the annual eye surgery camp done by the team from Christian Blind Mission led by Dr Keith from Ruhaaro Eye Centre. From 31st October – 12th November 2014 an annual eye surgical camp was held in Matany Hospital. It was conducted by the Ruharo Eye Hospital. They operated 156 patients. Cataract surgeries contributed 83% of all the operations. The rest included; trabs, intraocular surgeries, lid surgeries, aniridia etc.

Page 21 of 100 Table 2.7: Primary Eye Care

2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 No. of uncomplicated cases treated 1,399 1,833 1,563 692 1,039 1,045 No. of cases operated 76 275 137 394 333 455 No. of cases referred 12 18 16 8 6 8

Eye care services had improvement basing on the number of uncomplicated cases treated in the Hospital compared to the previous financial years.

Table 2.8: PHC Department: Ophthalmic cases seen during Financial Year 2014/2015

Ophthalmic Assistant Workload during FY 2014/2015 including static clinic and outreaches Eye disease No. Eye Surgery No. Normal eyes 16 LID Rotation 295 Allergic eyes 218 CAT 130 Acute red eyes 40 TRAB 7 Cataract 226 Enucleation 1 Glaucoma 59 Foreign body removal 6 Corneal scars 122 Retina 0 Active trachoma 23 Other intraocular 12 Non active trachoma 30 Other extraocular 0 Ocular trauma 66 Eviscerations 3 Refractive errors 46 Carcinoma/pterygum 0 Other diseases 199 EZIA (Aniridia) 1 Others 0 Total eye surgery 455 Total eye diseases 1,045 Outreaches 112

 SURVEILLANCE of Epidemic Prone Diseases

Surveillance reports have been collected on weekly basis from all the Peripheral Health Units of Bokora Health Sub-District throughout the Financial Year 2014/15.

The table below shows a summary of cases reported since 2012/13 to 2014/15

Table 2.9: Notifiable Diseases since FY 2012/2013 to 2014/2015

FY 2012/13 2013/2014 2014/2015 Cases Cases Cases Disease Deaths Deaths Deaths reported reported reported Cholera 0 0 00 0 0 Bacillary Dysentery 1,923 0 1,533 961 0 Measles 7 (suspects) 0 5 (suspects) 0 2 (suspects) 0 AFP/Polio 4 (suspects) 0 0 0 0 0 Bacterial meningitis 55 9 14 0 15 0 Meningococcal Meningitis 0 0 0 0 1 0 Malaria 90,845 55 86,241 65 59,397 67 Neonatal tetanus 0 0 0 0 2 1 Plague 0 0 00 0 0 Typhoid 217 0 4251 196 2 Yellow fever( suspects) 0 0 7 0 0 0 VHF 0 0 00 0 0 Guinea Worm 0 0 0 0 0 0 Animal bites/ Susp. rabies 490 0 402 0 480 1 Chicken pox 165 0 92 0 421 0 SARI 0 0 00 0 0 Maternal Death 0 0 0 7 + 16 0 4 due to HEV Perinatal Death 0 0 0 15 0 45 Hepatitis E (HEV) 0 0 1,494 (suspects) 31 177 (suspects) 0

Page 22 of 100 Malaria is the leading notifiable disease but with a low case fatality of 0.11%. Maternal deaths occurred in the Hospital. They were reported to the ministry and maternal death audits done. Hepatitis E outbreak continued in FY 2014/15 from the previous year but the numbers were reducing. The number of suspected Hepatitis E cases seen was 177. The outbreak was declared over in March 2015 by district health authorities. Bacterial meningitis was reported more commonly among children. No cases of polio, plague, VHF, meningococcal meningitis and Guinea Worm were reported.

HEALTH EDUCATION

Health education, a public health intervention cutting across all areas, was conducted at individual, family, community and Health Units level. The Health Educator, Hospital staffs, students, and Field Health Workers carry out the activity using various methods and tools to facilitate learning through voluntary adaptation of knowledge, attitude, behaviour, and practices for disease prevention, control and health promotion. It is quite evident that people’s attitudes are gradually changing towards western medicine practices. It is still a common finding that most people have been to the traditional healer before coming to the Hospital but on a general note the health seeking behaviour of the community is gradually improving.

Problems/Constraints faced

 New settlements and nomadic lifestyle.  Traditional and cultural beliefs, conservative tendencies.  Cost of funding outreaches is high with minimal support from government  Poor road network to some areas especially during the rainy season  Poor coordination of activities with other implementing partners in the District  Limited funds to carry all the health education services expected

Plan for next Financial Year 2014/15

 Improve quality of support supervision to peripheral health units.  Continue delivering an integrated health care package, comprising of MCH/FP/TBA, UNEPI, TBLCP, EDMP, school health, dental care and primary eye care activities.  Ophthalmic Assistant should be supported to extend the services to village level to reach people who are usually unable to reach to the health units particularly the elderly, disabled and other neglected people in the community.  An additional Ophthalmic Assistant to be trained.  Eye-Surgeon to continue with the annual surgical camps.  Continue with epidemiological surveillance of epidemic potential diseases (Cholera, AFP, Measles, Meningitis, …)  Lobby funds to support the population in the new settlements and to carry out HIV/AIDS activities especially family support groups and EPI outreaches.  Lobby through CUAMM facilitation for TBAs who refer mothers to the health facilities in order to improve supervised deliveries in the district.  Improve follow up of TB patients and supervise TB control activities.  Strengthen the epidemic preparedness and response activities.  Lobby for infrastructural development in health centres.  Strengthen village health teams in the whole health sub district

Page 23 of 100 CHAPTER THREE

GOVERNANCE AND MANAGEMENT

The Hospital operates under the direction of the Board of Governors (BoG), which takes its mandate from the Board of Trustees of Moroto Catholic Diocese through its Chairman, the Bishop. The Hospital constitution indicates that BoG meetings be held four times during a financial year. The flow chart below shows the Management Structure coordinating with the Hospital Management Team.

Board of Trustees of Moroto Diocese

Ministry of Board of Governors Uganda Catholic Health St. Kizito Hospital Medical Bureau Matany (UCMB)

District Health Diocesan Health Authorities Coordinator (DHC) Hospital Management Team: Headed by Chief Executive Officer, and consisting of the heads of the main departments

Medical Nursing Administrative Public Health Health Training Director Director Director Director Institution Director

Medical and Nursing Accounts / Prevention Tutors, paramedical departments; Administration and health Clinical departments Nurses and department; promotion in Instructors, / staff; nursing Maintenance own Support Staff Diagnostic support staff. infrastructure, catchment and students departments Cleaning and Equipment area; Pharmacy Domestic and Grounds; HSD services Department Transport and activities

Legend: - Hierarchical Authority and communication line = - Advisory Authority and communication line =

St. Kizito Hospital Matany Constitution - 11

As seen above the Hospital is owned by Moroto Catholic Diocese with its legal entity the Board of Trustees.

The religious congregations working in the Hospital have signed Agreements with the Ordinary defining the number of personnel of the congregations to the Hospital.

Page 24 of 100 Governance

Moroto Diocese has a Diocesan Health Commission (DHC) that oversees policy implementation and statutory undertakings for the Diocesan Health Institutions. The Hospital is represented in the DHC by the Medical Director and the Principal Tutor.

The Board of Governors

St. Kizito Hospital Matany Board of Governors is the supreme governing body of the Hospital and Nursing and Midwifery Training School. As such it is custodian of – and shall ensure compliance to the Constitution of the Hospital. The list of BoG members is in Annex 2.

During FY 2014/15 there were four BoG meetings (the fourth in July 2015, due to home leave of the CEO).

Table 3.1 BoG meetings

No of Dates of Board Reports presented / Key issues handled / decision Members meetings taken present 25/09/2014 1 Update on Personnel changes 13 Communication from recent UCMB training in 2 Labour Law and medical legal issues 3 Activity Report and Faithfulness to the Mission NMTS – Report from the HTI Statutory 4 Committee 5 PHC – brief report AOB – Electricity has reached Napak; External 6 audit completes today; Matany Hospital receives Golden Award from Medical Access 15/01/2015 1 Present the Annual Analytical Report FY 2013/14 13 2 Update on Development Projects 3 Audit Report FY 2013/14 4 NMTS – brief report 5 PHC – brief report; FHW Diocesan Health Assembly in February 2015 at 6 Matany Hospital 09/04/2015 1 Half Year Activity Report 13 Relationship between Napak District and Matany 2 Hospital in this time of financial constraints Introduce one flat fee for patients without employment (scrap within / outside the system). 3 Apply cost recovery rates for those who can afford. 4 NMTS – brief report 5 PHC – brief report 6 Brief report from AGM Results of Patient Satisfaction and Drug 30/07/2015 1 14 Prescription Survey 2 Personnel Issues 3 Financial Issues – Budget FY 2014/15 4 PHC – brief report 5 NMTS – brief report AOB - False reports on Fees-increase, attendants 6 request for help in spite of being helped

Page 25 of 100 During the BoG meeting of 25th September 2014 the personnel changes foreseen during the June 2014 meeting have taken place. New MS from 1st July 2014 onwards is Dr. John Bosco Nsubuga, who is holding a Master in Obs. and Gyn. Sr. Nataline Mowo was appointed Principal Tutor. The Board thanked the surgeon Dr. Franz Martig who was sent by CUAMM and will soon end his service at Matany. The MS shared about the recent held UCMB training in Labour Law and medical legal issues. It was noted during the workshop that there is increasing litigation involving many UCMB hospitals. Most litigation cases are about malpractice and human resource management. The Faithfulness to the Mission Report followed. While the general figures of accessibility, namely OPD attendance and admissions have dropped, deliveries, antenatal visits and immunisations have increased. As for the efficiency and staff productivity both indicators went up. The recurrent cost per SUO has increased which is beyond the control of the Hospital management. The indicator for equity, which is Fees per SUO has increased. The trend of almost four years of low fees/SUO could not any longer be maintained. In the quality indicators it was noted that both Maternal Deaths and fresh still births were higher than the other years. The explanation was that the Hepatitis E was the main contributor to this death toll. Maternity Ward maintained the 0% of Caesarean infection rate which is commendable. The qualified %age of staff has increased from 49 to 52%. During the NMTS report the missing of a Midwifery Tutor was discussed and a DM with a Degree in Nursing employed. During the PHC brief report the MS informed the house that he is planning monthly integrated outreaches to four settlements far from any medical health care point, e.g. Kaeselem, Komturunyo, Kokulonyo and Nakayot. He requested CUAMM for funding for supporting these “mobile clinics”. The main issue discussed during the BoG meeting of 15th January 2015 were the Annual Analytical Report of FY 2013/14. The fact that the utilisation of some services are decreasing while others are increasing has to be evaluated. Eventually the Hospital will settle to its real function, giving more Hospital expected services than being a primary health facility. The surrounding Health Units are now better staffed and medicines available. – The update on Development project achieved was quite impressing and are reported under the executive summary on page 9 at the beginning of this Report. The plans for FY 2014/15 were also shared. - The Audit report was presented to the Board which was after some discussions approved by the Board. - The Principal Tutor shared the Faithfulness to the mission report with the members in Minute 7. – During the PHC Report, the main issue discussed was about the FHW (Field Health Workers). This cadre which has been employed by the Hospital long before the PHC-policy of Government was put in place cannot any longer be maintained by Matany Hospital due to financial constraints. In the past the main health provision in the region was carried out by the Hospital. Nowadays more HUs (Health Units) are in place and VHTs trained. There are also more partners in Health in Napak District. As services have improved and funds are dwindling, their employment had to be terminated. – The last topic discussed was about the forthcoming Diocesan Health Assembly to be held at Matany Hospital.

It was interesting for the Board, during its meeting on the 9th April 2015, during the Half Year Hospital Activity Report that OPD attendance, admissions, immunisations, ANC, laboratory and radiology services have increased. – in another minute members were informed about the financial gap for running the HSD, which has up to now been covered by the Delegated Funds and Hospital Funds. The issue needs to be followed up with the District Authorities. The next topic discussed was to introduce just one flat fee for all patients without employment or under an insurance scheme. By this to eliminate the categories of patients “within the system” and “outside of system”. These categories were introduced in the past

Page 26 of 100 in order to help patients to respect the referral system and therefore seeking care from their nearest health unit. With this intervention the fees have to be unique. Matany Hospital has been adopting the lowest fees of all the UCMB Hospitals and its recovery from user fees stands at 8% of all costs. Sustainability issues are urgent to ponder and the changes brought now to the approval of the BOG are just the first step in the attempt to address them. More than a proper increase of fees, these changes aim at changing a system and the flow of patients in OPD and at the same time promoting a better quality of care. The setting up of a Dispensing Pharmacy in the OPD is an important element in addressing this improvement in the quality of services and at the same time correcting the flow of patients. It was stressed that Matany Hospital would not compromise their mission statement and access to Health Care will always be guaranteed especially to the destitute and vulnerable groups of society. Still, it was observed that some abuses of the lower rates practiced have taken place. Therefore, access to health care will be done by a 3 way system :  full cost recovery: for private clients (patients working for organisations/NGO’s, business enterprises, employed/civil servants and others who request for Private services).  Flat Rates: for patients with no income  Samaritan Fund: For the destitute A lively debate followed and a new fees structure was adopted, taking effect from 10th April 2015 onwards One area of concern during the NMTS report was the lack of Clinical Instructors which will be solved as soon as the newly qualified staff receive their transcripts. During the PHC activity report the house was informed that a MDR TB was identified in Irrir trading centre in January 2015 and receives treatment. After waiting for long the Hospital finally received 643 mama kits on 10th March from UNICEF. Under AOB members were informed that the long serving Principal Nursing Officer (PNO) and Comboni Sister Rosario Marinho will be transferred to another Health Unit in Karamoja towards October 2015. The Comboni Sisters are currently preparing a sister who will first have to undergo a Bachelor course in Nursing. In the meantime it is proposed that the current Deputy PNO will become the AgPNO.

The results of the Patient Satisfaction and Drug Prescription Survey carried out in May 2015, was the first topic to be discussed during the BoG meeting of 30th July 2015. There was again an improvement in the general performance of the Hospital than the previous year attested by patients. - The drug prescription survey aims to monitor and improve the Quality of Drug Prescription and dispensing practices in Matany Hospital. The polypharmacy rate increased compared to 2.28 in 2014 to 2.37 in 2015 but still below the WHO recommended rate of 2.6. The antibiotic rate increased from 24% in 2014 to 26% in 2015. This will need more attention during FY 2015/16. During the agenda point on personnel issues some personnel changes were discussed. The positions of Internal Auditor and Human Resource Officer have also been filled. – The Budget for FY 2015/156 was presented and after a short discussion approved. – During the NMTS Report the Principal Tutor shared the challenges of the recently conducted promotional exams. While three classes passed with distinctions and credits, the CM Intake had eight credits and eight failures. This has never happened in the history of the school and the affected students will get another chance. During the brief PHC Report it was mentioned that Local Government is currently recruiting health professionals which will affect also employees of the Hospital. The Christian Blind Mission is conducting in these weeks surgical camps for treatment of trichiasis trachoma in different Sub-Counties of the District. The Hospital Ophthalmic Assistant is participating. Following the increase of fees in April 2015 a number of people create unbelievable stories about this. The BoG advised the Hospital Management to sensitise the communities about the changes which took place.

Page 27 of 100 The Hospital has a Disciplinary and Welfare Committee with the main function of ensuring proper conduct by the staff. The disciplinary committee meets whenever a disciplinary evaluation is urgently needed.

The role of the Hospital Communication Officer is performed by the Administrator. An Ad Hoc job description and a draft of communication policy within and outside the Hospital are in place and need to be finally discussed by the BoG.

The position of Personnel Officer has never been created; this responsibility is currently held by the PNO. Job descriptions and employment manual are available for all cadres and clearly spelt out in their appointments. The human resource issue is of paramount importance in Matany Hospital and there is need to find funds and a personnel officer dedicated specifically to this task of human resource management. It is envisaged to employ a HR-Officer in the new FY.

General Staff assemblies are regularly held.

The Hospital recognised the need for the internal system management /process Auditor. This position is covered by a Technical Advisor to the management. Amidst many other tasks, he keeps an eye on the following together with the Accounts personnel:

 The Internal stock management processes  The internal control procedures  Follow up on prior years external audit recommendations for implementation, i.e. Asset register, engraving of fixed assets, etc.  Follow up on record keeping of all supporting documents for all transactions in the year

There was big improvement in the updating of stock cards. Auditors recommended ensuring that personnel files contain all the necessary information. To have the fixed asset register always updated was another area which was suggested to be keen on as to be enabled to revaluate the fixed assets.

Management

The Hospital is managed by the Hospital Management Team (HMT) with its executive body, (the Daily or Executive Board), formed jointly by the Chief Executive Officer (CEO), the Medical Director (MD) and Nursing Director (ND). This executive body meets daily (in the morning) with the main task of discussing issues arising during the day to day running of the Institution. Issues concerning finance, personnel, clinical care and project implementation are the commonest topics discussed.

The Chief Executive Officer has direct access to the Bishop in the event of need and ensures the function of liaison with the Uganda Catholic Medical Bureau, the Diocesan, District and National Health Authorities.

 The Hospital Management Team (HMT) is composed of the executive board together with the PHC Director and HTI Director. The HMT meets regularly and the chairperson is the Medical Director. See the composition of this committee in Annex 2.

 The HTI Statutory Standing Committee is required by the Health Commission of Uganda Episcopal Conference through UCMB. This Committee is specifically responsible for providing oversight on the Health Training Institution and reports to the Board of Governors. The composition of this committee is in Annex 2.

Page 28 of 100 In table 3.2 is a summary on the compliance with statutory commitments (with UCMB, Government and Ministry of Health, etc,). Management is following all these commitments seriously.

Table 3.2 Statutory Requirements

Did you No REQUIREMENT achieve it? Comment Yes, Partly, No Government / MoH Requirements 1 Paye Yes 2 NSSF Yes 3 Local service tax Yes 4 Annual operational licence Yes 5 Practicing licence for staff Yes 7 Monthly HMIS Yes UCMB statutory requirement 1 Analytical Report end of FY year Yes 2 External Audit end of FY year Yes 3 Charter (still valid)* Yes 5 Contribution to UCMB for the year 2014 Yes HMIS 107 PLUS financial report / 6 Yes quality indicators ending FY 2013/14 Report Status of staffing as of end of 7 Yes financial year 2013/14 8 Manual of Employment (still valid) Yes Manual of Financial Management (still 9 Yes valid) Report on Undertakings and Actions of 10 Yes the year

Accreditation status with UCMB

Matany Hospital fully accomplished the 10 statutory requirements and hospital under- takings set by the Uganda Catholic Medical Bureau and was awarded a certificate of accreditation for FY 2014/15 with 97% score attained (like the previous year) and valid until 31st December 2015. During the Hospital Managers Technical Workshop II organised by UCMB the new accreditation requirements set for the accreditation programme for 2015/16 a new Accreditation Certificate was received and the Hospital managed to maintain the good performance of 81%. It is the aspiration of the Hospital Management Team that we shall always strive to achieve this status year after year.

Hospital Guidelines and Manuals

The Hospital Charter, the Employment Manual, and the Financial and Materials Management Manual are still valid and in place.

A Hospital Strategic Plan covering the period of July 2011 to June 2016 was made with technical guidance from UCMB. It is a guiding tool for the operation and management of Matany Hospital. This Strategic Plan was approved by the BoG during its meeting held on 23rd June 2011 with its Theme: “Pursuing the Health and Well Being of the person and community through a holistic and integrated approach.” Copies of these documents are in the Hospital Library available to whoever wants to consult them. A copy of the Employment Manual is given to all the employees.

Page 29 of 100 Up to now the Hospital has no approved Information, Communication, and Data Management Guidelines which will have to be formulated and approved soon and then implemented.

Advocacy, Lobby and Negotiation

The Hospital has been involved in several advocacy endeavours. Hospital Management sought audience from the First lady and Minister for Karamoja Affairs and held a meeting with her on 6th June 2015. Several issues concerning the Hospital were discussed like lack of finances, shortage of human resource, renovation of NMTS, etc…..

The Hospital has continuously advocated for better health service delivery to its catchment area through the DHMT where the medical director is a member, UCMB, MoH, donors, and other partners.

The management continues to lobby for social support for vulnerable groups like ART clinic clients, children and elderly.

Regular general staff meetings help to update staff on achievements, challenges and future plans of the hospital. They actively participate in these meetings.

The Hospital has actively been involved in devising ways of improving health services to communities in hard to reach areas of the district where a big population of the district has migrated because of the fertile and better rainfall patterns in these areas. These populations are far from health units. This clinical outreach programme is funded by CUAMM

The Hospital had a news article in February in the Monitor newspaper highlighting the services provided by the Hospital to the people and its challenges.

A Diocesan Health Assembly was held on 19th February 2015 for the purpose of creating awareness of the current situation among the district leaders in Karamoja region and also advocate for improved partnership with local governments, development partners and Ministry of Health. The theme of the DHA was “Public Private Partnership in Health (PPPH): The experience and way forward for the PNFP Health Sector in Moroto Diocese”. From UCMB Dr. Ronald Kasyaba attended and presented the topic: The Private-Not-For- Profit sub-sector in the Uganda Health System - Successful Partnerships for Affordable Quality Health. At the end of the Assembly the organisers were encouraged to summarise the resolutions taken and send them to the various stakeholders and to the press.

Page 30 of 100 CHAPTER FOUR

HOSPITAL HUMAN RESOURCES

Introduction

During FY 2014/15 an average of 7 Doctors was present in the station at all times. Napak District has seconded four staff to the Hospital, one working in the Hospital and three in the Public Health Department. They are: The Orthopaedic Officer and at the PHC Department one Health Inspector for Bokora HSD, one Diploma Midwife and a Health Information Assistant. The Health Training Institution has presently three qualified Tutors: The Principal Tutor, the DPT and a Nurse Tutor.

STAFFING

The total number of employees as of 30th June 2014 was 208. Matany Hospital continues to be one of the main employers in Karamoja Region. Graph 4.1 shows the distribution between Karimojong and Non Karamojong Personnel.

Matany Hospital Personnel since FY 2010/2011 200 184 196 174 170 160 149

120

80 78 80 52 59 59

40

0 2011 2012 2013 2014 2015 Total: 236 255 254 248 208

Karimojong Personnel Non Karimojong Personnel

Graphic 4.1: Levels of Employment at Matany Hospital since 2010/11

The output from the NMTS significantly provides the main source of qualified nursing staff to Matany Hospital. The Technical Department relies on the supervision of one expatriate staff. The Hospital efforts in training Karimojong has not given the expected results as far as retention of staff is concerned. Most leave the Hospital after completing the bonding agreement. Over the years the academic standard of schools in Karamoja has improved but it is still difficult to get enough candidates for professional training. The high cost of quality education and other social issues are responsible for many school drop outs.

Page 31 of 100 Present situation (June 2015)

The expatriate staffs include; the Administrator (CEO), the Principal Nursing Officer, one Senior Medical Officer as a volunteer, the surgeon sent by CUAMM, a Diploma Nurse in charge of Pharmacy, the Technical Supervisor, and the Domestic Officer.

Trends

There has been a progressive increase in the availability of qualified health workers in the Hospital over the last years. The Hospital Management Team made it a priority to improve the staffing norms in various departments in the Hospital. However staff attrition is still an issue. The percentage of qualified staff in the Hospital has increased as the field health workers who were employed in the PHC Department have been stopped working from 31st December 2014 onwards as the introduction of the VHTs in the communities made their position almost redundant. It is hoped that the immunisation coverage will not be effected as this cadre was greatly assisting the lower lever units by reaching out with this service to the communities.

%age of qualified Staff 60% 57.7%

55% 51.6%

50% 48.6% 49%

45% 43%

40% 2010/11 2011/12 2012/13 2013/14 2014/15

Graphic 4.2: Percentage Trend of Qualified Staff since 2010/11

During 2014/15 there was an increase in the percentage of qualified staff as explained above. Some staffs were given opportunity for career development guided by the perceived institutional needs.

Table 4.1: Total No of staff at Matany Hospital compared to FY 2010/11 – FY 2014/15

end end end end end June June June June June 2011 2012 2013 2014 2015 MEDICAL OFFICERS 7 8 (1) 7 7 7 ALLIED MEDICAL PROFESSIONS 12 (8) 15 (8) 13(7) 14(7) 14(9) NURSING STAFF 74 (52) 78 (53) 80(38) 77(36) 70(43) ADMINISTRATIVE STAFF 9 (5) 9 (5) 11(4) 12(6) 14(7) PHC STAFF 31 (31) 37 (37) 37(37) 36(36) 3(3) TECHNICAL STAFF 40 (29) 43 (32) 41(29) 39(29) 36(30) SUPPORT STAFF 44 (44) 46 (46) 47(45) 46(43) 47(44) SCHOOL STAFF 15 (10) 15 (10) 14(10) 13(9) 13(9) KHRDCH STAFF 4 (4) 4 (4) 4(4) 4(4) 4(4) TOTAL 236 255 254 248 208 ( .) = Karimojong Personnel 184 196 174 170 149 Non Karimojong Personnel 52 59 80 78 59

Page 32 of 100 Turnover of Staff

The remoteness of the place and the hardships of living and working in an environment like Karamoja make the turnover rate of key health personnel inevitably high. In times when Local Governments recruit health professionals the turnover rate is going up. This happened in the years 2010/11, 2012/13 and 2014/15.

Table 4.2 Staff turnover

Staff FY FY FY FY FY Cadres Establishment 2010/11 2011/12 2012/13 2013/14 2014/15 Total staff 286 236 255 254 254 208 Enrolled cadres 139 102 124 125 128 120 (all combined) Enrolled staff lost 32 24 55 25 32 Turnover rate 31.5% 21.2% 44.1% 19.8% 25.3%

Turnover rate for each year is calculated as in the following example for enrolled cadres in 2010/11:

Total enrolled staffs lost (1st July 2010 to June 30th 2011)

(Total enrolled cadres available at June 30th 2010 + Total no. of enrolled cadres available at June 30th 2011) / 2

Graph 4.3 Staff turnover

Turnover Rate of trained staff in the last 5 Financial Years 50.0% 44.1% 40.0% 31.5% 30.0% 25.3% 21.2% 20.0% 19.8% 10.0%

0.0% FY 2010/11 FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15

MANAGEMENT

Human Resources’ Management is one of the most challenging tasks within an Institution operating in this region where leisure activities and social programmes are inexistent combined with poor road access and irregular transport services. Staffs have to content themselves with the simple commodities available in the Trading Centre and sometimes at high price.

The SNO has been assigned with the task of Human Resources Officer considering financial constraints to fill this post. Nurses, Doctors, Allied Medical professionals, and other qualified cadres, work 45 hours per week while some support Staff work only 30 hours per week as stipulated by the Employment Manual (revised in March 2011). This Manual provides the guidelines utilized in Human Resource Management in the Hospital and is made available to every employee at the time of induction.

Page 33 of 100 During FY 2014/15 there was an increase in the percentage of qualified staff and, according to perceived Institutional needs, some were given opportunities for career development. As mentioned before, the Hospital administration strives to pay salaries to the employees in line with those of public sector in order to compete favourably for the job market. Therefore at the beginning of FY 2014/15 a salary increase was effected as the previous two FY the salaries remained stagnant. All employees are covered by NSSF (National Social Security Fund) and are paid on a salary basis. The salary is composed of a basic salary to which some incentives (responsibility allowance etc.) are added. Recruitment of staff is from the NMTS, internal adverts and headhunt. All new staff have interviews and are inducted into the Hospital. They are given the employment manuals, job descriptions and contracts. Staff performance appraisals are done regularly with promotions effected where necessary depending on the positions available. All statutory salary deductions are made. Staff movements are also regularly reported to UCMB as an undertaking.

HUMAN RESOURCE DEVELOPMENT AND CAREER

The HMT has put over the years a considerable effort in designing a career development scheme and different Staff were benefiting from it, particularly Karimojong candidates. However it was observed that, in most of the cases, the sponsorship of natives was not a guarantee for retention since many prefer to work far from their relatives this scheme has been revised. Though still limited, a good number of staffs have chosen to renew their contracts and apply for further training through this scheme. As the resources of the Hospital become scarce also the effort to support the career development of our staff becomes a challenge. The Hospital has sustained an effort for the general wellbeing of the staff in terms of a relatively attractive remuneration package and recreational programs; senior hospital staffs live in fully furnished houses with running water, intercom and electricity. All these are provided as fringe benefits excluded in salaries of senior staff. The above provisions with availability of mobile telephone network have significantly softened the typically rural surroundings. Decent housing for nurses and other staff is provided, with installation of solar lighting into each apartment. An effort to increase the number of experienced / senior staff is being looked into seriously; the justification for this is due to the fact that the experienced Staff are more productive and efficient. It is from such personnel that other scarce cadres, e.g. Tutors, clinical instructors, counsellors, etc. are identified and developed.

To improve on knowledge and skills, CME’s and CNE’s are regularly carried out. These help to update the staff on the new developments in patient medical and nursing care. Topics are assigned to different Wards and doctors together with other cadres discuss the topic at their level of expertise. Visiting Doctors/Specialists occasionally offer CME’s and they broaden the type of topics and issues addressed. Topics discussed during this year include: 1) Cryptococcal meningitis 2) Ebola 3) Postpartum haemorrhage 4) Malnutrition in children 5) Rational use of Artesunate 6) Medical ethics 7) Care for the terminally ill patients 8) New WHO HIV treatment guidelines ( Done twice) 9) Infection prevention of MDR TB 10) Treatment of MDR-TB patients. 11) Helping mothers survive and helping babies breathe 12) Typhoid Perforations

Page 34 of 100 The Staff are also informed about quarterly review data and briefed on Hospital performance. Staff also attend workshops, seminars and other trainings organised by other stake holders in health.

Table 4.3: Personnel currently on training : (* Karimojong)

Duration of Number Duration bonding (to Cadre of staff sent for of training Source of funding be effected training (years) post-training) Diploma Nursing 1 1 1/2 Hospital 2 years Bachelor Business 1 3 Hospital 3 years Administration 1* Bachelor in statistics 1* 1 3 Hospital 3 years

 The main sources of funding for Staff Development have been external donations.  We have observed recently that some cadres, like Laboratory Assistants and Clinical Officers, are easily available and therefore we do not have to make provisions for sponsorship. The Hospital must make continuous provision for Diploma Nurses/ Midwives since these are the more movable cadres. The Training of Tutors for the NMTS is a continuous concern of Management in order to ensure proper Staffing of the School and quality training.

Conclusion

The HMT has invested a lot of resources both in developing and nurturing the Staff by providing dignified housing and other fringe benefits and we believe that the commitment and dedication of our Staff in the provision of care to the patients is evidenced by the out puts. The number of Staff renewing their contracts is increasing. During the exit interviews with those leaving we perceive that the reasons for turnover are more related with personal/family reasons rather than dissatisfaction with work environment or salary package.

Page 35 of 100 CHAPTER FIVE

HOSPITAL FINANCES

This Financial Year the Hospital managed to balance income and expenditure with a small surplus of 57,625,537/= UGX which partly covered the deficit of the previous two years. However it remains a big challenge for the Hospital Administration to make sure that the running costs are covered. As external donations are reducing, Management has to find sources from within in order to keep up with the rising costs. The income from user fees increased in this financial year as there were more patients paying the cost recovery rates and a fees-adjustment applied from April 2015 onwards. The out patients have dropped over the Financial Year as it has been experienced in most of the other PNFP Hospitals in Uganda as well as in the neighbouring Lower level Health Units. In the region are now more private clinics and drug shops operating and one wonders if they have all their official licences and trained health personnel to operate them. VHTs continue to have a good impact on the population in treating simple health conditions. The number of admission increased slightly. The PHC Conditional Grant was received 100%. Various types of external donations decreased, except external donations for capital development increased and fewer donations were received in kind. Government support in terms of Essential Drugs has decreased by 48 million UGX during this financial year while other income for sales and services has increased by almost 70 million UGX. The Hospital continues to use the financial program, FIPRO which was initiated by UCMB. It is a program for Accounting, Budget control and Cost analysis. Since many years the Hospital tracks costs per cost-centre/department, for better efficiency and timely decision making. - See the table below concerning various sources of income.

Table 5.1: Trend of Income by sources over the last 5 years, FY2010/11 to FY 2014/15

FY 2010/11 FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 INCOME UGX UGX UGX UGX UGX User Fees 175,402,500 167,002,700 140,422,290 216,100,950 272,439,130 PHC CG Hospital ¹ 521,426,150 487,649,667 557,348,975 529,372,125 537,666,660 PHC CG School ¹ 22,009,492 21,673,318 - 28,784,957 28,009,492 PHC CG HSD ¹ 46,504,440 46,543,538 30,296,650 35,194,103 35,000,000 Other School Income 152,147,540 200,070,535 217,344,462 136,189,483 164,022,600 External Donations 255,119,208 171,757,658 213,799,340 140,272,160 195,900,000 Funds (Cap. Dev’t) External Donations of 689,499,203 943,674,606 725,252,055 759,581,030 701,267,703 Funds ² External Donations 163,909,564 170,436,843 155,142,921 377,220,607 152,075,559 Goods/Services Value of EDP Drugs 30,421,888 79,791,928 113,536,037 75,646,673 27,298,165 received Received in kind for Not reported as 384,625,986 amount distorts 235,769,950 301,197,959 HIV/AIDS income figure Value of Lab Reagents included in included in included in included in 62,869,868 & Consumables EDP Drugs EDP Drugs EDP Drugs EDP Drugs Other Income ³ 275,919,414 203,072,940 184,516,715 173,258,762 242,688,621

TOTAL 2,332,359,399 2,876,299,719 2,400,529,312 2,707,390,799 2,657,565,890

Income

The trend details of the various income sources are compared over the last five financial years in Graph 5.1. User Fees income increased by 26%. This is mainly attributed to more

Page 36 of 100 patients paying cost recovery rates as well as a slight fees adjustment. The PHC CG to the Hospital, NMTS and for PHC activities were received by 100% and were 7.3 million UGX more than in the previous year. The general support towards the Nursing & Midwifery Training School increased as compared to last year by 20.4%. Bursaries from Government and Development Partners are the main support. External donations for recurrent costs have decreased by 7.6%, but remain the highest source of income for the Hospital, guaranteeing to keep the services highly subsidised. External Donations of Goods decreased as there were no major commodities received. However the donations for Capital Development increased by almost 40% or 55.6 million UGX. The value of essential drugs allocated from Government decreased by 64% or about 48 million UGX as compared to the previous year.

Graph 5.1 – INCOME SOURCES AND TRENDS

INCOME DETAILS & TRENDS FY 2010/11 - 2014/15

1,000,000,000

900,000,000

800,000,000

700,000,000

600,000,000

500,000,000

400,000,000

300,000,000

200,000,000

100,000,000

0 Ot her External Ext ernal Ext ernal Value of Received in PHC CG PHC CG PHC CG Other User Fees School Do nat ions Donat ions Do nat ions EDP Drugs kind for Ho sp it al ¹ School ¹ HSD ¹ Income ³ Income Funds of Funds ² Goods/Servi received HIV / A IDS

FY 2010/11 175,402,500 521,426,150 22,009,492 46,504,440 152,147,540 255,119,208 689,499,203 163,909,564 30,421,888 275,919,414 F Y 2 0 11/ 12 167,0 02,70 0 48 7,649 ,667 21,6 73,318 46 ,543,538 2 00,0 70,535 171,757,6 58 9 43,674,606 170,4 36,8 43 79,791,928 384,625,986 203,072,940 FY 2012/13 140,422,290 557,348,975 30,296,650 217,344,462 213,799,340 725,252,055 155,142,921 113,536,037 62,869,868 184,516,715 FY 2013/14 216,100,950 529,372,125 28,784,957 35,194,103 136,189,483 140,272,160 759,581,030 377,220,607 75,646,673 235,769,950 173,258,762 FY 2014/15 272,439,130 537,666,660 28,009,492 35,000,000 164,022,600 195,900,000 701,267,703 155,681,767 23,691,957 301,197,959 242,688,621

Graph 5.2 – User Fee / SUO (Indicates Equity or Affordability for patients to the Health Services)

User Fee / SUO

1,400 1,267 1,200 1,018 1,000 800 645 655 613 600 400 UCMB network: Average Fees/SUO during FY 2014/15 = 5,103 FY 2010/11 FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15

Comment: Equity (affordability) refers to user fees per SUO. It refers to the amount that a patient has to pay per hospital standard unit of output. If services are equitable, then the fee

Page 37 of 100 per SUO must remain low, so that even the poorest of the poor can afford. Equity for Matany Hospital had an increase of 249 from the previous year. The user fees/SUO increased by 24.4% to 1,267. The services provided by Matany Hospital remained for many years constant equitable as the services were highly subsidised. This trend could not be maintained from FY 2013/14 onwards as the increasing costs demanded higher contribution from the users. However the services continue being highly subsidised. There was a fees adjustment in April 2015 which did not contribute much to the annual figures. Another factor for higher user fees income was due to a higher number of patients who could pay cost recovery rates. The average Fees/SUO of all the Hospitals under UCMB was 5,103 for FY 2014/15. Matany Hospital however had 1,267 which was the lowest average fee/SUO in the country and thus Matany remained affordable.

Expenditure

Table 5.2: Trend of Expenditure over the last 5 years, FY2010/11 to FY 2014/15

FY 2010/11 FY 2011/12 FY2012/13 FY2013/14 FY2014/15 Expenditure UGX UGX UGX UGX UGX Employment Cost 941,716,096 1,070,688,081 978,620,282 1,089,165,679 1,210,141,232 Administration Cost 86,484,091 70,828,920 91,605,002 63,336,951 74,668,272 Property Cost 25,815,857 49,077,983 71,097,033 109,970,466 75,635,695 Transport and Plant 188,136,209 249,939,842 160,911,299 192,242,875 158,340,721 Cost Supplies and services 2,766,800 2,160,000 23,359,200 3,387,250 830,000 Medical goods and 429,695,863 605,227,717 540,047,196 681,874,764 519,121,533 medical Supplies Non-medical goods/ 40,754,387 101,980,959 139,300,752 90,157,825 56,764,327 suppl. PHC Activities 159,072,384 188,570,409 120,381,923 123,062,226 87,909,140 Major maintenance and 225,688,179 192,998,410 154,105,324 152,272,656 210,734,276 upkeep of buildings Staff Development Cost 74,970,899 81,931,000 75,068,587 32,175,099 15,606,500 Training School Cost 148,307,922 190,972,052 199,071,283 192,247,135 190,188,657 TOTAL 2,323,408,687 2,804,375,373 2,530,208,679 2,729,892,926 2,599,940,353

Comment: Employment Costs have increased as there were a few more qualified staff employed during FY 2014/15 as after two consecutive years without salary increase the salaries were raised. Administrative Costs increased as all the wards are now interlinked with a LAN and consequently more ICT equipment bought. In the Property Cost management tried to contain the costs. Transport and Plant Costs has decreased as fuel prices fuel prices reduced. Medical goods and supplies decreased as the Hospital Pharmacist bought drugs also from private competitive pharmacies and less from JMS which remains however the major supplier to the Hospital. Non-medical goods/supplies were mainly food items which the Hospital provided partly through the help of ISP in form of dry food rations to the patients. Expenditure for PHC activities reduced as by 31st December 2014 all the Field Health Workers who were paid by the Hospital since the early 80-ties were laid off. This was due to the fact that VHTs are now in place and direct funds to support their salaries were not forthcoming. Major maintenance and upkeep of buildings increased as the Administration Offices were extended. Staff Development costs have decreased as less staff were sent for higher courses. Clinical and paramedical cadres are now easier found on the job market. However management still believes in developing its own staff. The costs for the Nursing and Midwifery Training School have slightly decreased.

Page 38 of 100

Graph 5.3 – Expenditure Details and Trends over the last five years

1,400,000 1,200,000 1,000,000 X 800,000 600,000 '000 UG 400,000 200,000 0 Employ Admini Property Medical Non- PHC Capital NMTS ment Cost stration Cost Transport goods & medical Activities Develop

FY 2010/11 941,716 86,484 25,816 188,136 429,695 43,521 159,072 300,659 148,308 FY 2011/12 1,070,688 70,828 49,077 249,939 605,228 104,140 188,570 274,929 190,972 FY 2012/13 978,620 91,605 71,097 160,911 540,047 139,300 120,381 229,173 199,071 FY 2013/14 1,089,166 63,337 109,970 192,243 681,875 93,545 123,062 184,448 192,247 FY 2014/15 1,210,141 74,667 75,636 158,341 519,122 57,594 87,909 226,341 190,189

Graph 5.4 – Trend of Efficiency over the last five years

Trend of economic Efficiency over 5 years 11,000 10,509 10,000 9,747

9,000 8,431 8,121 8,000 6,893 7,000 Recurrent Costs/SUO 6,000

5,000 UCMB network: Average Recurrent Cost/SUO during FY 2014/15 = 15,240 4,000 2010/11 2011/12 2012/13 2013/14 2014/15

Comment: Efficiency is a measure of recurrent cost per unit output (SUO). In 2014/15, the recurrent cost per SUO decreased to 9,747 as compared to the previous year of 10,509. This is a decrease of 762 or 7.25% cost per output. This is a result of cost containment and proper use of resources. The economic efficiency has thus increased, in spite of inflation and rising costs.

Find in Annex 3 the Financial Report Table which is annually presented to UCMB.

Financial Year Result

FY 2014/15 ended with a surplus of almost 57.6 million UGX. This is attributed to the new CUAMM support mainly to the Maternal to Child Health component in the Hospital and the NMTS. The USAID-Sustain Project assisted with salary support which constituted 20% of the needed funds for salaries. Another intervention from the side of the Hospital

Page 39 of 100 Management was the containment of costs. However it remains a challenge to keep costs low. Clinicians are continuously reminded to avoid Polypharmacy in order to reduce costs for drugs. Management is further confronted with the increased costs of goods and services. Due to lack of funds, salaries were for two consecutive years not increased but for FY 2014/15 a salary increase was effected. Management strives to increase income through regular reports and by keeping in touch with faithful donors. However this has not been always possible due to a slim administration and other commitments.

Government Intervention

As it is shown by the graphs above, Government’s support to the Hospital in the form of PHC CG has slightly increased by 7 million UGX, comparing FY 2013/14 with FY 2014/15. Its support through Development Partners to the Hospital in the form of Essential Drugs has however decreased during FY 2014/15 by 52 million UGX. The budget figures for PHC CG had been the same figures for a couple of years now. How can the Hospital make up for inflation and higher costs? It is hoped that in future the allocation of funds from Government will be based on output rather than on bed capacity and other parameters. Appreciation is given to the Government not only for the financial support itself, but also for the level of co-operation that continued to be good. The release of funds by the Ministry of Health, were most of the time within the quarter they were meant for.

In the entire Karamoja Region there are, apart from Local Government, NGO’s, Schools, Health Units and a few building companies, no major employers. Therefore the vast majority of people living in this area are not able to afford hospital charges if asked for a cost recovery.

Table 5.3: Trend of Average user fees by department in the last 5 years

Average Fees FY 2010/11 FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 UGX UGX UGX UGX UGX OPD Adult & children 1,910 1,908 1,775 2,927 3,790 IP Maternity 6,589 5,205 4,123 4,777 10,135 IP Paediatric 960 959 915 1,396 2,434 IP Surgical Ward 27,346 32,538 29,647 32,108 52,229 IP Medical Ward 14,391 13,774 15,894 20,448 42,142 IP TB Ward 6,266 6,123 5,260 7,748 19,091

From the data in the table above the trend of user fees shows that the Hospital has been trying to keep user fees extremely low in spite of rising costs and inflation. However this trend could not be maintained. This resulted in a slight fees adjustment in FY 2014/15. Therefore the additional income from user fees was 53.9% as compared to year before. This was partly attributed that the Hospital started Memoranda of Understanding with Health Insurances and cost recovery rates were applied to their clients. In April 2015 the BoG of the Hospital decided a further increase of fees and to eliminate the fees difference for patients from within and outside the system (patients from and outside the catchment area).

Looking at table 5.4 below the cost recovery from the patients over the past five years in relation to recurrent cost varied from 7.54 to 12.91. In FY 2014/15 it was at 12.91%. In spite of the higher cost recovery rate Matany Hospital services are not sustainable and can be only maintained from donations of well wishers.

Page 40 of 100 Table 5.4: Cost Recovery Trend in the period FY 2010/11 to 2014/15

FY 2010/11 FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 UGX UGX UGX UGX UGX

Total User fees (a) 175,402,500 167,002,700 140,422,290 216,100,950 272,439,130 Total Recurrent 1,874,441,687 2,149,903,502 1,861,226,431 2,230,135,810 2,111,108,280 Expenditure (b) Cost Recovery Rate = 9.36 7.77 7.54 9.69 12.91 (a/b)x100

As Cost-recovery is still low the effort of management to solicit funds through programmes and donations is evident. - User Fees are captured from the various cost centres and evaluated monthly. Another factor is that often poor patients receive treatment free and the fees are downloaded on the Samaritan Fund account which is fed by external donations.

During FY 2014/15 there was a drop of out patients which was attributed to the early treatment of simple illnesses by the Village Health Teams. There are now more private clinics and drug shops in the region that treat patients. This is a risky development as most of those who run these clinics and drug shops are untrained people. Another factor is that the population has moved to more fertile areas within and outside the District.

Table 5.5: Trend of indicators of efficiency in use of financial resources

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

UGX UGX UGX UGX UGX Maternity Ward 25 beds 32 beds 32 beds 32 beds 36 beds Cost per bed 6,083,132 6,653,608 5,824,158 6,050,123 6,041,099 Average Fee per inpatient 6,589.0 5,204.9 4,122.9 6,792.0 10,134.6

Cost/SUOop 271,948 255,011 229,174 212,209 214,994 Paediatric Ward 119 beds 112 beds 112 beds 112 beds 88 beds Cost per bed 2,191,106 2,706,502 2,957,272 3,032,294 4,163,946 Average Fee per inpatient 960 959 915 1,417 2,434

Cost/SUOop 271,948 255,011 229,174 212,209 214,994 Surgical Ward 41 beds 41 beds 41 beds 41 beds 41 beds Cost per bed 3,292,814 3,191,193 3,629,280 3,899,209 4,777,033 Average Fee per inpatient 27,346 33,725 29,647 44,732 52,229

Cost/SUOop 271,948 255,011 229,174 212,209 214,994 Medical Ward 41 beds 41 beds 41 beds 41 beds 41 beds Cost per bed 4,496,979 4,044,340 4,704,914 4,722,047 4,872,256 Average Cost per inpatient 14,391 14,370 15,894 35,053 42,142

Cost/SUOop 271,948 255,011 229,174 212,209 214,994 TB Ward 58 beds 58 beds 58 beds 58 beds 44 beds Cost per bed 1,136,246 1,371,153 1,398,700 1,494,001 2,315,322 Average Fee per inpatient 6,266 6,123 5,260 10,287 19,091

Cost/SUOop 271,948 255,011 229,174 212,209 214,994 Cost per OPD activity 1,910 1,855 1,775 2,927 3,932

(NB: Total SUOop = Total OP + 15*IP + 5*Deliveries + 0.5*Total ANC + 0.2*Total Immunisation) Source: UCMB

Overleaf table shows in general a trend of rising costs. It is not possible with the inflation and rising costs to be more efficient in saving funds for activities and services. The cost per bed reduces when more beds are provided. In almost all the wards the cost per inpatient day showed a steady rise. The cost per OPD activities has risen by 1/3. This difference is

Page 41 of 100 explained that all the overhead costs have now been apportioned to the various wards, which were not calculated in the past. Due to cost containment efforts of the Hospital Management, the recurrent and also the total costs for FY 2014/15 did not increase. This had an effect also on the percentage of PHC Conditional Grant which remained constant for a couple of years but has not increased equally with the rising costs.

Graph 5.5 – PHC CG contribution towards total expenditure

% of PHC Conditional Grant over the last five FY's vs. expenditure 100.0%

80.0%

60.0%

40.0% 23.23% 21.74% 23.10% 25.39% 19.82% 20.0%

0.0% FY 2010/11 FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15

In table 5.6 below, the average cost of treating three of commonest disease conditions are compared to what is charged to patients.

Table 5.6: Cost and User fees for three common diseases seen in Outpatient Department and treatment of same diseases during severe manifestation in the Children’s Ward

Average Average Amount Amount Estimated charged charged as Disease cost to % of cost hospital (A) (B) (B/A)x100 Out patient department Malaria in children < 5 years 21,000 2,000 9.5% Pneumonia/URTI in children < 5 yrs 27,000 3,000 11.1% Acute diarrhoea in children < 5 years 21,000 2,000 plus 1,000 if 9.5% Antibiotic is needed or 14.3% Admitted in Paediatric Ward Malaria in children < 5 years 150,000 7,000 4.7% Pneumonia in children < 5 years 225,000 8,000 plus 1,000 if 3.6% Antibiotic is needed or 4% Acute diarrhoea in children < 5 years 137,000 8,000 plus 1,000 if 5.8% Antibiotic is needed or 6.6%

In the following tables 5.7 and graph 5.5 the possibility of sustaining the current level of services in the absence of PHC CG and donor funding is shown. In table 5.8 and graph 5.6 the sustainability ratio changes in the absence of donor funds but if PHC CG continues at the current level. (NB: This is the extent to which the Hospital is able to meet recurrent expenditures from locally raised revenues- user fees plus any other local sources of income)

Page 42 of 100 Table 5.7: Trend of sustainability ratio of the hospital in absence of both donors and PHC CG funding in the last 5 years (Local Revenue being only user fees and other locally raised funds e.g. IGA, excluding government funds)

FY 2010/11 FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 Table 5.7 UGX UGX UGX UGX UGX Total Local 442,567,195 370,075,640 364,939,005 389,359,712 515,127,751 Revenues (a) Total Recurrent 1,874,441,687 2,149,903,502 1,981,581,563 2,230,135,810 2,111,108,280 Expenditures (b) Sustainability 23.61 % 17.21 % 18.42 % 17.46 24.58 Ratio = a/b)x100

Graph 5.6 Trend of sustainability ratio in absence of both donors and PHC CG funding in the last 5 years 100.00

80.00

60.00

40.00 23.61 24.58 17.21 18.42 17.46 20.00

0.00 FY 10/11 FY 11/12 FY 12/13 FY 13/14 FY 14/15

Table 5.8: Trend of sustainability ratio of the Hospital in absence of donors funding but with PHC CG funding in the last 5 years (Local Revenue refers to “in-country funding” and therefore includes user fees, PHC CG, Local Government contributions, IGAs, etc.)

Table 5.8 FY 2010/11 FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 UGX UGX UGX UGX UGX Total Local 1,102,113,393 1,198,165,227 1,128,990,535 1,122,400,220 1,303,518,460 Revenues (c) Total Recurrent 1,874,441,687 2,149,903,502 1,861,226,431 2,230,135,810 2,111,108,280 Expenditures (b) Sustainability 58.80 55.73 60.66 50.33 62.21 Ratio = (c/b)x100

Graph 5.7 Trend of sustainability ratio in absence of donors funding but with PHC CG funding in the last 5 years 100.00

80.00 62.21 60.00 58.80 55.73 60.66 50.33 40.00

20.00

0.00 FY 10/11 FY 11/12 FY 12/13 FY 13/14 FY 14/15

The previous tables 5.7 and 5.8 and Graphs 5.6 and 5.7 show clearly the vulnerability of the financial situation of the Hospital although there was some improvement this FY 2014/15.

Page 43 of 100 External Audit

Every year the Hospital carries out an external audit. Key observations and recommendations were:

 Engraving of all Hospital Assets to be completed  Update all personnel Files  Fixed Assets Register to be updated  Make sure that all Payment Vouchers together with supporting documents be stamped “PAID” upon effecting payments  Avoid overwriting on stock cards; better strike through wrong entries still readable and enter correct information and countersign.

The previous audit recommendations were mostly complied with which was stated in the Management Letter for FY ended June 2014 and others were recommended as a way forward.

Procurement

The Hospital has currently no procurement manual. However the procurement procedures in the Hospital are very clear and have been satisfactory. However there is need of writing one. The procurement officer is the Hospital Administrator who co-opts various officers in special procurements. The needs of the various departments are listed and brought for verification to the Administrator.

Conclusion

It remains a challenge to contain costs with a proper utilization of resources. Resources are becoming evermore limited or rather the costs increase and income does not necessarily rise the same level. With the world economic crisis there is little hope that the meagre emergency fund of the Hospital can be invested. Taking these factors into account, the action plan for the next financial year(s) will focus on the following areas:

 Continue the dialogue with the Government at District and at National levels through the strengthening of co-operation, resource mobilisation and mutual trust. Secondment of more personnel through the District Service Commission would help cutting down on Employment Costs. However budget support to cover some percentage of the wage bill is preferred as it is easier to manage staff who receive their salary directly from the Hospital. The salary increase for FY 2014/15 was difficult to shoulder and with the increase of prices of daily commodities the next salary increase may cause a big

challenge to the Hospital.

 Continue monitoring the usage of financial and material resources at departmental levels with more involvement of the staff especially the departmental heads.

 Ensure that budget controls done quarterly and external Audit is carried out annually.

 Continue to make use of the accounting program (FiPro) with proper planning and monitoring of departmental costs

 Develop the next five year Strategic Plan

 Continue keeping structures well maintained

Page 44 of 100 CHAPTER SIX

HOSPITAL SERVICES

This chapter describes the activities of St Kizito Hospital Matany, with regard to comprehensive care of the patients and health of the community. The service package provided by the Hospital is sub divided into 3 sections: Preventive, Curative, and Supportive/rehabilitative services.

CURATIVE:

A. OUT PATIENT DEPARTMENT (OPD)

Introduction

OPD serves as an entry point for patients seeking services from Matany Hospital. According to its established function in the District Health System, the Hospital should offer to the public outpatient consultations of first contact exclusively for the immediate catchment’s area of the hospital (Matany Sub County), outpatient consultations of referral level (for referred patients only), inpatient and emergency (medical and surgical) services and a package of preventive and promotive services (for the immediate catchment area i.e. Bokora Health Sub District). This functional role has been commendable over the last year. Working schedule is from 08:00HRS to 18:00HRS from Monday to Friday and from 08:00HRS to 13:00HRS on Saturday.

OPD Staffing level during the financial year remained quite stable and adequate: the clinical team comprised one medical officer and three/four clinical officers fully responsible for seeing the out patients. The nursing staff level in the department has improved as compared to previous years. Since OPD is the main access point to service care provided by Matany Hospital, a well staffed and efficiently running OPD is a necessity. In April 2015 the OPD had a major restructuring with creation of OPD pharmacy. It relieved the nursing staff off the responsibility of dispensing drugs to patients. They could now concentrate more on other aspects of patient care like triage. The flow of patients and system of payment was also changed to cope with the diversity of clients’ needs.

Laboratory and radiology departments complement the functioning of OPD; in order to ensure diagnostic services, and guarantee quality of care provided to the out patients, these departments are kept functional throughout the readjustments in the OPD work schedule.

During Financial Year 2014/15 the total number of OPD attendances was 32,011, reduction of 3.2% visits as compared to the previous year. Although Matany Hospital is not a referral Hospital in the region, it was observed that 32.7% of the patients were from outside the catchment area. The monthly patients' turn up in OPD was high from July to October 2014 while the period from February to June 2015 had fewer patients seeking care. This trend correlates with the weather pattern. The rainy season is associated with an increase of certain diseases like malaria, pneumonia and diarrhoea especially in children. Fewer patients are seen during the dry season.

Page 45 of 100 Graph 6.1: Illustration of OPD attendance during financial year 2014/2015

Matany Hospital OPD Attendances during FY 2014/15 5,000

4,000 3,111 3,230 3,068 2,915 3,000 2,476 2,525 2,480 2,216 2,163 1,956 2,000 1,726 1,809

1,000 649 192 230 175 147 237 130 179 91 167 70 0 69 Jul-14 Aug Sept Oct Nov Dec Jan-15 Feb Mar April May Jun-15

Total Attendances = 29,675 Re-attendances = 2,336

Table 6.1: Trend of Out-patient Attendance in the period 2007/08 to 2014/15

OPD Department FY FY FY FY FY FY FY FY

07/08 08/09 09/10 10/11 11/12 12/13 13/14 14/15 New attendance 30,193 36,264 40,905 46,429 43,458 37,712 31,055 29,675 Adults 13,895 20,766 20,964 23,215 21,726 20,407 17,470 16,704 Children 16,298 15,498 19,941 23,214 21,732 17,305 13,585 12,971 Reattendance 2,008 3,102 3,146 2,339 1,832 1,640 2,019 2,336 TOTAL 32,201 39,366 44,051 48,768 45,290 39,352 33,074 32,011 OPD plus special 47,058 55,644 64,490 72,495 67,668 65,380 57,866 78,175 clinics

The number of outpatients compared to last year slightly dropped by 3.2%. This is attributed to increased work done by the VHTs who treat common illnesses like diarrhoea, fever and cough. There was an increase in new government health units where some patients go to seek care. Two government health centres were commissioned last year. The improved drug stocks in lower level health centres have reduced the number of patients needing to come to the Hospital. There are also several small private clinics and drug shops that have opened up in trading centres. The migration of communities to the fertile areas as a coping mechanism for the draught and famine, results in limited accessibility to the Hospital. There number of re-attendances remained the same. A new gynaecological OPD was started and a total of 608 patients were seen. More patients were seen in the dental, eye, surgical and private clinics compared to last year. However the number of VCT/HCT reduced by 58.4%. This was because for some months during the year clinicians stopped doing VCT due to lack of HCT client cards. VCT was being conducted only by the counsellors but later Baylor Uganda supplied the HCT client cards.

Graph 6.2: OPD attendance Trends over the last five years

OPD attendance trends over the last five years 100,000 80,000 60,000 40,000 20,000 0 FY 10/11 FY 11/12 FY 12/13 FY 13/14 FY 14/15 New attendance Adults Children

Special Clinics Reattendants Total

Page 46 of 100 Table 6.2: List of Top ten OPD diagnoses in Financial Years 2012/13 to 2014/15

FY 2012/13 FY 2013/14 FY 2014/15 1 Malaria 12,437 1 Malaria 9,392 1 Malaria 9,089 2 RTI 7,461 2 RTI 7,079 2 RTI 4,676 3 GID 2,199 3 GID 2,562 3 GID 2,326 4 Eye Conditions 2,182 4 Eye Conditions 1,474 4 Pneumonia 1,217 Diarrhoeal 5 Skin Diseases 1,709 5 1,535 5 UTI 1,186 Diseases Diarrhoeal 6 1,424 6 Skin Diseases 1,158 6 Skin Diseases 882 Diseases 7 UTI 1,137 7 UTI 1,476 7 Eye conditions 809 8 Pneumonia 955 8 Pneumonia 1,168 8 Diarrheal Diseases 760 9 Injuries(all types) 917 9 STDs 614 9 Injuries 663 10 Anaemia 662 10 Hypertension 586 10 STDs 576

Malaria is still the top diagnosis made in OPD with majority being children. However, there is a general downward trend of the number of malaria cases seen over the years. This is because of the home based management of malaria through ICCM by VHTs who are well facilitated by IRC which ensures that they have a constant supply of anti- malarial drugs. The routine distribution of ITNs in health facilities during the course of the year and intermittent preventive treatment among pregnant women could all have contributed to declining malaria cases. Pneumonia, urinary tract infections and injuries increased last year while hypertension dropped from the top 10 OPD diagnoses. Hygiene related conditions are still prevalent in the community.

Graph 6.3: Top ten causes for OPD Attendance in Matany Hospital during FY 2014/15

Top ten causes for OPD Attendance in Matany Hospital during FY 2014/15 Eye conditions Diarrheal D'ses Injuries 4% STI 3% 3% Skin D'ses 3% 4% Malaria UTI 42% 5% Pneumonia 5%

GID 10% RTI 21%

Graph 6.4: Top ten causes for OPD Attendance in Bokora HSD during FY 2014/15

TOP TEN CAUSES FOR OPD ATTENDANCES IN BOKORA HSD FY 2014/15

Intestinal ENT worms 2% Injuries Pneumonia 2% 2% 2% UTI Skin Diseases 1% Malalaria 4% 47% Diarrhoeal D'ses 4% GID 4% RTI 32%

Page 47 of 100 The graphic overleaf gives an overview of the top ten causes for seeking medical care in all the 14 health facilities in the HSD. Malaria, RTI and diarrhoeal diseases contribute highest disease burden in the community. Hygiene related diseases still make a big percentage of causes for OPD attendance in the HSD. Relevant district authorities need to emphasise promotion of hygiene and proper waste disposal.

SPECIALIST OPD CLINICS

Matany Hospital offers specialised outpatient clinics in Dental Care, Eye care, Comprehensive HIV/AIDS, Antenatal/Postnatal Care, Infant and Young Child care Surgical OPD and gynaecological OPD. With exception of HIV/AIDS Clinic which runs twice a week (Tuesdays and Fridays), the rest of the clinics are functional from Monday to Saturday. There was an increase in the number of patients seen in the specialised clinic by 86.2%. The HIV/AIDS clinic, VCT, eye and surgical clinics remain the busiest.

Dental Clinic

The Hospital provides a limited number of dental services as seen below. Although Dental Care is one of the components of Primary Health Care, its service demand is still low from the catchment population. For this reason, employment of a dentist/oral surgeon is one of the least priorities of Matany Hospital. The senior human resource in this department is a Dental Assistant, with a certificate in dental care.

Table 6.3: The top three procedures done in the course of the year

No of No of No of No of patients patients patients patients Dental Procedure 5 yrs and 5 yrs and 5 yrs and 5 yrs and above above above above 2011/12 2012/13 2013/14 2014/15 1 Tooth extraction 457 403 377 299 2 Dental fillings 163 154 76 80 3 Scaling and polishing 107 62 9 16

Orthopaedic and Physiotherapy

This department is annexed to general surgery. The patient flow to the orthopaedic department is either through the OPD for the outpatients, or from the surgical department, thus catering for both in and out patients. For its proper functioning, the expected staffing norm is supposed to comprise two Orthopaedic Officers and a physiotherapist. Currently the Hospital has one Orthopaedic Officer and a Physiotherapist. For quality assurance and proper follow up of patients, this team works under the supervision of the surgeon or medical Officer in charge of the surgical department. The workload in the department reduced by 39%. A total of 1,713 patients were seen in the orthopaedic unit. With the improved security and mobility, majority of orthopaedic cases are due to road traffic accidents and assault. Occasionally, sporadic cases of congenital abnormalities (club foot), T.B of the spine are treated. Clients for Physiotherapy are identified from all departments, and daily follow up is done for those that are in patients. Tables 6.4 and 6.5 below show the orthopaedic and physiotherapy rehabilitative work load during the year 2014/15.

Page 48 of 100 Table 6.4: Orthopaedic procedures done from FY 2011/12 to FY 2014/15

No of patients Orthopaedic procedures done 2011/12 2012/13 2013/14 2014/15 1 Plaster ( POP) 494 446 664 501 2 Open reduction and internal fixation 141 182 177 200 3 Others 1,282 1,191 1,972 1,051

Table 6.5: Physiotherapeutic services in the Hospital in the last four years

No of patients Condition handled 2011/12 2012/13 2013/14 2014/15 1 Trauma 954 1,191 1,366 1,210 2 Degenerative 289 261 43 53 3 Congenital 41 40 51 53 4 Infectious problems 162 184 83 71

HIV AND AIDS SERVICES

HIV Counselling and Testing/HCT

The regional prevalence of HIV in Karamoja is 5.3% which is lower compared to the national prevalence of 7.3% but is increasing rapidly from 1.7% in 2005. Factors contributing to this include; ignorance about HIV/AIDS, widow inheritance, polygamy, female genital mutilation especially among the Pokot, stigma, rural-urban migration where returnees who are infected from other towns come back and spread the disease, etc... Matany Hospital, in line with the National policy of provider initiated testing and counselling (PITC) is testing all patients who turn up to the Hospital for any health services. The objective of this policy is to increase the number of people who are aware of their HIV status. Those found to be infected must be initiated to treatment thereby reducing transmission rates of HIV. Matany has been carrying out HIV testing and counselling services and has an HIV/AIDS clinic which was started in May 2005. The hospital is also a national sentile site for HIV surveillance. In the last financial year 3,134 clients were tested which was decrease of 58.4% compared to the previous financial year. HIV positive clients were 288 (9.2%). The number of individuals with discordant results has increased by 100% from 13 last year to 26 this year. This has brought a challenge in counselling of these couples and caused conflicts in such relationships.

Procurement of ARVs and laboratory supplies is by Medical Access Uganda (MAUL). This has greatly reduced the problem of Anti-retroviral drugs and laboratory HIV supplies stock outs. The Hospital has two professional counsellors who are not enough to do all the counselling. So to further boost the utilization of counselling and testing services, some staff and clinicians have undergone in service capacity building in provider initiated testing and counselling initiative.

There is need to extend HCT services to hard to reach areas and people with disabilities. HIV sensitization programmes need to be scaled up and also involve elders, religious leaders and more males in the campaign against HIV.

Page 49 of 100 Table 6.6: HIV Counselling and Testing (by gender and age group) and Relationship to Co-trimoxazole Prophylaxis and TB Detection

No of No of No of individuals No of individual Individual No of individual Individuals Total Category 0- <2 yrs 2 - <5 yrs 5- <15 yrs 15 – 49 yrs >49 yrs M F M F M F M F M F H1-Number of 40 43 1,028 1,172 227 223 2,733 Individuals counselled H2-Number of 25 18 21 23 141 115 1,073 1,232 244 242 3,134 Individuals tested H3-Number of Individuals who recei- 19 10 15 18 139 113 1,073 1,232 245 241 3,105 ved HIV test results H4- Number of individuals who received HIV results 9 6 10 12 4 12 171 186 16 22 448 for the first time in this financial year H5-Number of Individuals who tested 0 0 0 0 0 0 103 148 0 0 288 HIV positive HG-HIV positive individuals with 0 0 0 0 0 0 64 79 11 0 154 suspected TB H7-HIV positive cases started on Cotrimo- 0 0 0 0 0 0 132 178 18 3 154 xazole preventive therapy (CPT) H8-Number of Individuals tested 1 0 0 0 0 0 742 1,012 121 0 1,876 before in this financial year (re- testers) H9-Number of individuals who were 422 Counselled and tested together as couple H10-Number of individuals who were Counselled and 422 received results together as couple H11-Number of individuals with 13 Concordant positive results H12- Number of individuals with 26 Discordant results H13-lndividuals counselled and tested 2 for PEP H14-Safe male 2 3 1 2 0 0 Circumcision

Table 6.7, overleaf shows the trend of people counselled and tested for HIV since 2010/11. Note that the percentages of the positive results shown do not depict the prevalence of HIV in the catchment population. The proportion of people who access services in the catchment area is quite limited by the poor health seeking behaviour and also by the fact that up to 40 % of the population in the HSD does live beyond 10 km from the nearest Health facility.

Page 50 of 100 Table 6.7: Trend of HCT in the five Years (2010/11 to 2014/15)

2010/11 2011/12 2012/13 2013/14 2014/15 Positive Negative Positive Negative Positive Negative Positive Negative Positive Negative 354 1,786 334 3,534 276 5,805 224 7,311 288 2,836 Total 2,140 Total 3,868 Total 6,081 Total 7,535 Total 3,124 (16.5%+ve, (8.7%+ve, (4.5%+ve, (2.97%+ve, (9.2%+ve, 83.5%-ve) 91.3%-ve) 95.5%-ve) 97%-ve) 90.8%-ve)

Graph 6.5: Data of table 6.7. - Trend of HCT in five Years (2010/11 to 2014/15)

8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 - FY FY FY FY FY 2010/11 2011/12 2012/13 2013/14 2014/15 Total Positive Negative

EMTCT

The Elimination of Mother to Child Transmission (EMTCT) is a key component of the MCH activities. All mothers at the ANC are tested for HIV and all those who are positive are initiated on option B+ so as to reduce transmission to the unborn baby to less than 5%. These mothers are followed until delivery and postnatal period, their exposed infants are enrolled at mother-baby care points where EID is done and are followed up until they reach 18 months of age when their final HIV status is confirmed. They are later discharged if negative and those positive are enrolled into chronic care in the ART clinic. The Hospital is implementing the option B+ EMTCT strategy. All the mothers were counselled and tested for HIV. The number of exposed infants tested for HIV by PCR below 18 months was 32 of which two tested positive and were started on ARVS. Follow up of exposed infants is still big challenge.

Turn up for the second PCR and Rapid test at 18 months is still low since most mothers cannot wean off their babies from breast feeding due to lack of alternative feeds to give the baby after one year. The current existing food insecurity is a hindrance to EMTCT. Since there is a relative risk of passing the infection through breast feeding, it is not yet established how many of the above infants could have possibly acquired the infection. As a measure to improve on the early infant diagnosis, the Hospital has put in place an EID (Exposed Infant Diagnosis) focal person whose role is to ensure enrolment of HIV positive mothers and their infants into the continuum of HIV/AIDS care. Male involvement in ANC and couple testing has reduced by 8.8% compared to last FY. The number of HIV+ mothers who attended the post natal clinic was 68% which was an improvement compared to the 30% of last year. To increase postnatal attendance, linkage from the Young Child Clinic has been strengthened by ensuring that all mothers returning for DPT1 attend PNC and retesting for HIV is done for all the mothers. Peer members also encourage HIV+ mothers to attend PNC.

Page 51 of 100 Table 6.8: Performance of the EMTCT Program over the last five years

EMTCT INDICATORS 2010/11 2011/12 2012/13 2013/14 2014/15 A12-pregnant women counselled, test and 1,351 1,572 1,595 2,067 1,653 received HIV test results A 13-HIV positive pregnant women given 30 68 31 19 15 co-trimoxazole for prophylaxis A15 HIV Positive Pregnant women 23 63 27 19 15 assessed for ART eligibility A16-pregnant women who knew their HIV(+) status N/A 15 22 26 17 before the 1st ANC visit SD NVP 0 N/A 5 0 0 A 17-pregnant women given AZT - SD 48 N/A 11 0 0 ARVs for prophylaxis NVP (EMTCT) 3TC-AZT-SD 30 N/A 5 0 0 NVP EMTCT INDICATORS (cont.) 2010/11 2011/12 2012/13 2013/14 2014/15 A 18-0thers Specify for regimens covered N/A 0 1 45 14 (Option B+) A 19-Prenant women on ART for their own N/A N/A 25 45 32 health A 20-Male partners tested and received HIV results N/A N/A 872 852 777 in EMTCT 6.2.3 POSTNATAL 2010/11 2011/12 2012/13 2013/14 2014/15 P2-Number of HIV + N/A 33 52 15 21 mothers followed in PNC 6.2.4 EXPOSED INFANT DIAGNOSIS (EID)

SERVICES E1-Exposed infants tested for HIV below 18 months (by N/A 33 52 50 32

1st PCR) E2-Exposed infants testing N/A 5 2 02 2 HIV positive below 18 months E3-Exposed infants given Septrin for prophylaxis N/A 27 22 50 32 within 2 months after birth

Mothers enrolled into EMTCT program are followed up by the counsellors and the PHC department. But still some are lost to follow up.

ANTIRETROVIRAL THERAPY

The ART clinic which was started in 2005 has a cumulative number of individuals ever enrolled in the clinic of 1,954.The number of new patients enrolled in HIV care last financial year was 114. The number of individuals active in the clinic is 735 of which 710 are on ART. The ART clinic runs from 9:00am to 5:00pm every Tuesday and Friday. The client response to seek treatment and care has generally improved however; stigma still remains a big challenge. Following continuous counselling and health education, more clients are adapting to positive living. The ART clinic team has also been conducting outreaches to five lower level units in the HSD (Irrir, Lorengechora, Lotome, Kangole and Apeitolim).The clinic has a family social support group which holds monthly meetings, a drama group and it carries out ‘Know your child status’ activities twice a year. The workload is progressively becoming more stressful to the assigned human resource as all of them have got other job obligations in the Hospital other than work in the ART clinic. This has posed a human resource challenge in the ART clinic. CUAMM and Baylor support and the outreach activities of the clinic.

Page 52 of 100 The main challenges in the clinic include; lack of nutrition support for clients, stigma, low male involvement, long distances trekked by clients, mobile community which makes follow up difficult. Clients also need livelihood programmes to support them economically. The Hospital has tried to address the above challenges by having one medical officer, three clinical officers, two expert clients and two counsellors involved in the comprehensive care of clients on each clinic day. HIV/AIDS patients are also routinely assessed for Tuberculosis and 38 clients were started on anti-TB drugs. The supply of anti-TB drugs from NMS has been better this year compared to the previous years.

Table 6.9: Number of PHAs started on ARV by age group and gender in the last year (2014/2015)

No. of No. of No. of No. of individuals < individuals individuals individuals Total 2years 15years and Category 2-< 5years 5-14years (24months) above Male Female Male Female Male Female Male Female Number of new patients enrolled in HIV care at this 1 2 1 0 2 2 55 81 144 facility during the year Number of pregnant women enrolled into care during the 0 12 15 year. Cumulative Number of individuals on ART ever 6 7 26 20 18 18 491 639 1,225 enrolled in HIV care at this facility Number of HIV positive patients active on pre-ART 0 0 0 0 1 0 46 94 25 Care Number of HIV positive cases who received CPT at last visit 7 11 33 23 70 85 433 540 735 in the year. Number eligible patients not 2 0 1 0 2 0 67 73 06 started on ART Number of new patients started on ART at this facility during 1 2 1 0 2 2 54 55 117 the year. Number of pregnant women started on ART at this facility 0 12 12 during the year. Number of HIV positive 1,3 patients assessed for TB at 8 11 40 27 67 77 1,820 735 56 last visit in the year Number of HIV positive patients started on TB 0 0 1 0 1 0 17 19 38 treatment during the year Net current cohort of people on ART in the cohort completing, 4 2 3 5 4 6 88 116 228 12 months during the year Number of clients surviving on ART in the cohort completing, 2 2 1 4 3 5 39 86 142 12 months on ART during the year Number of people accessing 1 1 1 2 0 2 14 40 17 ARVs for PEP

Page 53 of 100 Mental Health

Mental health is one of the components of Primary Health Care, and Matany Hospital being a general health facility is mandated to provide mental health services among its service profile. There is no specialised psychiatric clinic run by the Hospital but the patients are taken care of in the routine OPD and in patient service delivery. Through an initiative by UCMB to improve mental health services in all hospitals in the Catholic Health Services network, all hospitals under the umbrella were expected to develop human resource capacity in mental health care. Matany Hospital had a Psychiatric nurse during the year. Psychiatric/mental health services are included in the routine PHC outreaches to the community. This was aimed at addressing the fact that most of the psychiatric patients are neglected in the community and therefore miss out the necessary care.

Table 6.10 below, shows the disease burden of the top five psychiatric conditions in the community. Epilepsy remains the commonest condition seen in the catchment population. Its high prevalence is attributed to being a sequel of cerebral injury following childhood febrile illnesses. A few cases may be related to cerebral trauma, intrauterine infections and intrapartum complications like hypoxia. Most depression cases are likely due to psycho– social stress factors (substance abuse, gender based violence, child abuse, extreme poverty, loss of loved ones etc) in the community. Through continued community sensitization and mental health promotion, we hope to gradually improve community attitude and perceptions towards mental health. Given the low utilization of mental health service, and also due to the fact that psychiatry is a highly specialised area in medicine, it is not a hospital priority to employ a psychiatrist. Patients who require more specialised care are referred to appropriate centres for better care.

Table 6.10: Top five mental health diagnoses

2011/12 2012/13 2013/14 2014/15 Top five mental health No. of No. of No. of No. of diagnoses Patients Patients Patients Patients 1 Epilepsy 263 483 111 182 2 Depression 20 46 25 77 3 Alcohol and Drug abuse 12 202 8 25 4 Anxiety Disorders 11 136 22 15 5 Dementia (Mania) 2 13 1 5

Ophthalmology

Eye care is also one of the components of primary health care. Most disability due to eye conditions can be avoided through timely and appropriate treatment. Matany hospital provides a wide spectrum of eye care services that includes medical treatment and eye surgery. The Eye care clinic in the hospital is run by an Ophthalmic Assistant whose basic training/qualification is a certificate in eye care. He is able to diagnose and treat most eye conditions, screen for refractive errors and dispense spectacles with the overall supervision of the clinical team. He has been trained to carry out TT-surgery by Dr. Keith Waddel. The more specialised surgical treatment is provided through ophthalmology camps carried out by ophthalmologists. During FY 2014/15, one surgical camp was conducted in November 2014 with a total of 156 Patients operated. Cataract is the main indication for surgery contributing 83% of all ophthalmic surgeries done. Ophthalmic Assistant performed 295 lid rotations in the year.

The pathology mix for the eye conditions includes the following; allergic and bacterial conjunctivitis, cataract, eye trauma, entropion, active trachoma infection with some cases of

Page 54 of 100 trachomatous trichiasis, corneal ulcers and scarring. Cases of glaucoma are not common among the catchment population.

Table 6.11: Trend in numbers of Ophthalmology services over the last 5 years

2010/11 2011/12 2012/13 2013/14 2014/15 No. of uncomplicated cases treated 1,833 1,563 1,518 1,039 1,355 No. of cases operated 275 137 234 322 374 No. of cases referred 18 16 6 6 0

Utilisation of Ophthalmology services has increased by 30.4% compared to last year. The Hospital organises annual surgical camps conducted by the team from Ruharo eye centre, headed by Dr. Keith Waddel.

Palliative care

Care for the terminally ill is one of the challenging tasks that Matany Hospital has to undertake. There is no Community Based Organization or Civil Society Organization providing support to the terminally ill patients in the district. Home based care for the chronically ill patients is also nonexistent, leaving the entire burden of palliative care to the Hospital. Over the last ten years, there has been a gradual increase in numbers of chronically ill patients. This trend is associated to high levels of poverty, poor health seeking behavior, increasing prevalence of HIV/AIDS and cancers. Liver cirrhosis with ascites secondary to Hepatitis B infection and excessive alcohol consumption has also become one common cause of palliation among patients on the Medical ward. The emergence of chronic diseases such as Hypertension, Diabetes and Asthma have set a new dimension of high cost implications on the Hospital since most of the affected patients are very poor and unable to afford the already subsidized charges in the OPD when they return for periodic reviews and refills. Besides providing treatment and nursing care to these patients, the Hospital provides them with food as well. The Samaritan fund set aside by the Hospital to provide support to this category of patients has not been sufficient with the little contributions to this fund sourced from friends and benefactors of the Comboni Missionaries. Resource mobilization for such essential humanitarian undertakings is progressively becoming more challenging for the PNFP hospitals. The proposed National Health Insurance scheme that should have lifted this corporate responsibility mantle from the Hospital has never come to existence. It is high time other options are explored to write palliative care projects in order to solicit for the necessary support in palliation of our terminally ill patients. The palliative care section is run by a registered nurse counselor trained in Palliative care. There is still need to train another health professional to be able to ensure continuity of service in event of her absence. Pastoral care is provided by a missionary sister to patients on a daily basis. A combination of palliative and pastoral care are very essential in the care of the terminally ill as they provide for both medical and spiritual support.

Page 55 of 100 B. INPATIENT WARDS

Organization and management

Matany Hospital has got five In-patient care departments; Maternity, General Surgery, Internal Medicine, Paediatrics and TB wards. The management and organization of each ward is under the care of a diploma nurse, medical officer or specialist. They are charged with the responsibility of quality assurance in patient care and treatment, duty allocation and supervision of junior staff. The criterion for admission includes critically ill patients and those who cannot take oral treatment. During the triage process, the categories of patients who are moderately ill are kept under observation while on treatment for at least 24 hours. They are then reassessed and either allowed home on treatment or admitted for continued inpatient care. Discharge is on clinical improvement and a patient should be able to feed and take oral treatment at home. Some patients are discharged on request with full consent of the patient and care taker. This scenario is common with terminally ill patients or those for whom the caretakers feel they can find better treatment elsewhere. Under both circumstances, the patient’s charter is strictly observed for medico–legal purposes. Ward rounds are done twice daily by the clinical team, nurses and paramedics in each respective department. A general ward round is done in the morning to review all patients who spent a night in the ward. In the evening round, critically ill patients are reviewed, newly admitted patients from OPD are re assessed and patient review with laboratory results is also done. Treatment schedules used strictly follow the National Clinical Guidelines for the dosage, route and frequency of specific drugs. The Hospital also has in place some treatment protocols adopted from World Health Organization. The last FY 9,556 patients were admitted, with children’s ward having the highest admissions and contributing 48.4% of inpatients. Monthly admissions are distributed according to the climatic season with the busy months corresponding to the rainy season.

The T.B ward had the least number of admissions. The expected number of TB cases in the catchment population is 436 patients for 2014/15. Matany Hospital treated 512 patients, a case detection rate of 117%. This is above the expected National Case detection rate of 70%. The identification of TB cases follows the national algorithm for TB diagnosis. History of the patients, physical examination and investigations are done to make the diagnosis.

Treatment also is according to the national TB treatment guidelines. The average length of stay on TB ward has greatly reduced from 35 to 25.6 days. In the past the Hospital implemented hospital based DOTS where patients were discharged after completing the intensive phase. This led to long durations of stay on the ward but reduced defaulting rates. The National T.B treatment protocols recommend two weeks of in-patient treatment and then allow patients back home to continue with CB DOTS. The Hospital started implementing this guideline in this FY which has led to reduction in the average length of stay on ward unless they are critically ill. However this may increase defaulter rates since many patients are lost to follow up thereby increasing a risk for MDR-TB. Patients who default are traced with the help of VHTs and until December 2014 by Field Health Workers.

Page 56 of 100 Table 6.12 below shows the various in-patient indicators for the respective departments.

Table 6.12: Utilization indicators per ward and for the Hospital for 2011/12 – 2014/15

Surgical Medical 2011/ 2012/ 2013/ 2014/ 2011/ 2012/ 2013/ 2014/ WARD WARD 12 13 14 15 12 13 14 15 (41 Beds) (41 Beds) Patients Patients 1,117 1,205 1,169 1,128 1,237 1,291 958 1,033 Discharged Discharged Duration of stay Duration of stay 9,334 12,521 18,949 16,024 10,781 10,174 10,699 10,963 (No. of days) (No. of days)

Avg. duration of Avg. Length of 8 11 16.2 14.2 6 7 11.2 10.6 stay (No. of days) stay (No. of days)

Bed Occupancy Bed Occupancy 62% 84% 127% 107% 72% 68% 71% 73% Rate Rate

Turnover Interval Turnover Interval 5.1 2.6 -3.4 -0.9 3.4 4.4 4.45 3.9 (No. of days) (No. of days)

Throughput per Throughput per 29 27 29 28 Bed (No. of 41 35 23 25 Bed (No. of pts) patients) Paediatric 11/12 12/13 13/14 2014/15 Maternity 11/12 12/13 13/14 2014/15 WARD (112 (112 (102 (88 WARD (32 (32 (32 (36 beds) beds) beds) beds) beds) beds) beds) beds) Patients Patients 5,327 4,859 4,026 4,217 1,716 1,973 1,635 1,790 Discharged Discharged Duration of stay Duration of stay 36,343 30,247 30,247 27,600 8,498 8,764 8,764 12,060 (No. of days) (No. of days) Avg. duration of Avg. duration of 7 6.2 7 6.5 5 4.4 5 6.7 stay (No. of days) stay (No. of days) Bed occupancy Bed occupancy 88.9% 74% 81.2% 86% 73% 75% 157% 92% Rate Rate Turnover Interval Turnover Interval 0.2 2.2 1.7 1.1 1.9 1.5 4.0 0.6 (No. of days) (No. of days) Throughput per Throughput per Bed (No. of 52 43 45 48 Bed (No. of 51 62 46 50 patients) patients) T.B Adults 2014/ 15 2011 2012/ 2013/ OVERALL 11/12 12/13 13/14 2014/15 WARD (44 (284 (284 (284 (250 /12 13 14 Indicators (58 Beds) beds) beds) beds) beds) beds) Patients Overall 309 398 326 438 79% 79.6% 77.4% 85.6% Discharged B.O.R No. of patient Turnover 17,778 15,008 11,531 11,221 2.2 4.9 2.5 3.1 days interval Avg. Length of Throughput stay (No. of 58 38 35 25.6 40.9 34.4 32.7 32 per bed days)

Bed Occupancy Avg. Length 83.7% 70.9% 54.5% 69.8% 7 8 9 8.1 Rate of stay

Total Turnover Interval 11.2 15.5 29.6 11 Inpatient 81,881 82,544 80,190 77,868 (No. of days) Days Throughput per Bed (No. of 8 7 6 10 patients)

The general average length of stay reduced from 9 to 8.1 days with TB ward having the most significant reduction of 9.4 days. However, maternity ward length of stay increased

Page 57 of 100 from 5 to 6.7 days because of the increased number of gynaecological cases seen on the ward in the last FY. The bed occupancy rate increased from 77.4% to 85.6%. Surgical ward still has the highest bed occupancy rate (107%) because the patients stay long (14.2 days) yet the beds are fewer compared to the number of patients admitted meaning that some miss beds. Some of the stable orthopaedic cases on traction are utilising the free rooms on Paediatric ward. This explains why it also has the least turn over interval of – 0.9.The bed occupancy rate reduced on maternity but the ward had the highest throughput per bed of 50. This because patients stay for a short period on maternity ward. TB ward beds are the least utilised (throughput per bed), with 10 patients using a single bed in a year and has the highest number of days between patients (turnover interval) of 11 days.

Table 6.13: Top 10 causes of admission

Cause of Admission Cases 1 Malaria 2,559 2 Pneumonia 753 3 Anaemia 646 4 TB 512 5 Diarrhoeal Diseases 471 6 Respiratory Infections 423 7 Injuries 415 8 Urinary system diseases 305 9 Skin Disease 265 10 Cardiovascular Disease 189

Table 6.13 above and the graphic below show the top ten causes of admission in Matany Hospital. The pattern of causes of admission is similar to that of cases seen in OPD. Few RTIs are admitted because most are simple illnesses and are treated as out-patients. Only the more serious chest infections like pneumonia are admitted. Malaria remains the leading cause of admission contributing 26.8% of in-patients. This is followed by Pneumonia and anaemia. Cardiovascular conditions have increased in the community. Treatment of these conditions and other chronic illnesses has been highly subsided to make it affordable for patients.

Graph 6.6: Ten top causes of admission during FY 2014/15

Ten top causes of admission during the FY 2014/15 Genito-urinary Skin D'ses Cardiovascula diseases 4% r D'ses TB 5% 1% Malaria 6% Injuries (All 40% types) 7%

Respiratory infections 7% Diarrhoeal D'ses Anaemia 8% 10% Pneumonia 12%

The Graphic 6.7 shows the top causes of mortality in Matany Hospital. Perinatal conditions are the leading cause of mortality, followed by tuberculosis, cardiovascular, pneumonia and liver disease. Severe malnutrition has dropped out of the top ten causes of death. Perinatal conditions included; prematurity, respiratory distress, hypoglycaemia and neonatal sepsis. Treatment of anaemia is a serious challenge to the Hospital. Ensuring constant supply of blood is difficult since Karamoja region does not have a blood bank.

Page 58 of 100

Graph 6.7: Top causes of death during FY 2014/15

Five top causes of death during FY 2014/15 in Matany Hospital Respiratory Perinatal infections Acute renal conditions (All Other types of (other) failure types) meningitis 5% 4% 21% 5% Malaria 7%

Liver diseases TB (other) 14% 9%

Liver Cirrhosis Pneumonia Cardiovascular 10% 11% D'ses 14%

Table 6.14: Trends of the top causes of death in the Hospital

TOP 10 CASE FATALITY RATES A B Case Fatality Rate List Causes of Mortality No of Disease Total No of cases (A/B) x 100 during the Financial Year specific deaths of the disease admitted 1 Perinatal conditions 46 144 31.94% 2 TB 38 512 7.21% 3 Cardiovascular Disease 32 189 16.93% 4 Pneumonia 25 753 3.32% 5 Liver Cirrhosis 23 104 22.16% 6 Liver diseases (other) 20 74 27.03% 7 Malaria 15 2,559 0.58% 8 Other types of meningitis 12 48 25% 9 Respiratory infections (other) 11 423 2.60% 10 Acute Renal Failure 9 42 21.43%

Comment: Perinatal conditions, liver disease, renal failure and cardiovascular diseases have high case fatality rates.

Maternity Ward

Maternal child health is one of the quality indicators in Matany Hospital. Unfortunately the reproductive health indicators in Karamoja region are among the worst in the country. This is attributed to the fact that quite few mothers seek medical attention and most of the society is still conservative to traditional medicine and birth attendants. The number of ANC first visits was 1,289; a slight drop of 10 from the previous financial year. However, there was a good turn up for ANC fourth visit from 601 to 800, an increase of 33.1%. Most mothers come late for the first ANC visit with some reporting in the third trimester. The dropout rate between the first and fourth antenatal visits has reduced from 46% to 38% this year. More mothers are attending the 4th ANC visit from 46% of last year to 62% this year. This is higher than the national average of 47.6% according UDHS 2011. This trend can be attributed to the intense health education done in the ANC. The expected number of pregnant women in the catchment area (Matany sub county) was 1,140 but 1,289 women attended the first ANC. This made the first ANC coverage of 113%. The distribution of insecticide treated mosquito nets has greatly attracted mothers to

Page 59 of 100 ANC. The clinic is run by a double registered nursing officer who is also a trained counselor. She is assisted by other midwives and students. Mothers receive all ANC services in one place.

Post natal attendance is gradually increasing. The number of post natal mothers seen was 765 which was an increase of 15.4% from last year. More mothers who deliver in the Hospital are attending the postnatal care. Of the 1164 mothers delivered, 66% returned for PNC. Continuous sensitization of mothers is needed to increase awareness about maternal health services. There is also an effort to use TBAs as change agents to refer mothers who go to them to seek better services at health facilities. Table 6.15 below shows some ANC and post natal care indicators.

Table 6.15: Antenatal and Postnatal indicators

ANTENATAL 2010/11 2011/12 2012/13 2013/14 2014/15 A1- ANC 1st Visit 1,309 1,578 1,461 1,299 1,289 A2- ANC 4th Visit 280 263 259 601 800 A3- Total ANC visits new clients + Re-attendances 2,522 2,731 3,141 5,004 4,859 M- ANC Referrals to unit 160 26 128 194 158 A5- ANC Referrals from unit 13 10 0 0 18 POSTNATAL P1- Post Natal Attendances 561 831 419 663 765 P2- Number of HIV+ mothers followed in PNC 34 33 35 8 56 P3- Vitamin A supplementation 2,038 1,415 1,342 695 641 P4- Clients with pre-malignant conditions for breast 0 0 0 0 0

Comment: Postnatal attendances have increased compared to last year.

Maternity Admissions:

Table 6.16: Maternity ward admission – (Deliveries and Births indicators)

Deliveries and Births indicators 2010/11 2011/12 2012/13 2013/14 2014/15 Total Admissions for delivery 922 967 952 1,060 1,164 Deliveries in unit 922 967 952 1,060 1,164 Normal delivery 648 684 612 815 852 Abnormal delivery (incl C/S) 274 283 340 245 312 Live birth in units 934 971 975 1,052 1,137 Babies born with low birth weight (<2.5Kgs) 81 135 162 149 139 Fresh Still births in unit 13 14 16 14 +7 due 16 to HEV Macerated still births in unit 32 11 12 14 11 Newborn deaths (0-7days) 13 12 17 15 45 FSB died in hospital (FHS heard before del) N/A N/A N/A N/A 2 Maternal deaths 5 8 6 7 +16 due 4 to HEV For Live Births 2010/11 2011/12 2012/13 2013/14 2014/15 Full term Normal wt 756 777 672 903 967 Full term Low birth wt 102 130 144 149 127 Premature 76 64 61 76 43 For Caeserean Sections Elective C/S 30 26 39 34 40 Emergency C/S 228 244 287 211 228 Total C/S 258 270 326 245 268 C/S as % of Total deliveries 28 27.9 34.20% 23.11% 23.02% Emergency C/S as % of all C/S 88.4 90.4 88.04% 86.12% 85.07%

During the Financial Year, the number of deliveries in the hospital was 1,164, with an increase of 104 deliveries from the previous FY. 852 of the deliveries were by spontaneous vaginal delivery, while 268 were by caesarean section. The macerated still births were 11, while Fresh Still Births were 16. Only two mothers lost their babies in the Hospital, the rest

Page 60 of 100 (14) of the FSBs did not have active foetal heart beats at admission. One of the Hospital FSBs was to a mother who reported to labour suite with two previous scars in labour but refused to consent for surgery together with the husband. They escaped from the ward in the night only to come back when the mother had already ruptured. The rest of the FSBs were due to delay to report to the Hospital and not attributed to errors in monitoring progress of labour.

Upon admission of a mother into labour ward, labour is managed according to the recommended guidelines by the Ministry of Health, and closely monitored by the midwife using a partograph, which is plotted for each mother in active labour. The doctor attached to Maternity ward periodically reviews mothers in labour, and makes necessary interventions as indicated. The medical officer consults the specialist where there is need. All caesarean sections are sanctioned and performed by the doctor on duty in maternity ward or the doctor on call. Table 6.16 overleaf gives a summary of deliveries conducted in the Hospital during the period under review.

A Fresh Still Birth is a baby delivered with the skin intact and not macerated, indicating that the death occurred within 24 hours before delivery. It is a quality indicator of obstetric services. Total Still Birth Rate takes into account all the foetal deaths while the Fresh Still Birth rate takes into account foetal demise in the hospital after admission (or shortly before admission and is delivered within less than 24 hours of admission). For FY 2014/15 the Total Still Birth Rate was 2.3% (27), a reduction of 1% compared to the previous year. The fresh still birth rate in the hospital of babies admitted with foetal hearts was 0.17%.

Caesarean Sections

Graph 6.8: Trend of deliveries over the last five years

Norm. Delivery vs. CS over the last five years 1,400 1,164 1,200 922 967 952 1,060 1,000 852 815 800 684 648 612 600 400 258 270 326 245 268 200 - FY 2010/11 FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15

Total adm. Normal Caeserean for delivery Delivery Secion

During FY 2014/15 the caesarean section rate as a percentage of total deliveries was 23.02%, a decrease of 0.09% compared to last year. The expected percentage of deliveries by caesarean section is 15% but considering that Matany Hospital receives many referrals; most of these mothers end up having to deliver by c/section. Caesarean section accounts for the greatest percentage (15%) of major operative procedures done in the Hospital.

Page 61 of 100 The main indications for C/S were:

1. Obstructed labour 6. Severe oligohydromnios 2. Foetal Distress 7. Poor progress of labour 3. Ante partum haemorrhage 8. Cord prolapse 4. Cephalopelvic disproportion 9. Malpresentation and lie 5. Previous C/S section (2 or more) 10. Maternal distress

Maternal deaths

Pregnancy and child birth are expected to be a pleasant experience for the mother, the baby and the community. It is not expected that any mother should die during pregnancy and child birth. However, a number of unfortunate circumstances have led to the occurrences of the unacceptable phenomena. Three delays are likely responsible for the cause of a maternal death, whenever it occurs; the delay by the mother to make a decision to seek medical attention, the delay to get the health facility; and the delay to initiate the correct management/procedure once at the health facility. The first and second delays have always been the major cause maternal deaths in the hospital. During FY 2014/15, four maternal deaths occurred in the Hospital. Three of them died because of postpartum haemorrhage with severe anaemia and were all late referrals, two from Kotido and one from Lorengechora health centres. The fourth mother died of disseminated intravascular coagulopathy secondary to severe PET. Maternal death audits were done as per the Ministry of Health recommendation using the standard guidelines. Each of the events was reported to the District Health Office and Ministry of Health HMIS data bank.

Treatment and care of Gynaecological cases:

A section in the maternity ward is designated for the treatment and care of gynaecological cases. The common gynaecology cases for admission include; abortions, ectopic pregnancies, tubo–ovarian masses, dysfunctional uterine bleeding, fibroids and malignancies. Cases of birth related injuries are occasionally hospitalised with most of them being mothers who delivered in the village or referred from lower level health units in the neighbouring districts. The Hospital has since the beginning of the financial year employed an obstetrician/gynaecologist to guarantee specialised care for mothers so as to minimise maternal deaths. The specialist is also expected to play a role in bed side teaching and mentorship of the midwifery trainees, midwives and junior doctors.

The high caesarean section rate (23.02%) in the Hospital is due to referrals from other health facilities. Graphic 6.9 below shows a comparative analysis of the provenance of mothers who underwent caesarean section over the last four years. 75% of the mothers who underwent C/S were from Bokora HSD/Napak district while the remaining proportion was from Moroto, Kotido, Katakwi, Nakapiripirit and others.

Page 62 of 100 Graphic 6.9: Provenance of women who underwent CS in Matany Hospital in the past five years

Provenance of women who underwent CS 90% 80% 70% 60% 54% 50% 40% 30% 20% 14% 14% 10% 9% 5% 4% 0% Napak Moroto Kotido Katakwi Nak'pirit Others

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

From this analysis, it is quite evident that a significant amount of workload is imposed on Matany Hospital by the limited performance of the health care system in the neighbouring districts. The cost implications of this factor is a burden that Matany Hospital should struggle to contain, against all odds of resource mobilisation. From the catchment population of (UBOS projection, 2014/15) for Napak district, the expected number of pregnancies was 7,261 with 7,043 births. The total number of supervised deliveries in the district was 4,873. Out of which 1,164 were in Matany Hospital while the remaining 3,709 were in the Lower level health units. Therefore Matany Hospital contributed 24% of the supervised deliveries. The overall percentage of supervised deliveries in Napak was 69.2%. Matany Hospital had a total of 4,859 ANC visits out of which 1,289 were first visits and 800 fourth visits. The total ANC visits in the district were 6,318 compared to 5,700 of last year. Generally there is a positive trend in uptake of maternal health services in the district.

C. OPERATING THEATRE

One of the busiest and most expensive departments in the Hospital is the operating theatre. Due to its efficiency and reliability, workload of Matany’s operating theatre is increasing. We perform both elective and emergency surgeries. Elective surgery is one which is planned and done at the convenience of the patient and surgical team while Emergency surgery is that which if not performed urgently, the patient’s health would be severely compromised and may lead to fatality. Operating theatre works 24hrs due to the ever constant availability of water and electricity. A wide range of major and minor surgical procedures are carried out in the theatre as depicted in the data provided below.

Table 6.17: Top ten surgical procedures done in the course of the year (out of 2,146)

No Top ten surgical procedures done Number of Patients Proportion % 1 Caesarean Section 268 23% 2 Debridement 203 15% 3 Abscess Incision and Drainage 186 11% 4 Laparotomy 154 10% 5 Orthopaedic Surgery 143 9.1% 6 Urogenital Tract Surgery 124 7.6% 7 Excision Soft tissue 119 7.3% 8 Osteomyelitis Surgery 99 6.1% 9 Lymphadenectomy 94 5.8% 10 Herniorrhaphy 78 6%

Page 63 of 100

The key indications for surgery over the last five years are seen in table 6.18 below.

Table 6.18: Trend of surgical activities in the period from 2010/11 to 2014/15

2010/11 2011/12 2012/13 2013/14 2014/15 Major operations (incl C/S) 1,119 1,016 1,059 1,047 714 Emergencies 293 314 380 516 282 Emergency Op as % of total 26.2 30.1 57.3 49.3 39.5% major operations Minor operations 1,237 1,128 1,024 1,226 1,432

The number of operations done was less than those for the last financial year.

D: DIAGNOSTIC SERVICES

Laboratory

By the end of June 2015, the human resource in our Laboratory included two Laboratory Technicians and four Laboratory Assistants. The Laboratory is a very busy department in the Hospital with a diagnostic role to both the outpatients and inpatients. The staffs were able to cope with the increased workload. They maintained a 24-hour on call service throughout the year. The capacity of the laboratory to carry out some tests like histopathology, culture and sensitivity is still lacking, thus samples for these tests have to be sent to Kampala.

The Laboratory acquired new diagnostic machines during the year. These include; GeneXpert, chemistry analysers (Humastar 80 and Hemolyte), Hemacount and CD4 FAC count. These machines have increased the productivity of the laboratory, reduced the turnaround time of results and provided a wide range of investigations for clinicians to request. The laboratory has also been extended to create more needed space. It has joined the SLAMTA/SLIPTA program and was assessed by Central Public Health Laboratories at the end of the financial year. This program should improve the quality of the laboratory services.

Table 6.19: Trend of Laboratory testing workload in the period 2010/11 to 2014/15

FY FY FY FY FY Type of laboratory test 2010/11 2011/12 2012/13 2013/14 2014/15 Blood smear for Malaria parasites 20,563 19,298 18,708 19,127 14,752 Blood smear for other purposes 100 59 137 49 10 WBC Count (total and differential) 2,134 3,098 3,282 4,306 3,524 Sputum smears (specific MT/a specific) 4,450 4,515 2,638 3,998 3,797 Urethra, vaginal smears & pus smears 156 186 8,07 585 276 Haemoglobin estimations 6,945 5,425 7,828 9,343 11,316 PCV 94 1,557 0 0 0 Sickling Test 99 79 69 81 14 ESR 255 304 468 923 111 Blood grouping and X-Matching 7,825 5,327 6,291 7,705 7,823 Urine examination 3,375 3,695 2,773 3,972 4,230 CSF examination 135 315 126 89 143 Other body fluid examinations 80 93 0 0 288 Stool examinations 541 704 770 622 854 Widal test 1,593 1,168 1,997 2,137 782 VDRL 4,393 3,271 4,785 5,460 2,327

Page 64 of 100 FY FY FY FY FY Type of laboratory test 2010/11 2011/12 2012/13 2013/14 2014/15 Serum Creatinine 490 672 1,177 1,158 1,295 Blood Glucose 319 284 214 472 794 Pregnancy test 562 608 963 588 630 HIV test 5,289 6,358 8,948 10,314 10,253 Hepatitis B. 2,677 1,594 1,961 2,033 2,368 SGOT 349 806 1,305 1,315 815 SGPT 359 806 1,305 1,315 802 Other 13,077 24,108 18,674 7,625 16,547 TOTAL 75,860 84,330 85,226 83,217 83,751

As standard it is recommended that each patient should at least have one investigation done in the laboratory so as to guide the clinicians in making a correct diagnosis. This limits the tendency by Clinicians to treat patients by giving the best guess treatment.

Graph 6.10: Average Laboratory Investigations requested per patient

Average Laboratory Investigations requested per patient since FY 10/11

83,751 90,000 84,330 82,432 83,217 75,860 80,000 70,000 61,912 60,410 55,121 60,000 41,566 50,000 40,238 40,000 30,000 20,000 10,000 1.2 2.1 1.4 1.5 2.0 0 FY 10/11 FY 11/12 FY 12/13 FY 13/14 FY 14/15

No. of Lab. Investigations No. of Patients Average

Graph 6.10 above shows that over the last five years, the standard of at least an investigation per patient was achieved. In the previous FY each patient had an average of 2.0 investigations done.

Blood transfusions

Most blood supply to the Hospital was from Nakasero Blood Bank and Mbale Regional Blood Bank (MRBB), supplied on request. The blood from Nakasero is most times delivered by air, thanks to Mission Aviation Fellowship (MAF). The Quality Assurance Team from MoH strongly advised the Hospital to stop local blood collection and screening as the Hospital has not got the capacity to do PCR testing for HIV in window period. One blood donation drive was conducted in June 2015. Blood was sent to Mbale regional blood bank for screening. In view of the cost implications of transporting blood from Nakasero and Mbale, there is urgent need to establish as a short term intervention a blood collection centre and eventually a regional blood bank in Karamoja to cater for the needs of blood transfusion services in the Regional Referral Hospital Moroto and the four general hospitals and health centre IVs in the region. During FY 2014/15 the total number of Blood

Page 65 of 100 Transfusion was 2,536 which was an increase of 63% compared to the previous year (1,613).

Graph 6.11: Blood Transfusion Services

Blood Transfusion in Matany Hospital during FY 2014/15 297 300 274 255 245 250 217 211 200 187 186 200 171 158 135 150

100

50

0 Jul-14 Aug Sep Oct Nov Dec Jan-15 Feb Mar Apr May Jun-15

The main indications for transfusions were anaemia due to severe malaria and haemolytic anaemia due to septicaemia especially in children while in adults the main reasons for transfusions were gynaecological and obstetric emergencies, surgical interventions and cancer patients.

IMAGING SERVICES

X-Ray Investigations

By the end of June 2015, the human resource in our X-Ray Department included two Dark Room Assistants, who were trained on the job and have gained a lot of experience over the years. The number and quality of X-rays taken still remained high attributed to the competence of these two personnel.

Table 6.20: X-ray examinations done over the last seven years in the Hospital

Year 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 Chest 2,405 3,2142,848 3,296 3,065 3,407 3,410 Plain Abdomen 131 141 141 106 156 159 150 Barium Enema 1 1 1 1 5 8 3 Barium Meal 16 14 12 12 33 30 47 Traumatology 1,370 2,000 1,739 1,321 1,562 2,278 2,004 Skeletal 773 937780 854 814 863 904 Urogenital 48 30 0 0 0 0 0 TOTAL 4,744 6,3375,521 5,590 5,635 6,745 6,518 No. of Patients 4,615 6,077 5,327 5,546 5,491 6,373 6,350 Chest Screening

It remains a challenge to get trained personnel and at the same time to keep personnel cost low. Over the years a higher demand for x-rays and ultrasound was observed as clients are referred from different Health Units in Karamoja for these investigations. This proves that the staff in the department who were trained in the past by visiting radiologists have gained great experience.

Page 66 of 100 Graph 6.12: Trend of x-ray examinations over the past five years

Trend of x-ray examinations over the past five years 7,000 6,745 6,598

6,000 5,521 5,590 5,635 5,000

4,000

3,000 2010/11 2011/12 2012/13 2013/14 2014/15

Ultrasound

The Hospital continues to rely on the senior x-ray attendant who had been trained on the job some years ago in order to guarantee this service. He is advancing his skills by self motivated studies on the subject. This year he had a three months training in Italy in operative ultrasound scan.

Table 6.21: Ultrasound examinations done over the last five years in the Hospital

Year 2010/11 2011/12 2012/13 2013/14 2014/15 Obstetrics 1,282 1,415 1,208 1,442 983 Gynaecologic 847 968 849 911 855 Liver, Spleen 1,186 1,707 572 1171 2068 Abdomen 2,240 2,517 2573 3393 2061 Urogenital Organs 481 376 269 439 460 Heart 262 206 393 567 442 Tissue 259 348 388 910 759 TOTAL 6,557 7,537 6,484 8,833 7,628 No. of Patients 4,282 5,235 4,860 6,211 4,339

Graph 6.13: Trend of ultrasound examinations over the past five years

Trend of ultrasound examinations over the past five years 9,000 8,833

7,500 7,537 7,628 6,557 6,484 6,000

4,500

3,000 2010/11 2011/12 2012/13 2013/14 2014/15

Page 67 of 100 Pharmacy

The Hospital has a cool and dry, burglar proof, and well organized storage space for drugs in the General Store while stock for regular consumption in the various departments is kept in the hospital/Dispensing Pharmacy. The pharmacy is headed by the PNO who oversees daily drugs and supplies logistics. The Hospital does not have a qualified pharmacist as yet. The head of departments make orders using JMS ordering forms whenever the minimum levels of stock are reached and stock out of essential drugs are rare. Stock Taking exercise is done half yearly and expired drugs discarded according to recommended standards. We have not registered any other loss of drugs apart from expired drugs. Drugs are ordered from the various departments and are kept in the department drugs store managed by the department in-charge. Treatments to patients are administered by qualified Staff and are carried out within the department itself. Regular treatment schedules are kept as per doctors’ orders and patients are very compliant with this regiment of administration.

The majority of the drugs can be ordered by the Ward In-charge for the routine treatments. Special/expensive treatments (Ceftriaxone IV etc.) need to be authorized by the MS and a special order form has been designed for it. During restructuring of the OPD, a pharmacy was created to improve on drug management and service to patients. Two staff are managing it.

Table 6.22: The ten most used drugs in our Hospital are:

Injectables Tablets 1 Ampicillin Amoxicillin 2 Frusemide Ampiclox 3 Gentamycin Ibuprofen 4 Cloxacillin Erythromycin 5 BenzylPenicillin Metronidazole 6 Diclofenac Cotrimoxazole 7 Ceftriaxone Chloramphenicol 8 Metronidazole Folic acid 9 Ciprofloxacin Multivitamins 10 Hydrocortisone Paracetamol

The total expenditure on drugs during this FY was of about 190,776,000/= UGX plus donated ARV drugs. The percentage of the ten top most used drugs on the total amount for drugs used is 42%.

Drug expenditure is significant and the possibilities of economising are related with drug prescription practices by the clinicians. Proper history taking, examination and right investigations help to make the correct diagnosis and this prevents poly pharmacy and ensures good quality service provided to patients hence also reduces expenditure on drugs. The unavailability of drugs in JMS at times is another factor which may increase hospital expenditure since drugs out of stock in JMS means to look for important/essential drugs in private pharmacies always at a higher cost.

The above mentioned drugs are regularly monitored along with Quinine Tabs and injectables, syrups and creams, ophthalmic drugs, insulin and reagents for the laboratory. The monitoring tools used are the stock keeping cards and physical count done by the Dispenser and this has been effective in preventing stock outs of essential drugs.

Page 68 of 100 CHAPTER SEVEN

HOSPITAL SUPPORT SERVICES

The services supporting the Hospital running are: Administration and medical records, domestic services, General Store and food distribution to extremely vulnerable individuals and chronically ill patients, and ambulance service. The technical services are provided by the Technical Department which carries out all the necessary maintenance and renovation and raising new structures that take place in the Hospital. The mortuary and burial service is another supportive assistance to the community.

A) Administration and Medical Records

The Administration Department is staffed with ten employees. The Administrator/CEO supervises the accounts department with one senior accountant, one Bachelor in Business Administration and one accounts’ assistant, three cashiers (two in OPD and one for the inpatient), the General Office with one secretary and one assistant being trained on the job and the ICT Department with Technical Advisor and an ICT Officer. The supervision of technical personnel, procurement and logistics are under the responsibility of the Administrator. He is also exercising the function of communication officer. The stores of the Hospital are under his responsibility but its supervision is delegated to different Officers. The Stores and basic accounting procedures are clearly described in the Financial and Material Resource Manual.

HMIS Data are compiled by the HMIS Focal Person and one assistant. They are supported by the Health Information Assistant who is a staff in the Public Health Department. The data is computerised following the HMIS formats as required by the MoH. Reports are regularly produced and are verified by the Medical Director. Then they are sent to the DHO and copied to the MoH. Since July 2013 the information concerning health services are automatically uploaded to the electronic system DHIS2. This is a system that handles all the health related data which is controlled by the MoH.

B) Domestic Services

The domestic service comprises catering and domestic store keeping, food preparation and supply, laundry, tailoring, compound and ward cleaning, waste disposal and waste water treatment. The domestic services of the Guest House and the Teaching Centre are as well available for workshops and seminars. They generate some income so much needed to cover the running costs of the Hospital.

C) General Store and distribution of food

The General Store is under the supervision of a missionary sister and three support staff members. Throughout the FY 2014/15, in collaboration with Insieme Si Può (ISP) the Hospital has been providing nutritional support to extremely vulnerable patients. The types of food supplied and quantities are tabulated below. The Hospital provides dry ratio food for most patients admitted. However food supplies are reducing and at times this support had to be halted for a while. Special feeding programmes are in place for malnourished children in the Inpatient Therapeutic Centre (supported by UNICEF, through supply of formula feeds) and TB inpatients (supported by IDEA, Turin).

Page 69 of 100

Table 7.1: Food distributed in FY 2011/12 - FY 2014/15

Amount Amount Amount Amount Food specification distributed during distributed during distributed during distributed during FY 2011/12 (kg) FY 2012/13 (kg) FY 2013/14 (kg) FY 2014/15 (kg) Beans 19,834 13,205 16,500 14,400 Rice 2,220 3,976 4,727 4,318 Corn-meal / Maize 33,222 27,928 23,520 19,450 Vegetable Oil 3,046 1,472 2,833 2,386 Sugar 4,820 2,000 4,372 4,456 Dry Skimmed Milk 1,654 1,455 1,737 1,611

D) Ambulance Service

The Hospital offers ambulance services within the catchment area and occasionally referrals to Mbale or Kampala. There is a call line for this service. The road situation to reach the Health Centres in the catchment area (Bokora Health Sub-District) in the rainy season is causing delays, as longer routes have to be used and high cost of maintenance to the vehicles. With the strong UNIMOG Ambulance, which was received last year, even patients in emergency situations in hard to reach areas can now be rescued. Two Toyota Landcruiser Ambulances (procured 2003 and 2010) are regularly serviced by the mechanic section of the Technical Department and are kept at all times in working condition. The cost of each trip varies. As a baseline 1,500/= UGX per km are calculated for fuel, wear and tear and driver’s allowance. The Hospital has maintained extremely subsidised charges for ambulance calls to the community, especially for children and obstetric emergencies as an affirmative action to promote maternal and child health. With the new CUAMM support, services for pregnant women and neonates are free of charge. Also a subsidised ambulance service is provided to transport the deceased from the Hospital to their homes within the catchment area. Since September 2013 the Hospital received support from the First Lady and Minister for Karamoja Affairs with an ambulance plus driver in compensation for the confiscated vehicle by court bailiffs and was promised to remain in Matany until the vehicle is returned. Other Hospital vehicles are one Toyota Landcruiser for the PHC Department to carry out support supervision and integrated programmes. A four wheel drive Hospital lorry (Benz 911) to ferry Hospital supplies, drugs, surgical sundries, building materials, food, etc. mainly from Kampala (470 km one way). This needs replacement soon. Another Benz 911 with a crane and a tractor with two trailers are available for the Technical Department.

E) Technical services – The Technical Department

The Technical Department with a total of 35 established employees is a guarantee that maintenance and renovation works are done daily in the Hospital. New building projects within the Hospital are carried out by and only by this workforce as quality work is guaranteed. It is supervised by a Comboni Lay Missionary. The following cadres are present: mechanics and drivers, electricians, plumbers, metal workers, builders, carpenters, and store keeper. There are also some workers in the tree nursery for the tree plantation project of the Hospital. Besides the ordinary routine maintenance and repair of equipment and buildings, the works carried out in 2014/15 were: Completion of the extension of the Administration Block, Completion of the construction of a transformer house, Complete renovation of the Hospital corridor, starting with the Extension of the Laboratory and annexed to it with a oxygen generation room, re-surfacing of the three beds of the biological waste water treatment plant, etc. Various services to the public as income generating activity by this

Page 70 of 100 department to supplement the running costs of the Hospital prove the importance of this department. The water supply to the Hospital has been constant during the course of the FY. Water is provided by two bore-holes (one about 1,500 m West of the Hospital), with one submersible pump linked to the Hospital generator by an underground cable, and another within the Hospital compound, with a solar panel operated submersible pump. The above mentioned biological waste water treatment plant provides clean water for watering plants in the compound and a fruit tree plantation. Two underground water reservoirs for rain-water collected from the entire hospital roofs, supplies water to the laundry, thus reducing the water consumption from the boreholes. Electricity is produced by generators and an extensive photovoltaic plant.

 Recommendations

The weather condition in Uganda due to global warming has greatly changed in the passed few years. The quality of the roads has deteriorated which resulted in higher fuel and maintenance cost of vehicles. Demand of oil products in the world have risen sharply as well which has direct impact on the cost of service delivery of the transport division (ambulance and transport of goods). Therefore the cost per km should be reviewed and future reserves have to be put aside on a separate account for replacement of equipment.

F) PASTORAL CARE

The spiritual support of the patients is of vital importance to give a holistic approach to healing. Pastoral care of the sick people is one of the essential care package provided to our patients. A pastoral care giver trained by UCMB and the Priests of the Parish are readily available for this service whenever necessary. However, their services were only on call or part time. Since January 2012 a missionary sister is fully dedicated for pastoral care of the patients and her impact is felt (see below table 7.2). The Sister follows a weekly plan in order to cover all the wards of the Hospital, organises three times a week prayer moments in the afternoon, alternating in the various wards. Holy Mass is celebrated in the Hospital Chapel with participation of staff, students, attendants and patients every Thursday and on special occasions, like the World Day of the Sick, etc. The Hospital premises are made available to other Christian denominations for their worship as an ecumenical gesture.

Table 7.2: Trend of activities in Clinical Pastoral Care of the Sick

Activity / Indicator FY 2012/13 FY 2013/14 FY 2014/15 No. of patients visited or 5,504 8,025 9,431 counselled No. of patients baptized 2 3 12 No. of patients confirmed 0 0 0 No. of patients given Sacrament 1 0 0 of marriage No. of patients anointed 9 18 34

Page 71 of 100 CHAPTER EIGHT

QUALITY AND PATIENT SAFETY IMPROVEMENT

During the FY2014/15, the Hospital has strived to continue offering quality care to patients by carrying out several quality improvement activities. Among these were quality checks including, patient satisfaction and drug prescription surveys; the feedback was given in a general staff meeting as well as the recommendations and suggestions made for improvement and implementation. Assessment of the various wards following the 5 S’s entailed in quality assurance was also done which has resulted in general improvement of service delivery in the wards.

1. QUALITY IMPROVEMENT ACTIVITIES UNDERTAKEN

The table below shows the quality improvement activities which were carried out and the subsequently effects realised

Activity Effect Incident and error reporting on the wards Improved patient safety practices Use of the surgical safety checklist pre Improved patient safety intra operative and operatively for all patients quick recovery. Weekly case conferences is done by the Harmonized patient management by the clinical team, where challenging cases are clinical officers and the medical officers and the discussed team updated on new protocols. Weekly continuous medical/nursing Education. Improved case management and professional development of Staff. Patient satisfaction and drug prescription Raised awareness of poly pharmacy and its survey, and feedback shared during the implications. - All services offered are aimed at general staff meeting. satisfying the patients. - Availability of minimum stock levels of essential drugs The Quality Assurance Committee Awards were instituted for the best department implemented in all Departments the 5 S’s and monitoring has been ongoing. (Sort, Standardise, Shine, Set and Sustain) Daily reporting and updates by Department In Improved problem solving as to clarify issues Charges immediately and not wait for a general meeting at the end of the month to solve some key issues Posting of a double trained nurse/midwife with Reduced waiting time for mothers at the ANC counselling skills at the ANC to ensure that and increased male involvement in ANC and HCT is done at the same point. increased PNC attendance was noted. Daily clinical team meetings with audit of all Improved patient management and cases managed during the call period professional sharing of experiences leading to improved team work Monthly support supervisions of the lower level Improved services offered at the LLUs units within Bokora HSD Institution of case management protocols on Standardising management of common maternity ward obstetric cases. Maternal death audits Improvement management of Postpartum haemorrhage and PET which caused the 4 maternal deaths in the year. Perinatal death audits Improved neonatal care. Instituted routine administration of dexamethasone in women at risk of preterm labour, Kangaroo mother care and protocol on management of preterm babies. Quality assurance team of the Hospital carried Better organisation, administration and out support supervision and assessment of the infection control in all departments. various departments

Page 72 of 100 Activity Effect Staff attended several external workshops and Increased knowledge on the various topics trainings organised by various stakeholders discussed in the different trainings like MDR TB, infection control, SLAMTA, obstetrics. Follow-up CMEs were conducted. Onsite mentoring of Hospital staff by several Improved service provided like data stakeholders like MoH, SUSTAIN, Baylor, management, logistics management. CUAMM, Medical access, etc.

2. QUALITY INDICATORS

A. Technical competence and effectiveness of care

Table 8.1: Proxy Indicators measuring the effectiveness of care in the Hospital

2011/12 2012/13 2013/14 2014/15 Explanation Recovery rates on discharge: patients in Recovery one year discharged as clinically recovered 96.9 96.2 95.2 95.2 Rate from that episode of disease (from all wards) following treatment. Maternal 2.17% Maternal death rates: is not a population 0.46 0.4 0.34% based maternal mortality rate or ratio that death rate 0.66 you may often comes across. Fresh still 1.98% Fresh still birth rate: Fresh Still births 1.45 1.64 0.17% births rate 1.32% have intact smooth skin not macerated. Early neo-natal deaths rate. Number of Early babies who died within the 7th day from Neonatal 1.45 1.43 1.42% 3.87% birth divided by the total number of death rate deliveries in the hospital in that year expressed in percentage terms. *highlighted are the rates including Hepatitis E cases

Recovery Rate

Our recovery rate remained the same and was within acceptable standards if we consider the severity of medical cases reaching the Hospital.

Maternal deaths

During FY 2014/15, four maternal deaths occurred in the Hospital, giving maternal death rate of 0.34%. Three of them died because of postpartum haemorrhage while one died of disseminated intravascular coagulopathy secondary to severe PET. Maternal death audits were done as per the Ministry of Health recommendation using the standard guidelines. Each of the events was reported to the District Health Office and Ministry of Health HMIS data bank.

Fresh still births The fresh still birth rates have decreased to 0.17% from 1.98% in the previous FY. Efforts have been made by the Hospital to keep the fresh still birth rate as low as possible. However, more training in comprehensive emergency obstetric care is required to empower all the midwives in the District. Early neonatal deaths Early neonatal deaths increased from 1.42% to 3.87%. Major cause of death was prematurity. Protocols were introduced on management of preterm babies. Emphasis was put on administration of dexamethasone to mothers with high risk of preterm delivery, control of infection, prevention of hypoglycaemia and hypothermia. Kangaroo mother care was introduced. Neonatal referrals from lower level health units were also difficult to manage as they were referred late already with severe infection. Presence of new borne resuscitation equipment at LLHUs and education of the Midwives will greatly improve wellbeing of the new born. More efforts have to be made to keep the early neonatal death rates as low as possible.

Page 73 of 100 B. Safety of Intervention

The chosen indicator for measuring safety of intervention is Caesarean section infection rate.

Table 8.2 shows trend of C/S Infection rates over the last 5 years

2010/11 2011/12 2012/13 2013/14 2014/15 Explanation C/S infection c/s infection rate 1.55% 0.37% 0% 0% 0% Number of post-operative rate mothers who get infections

There were no cases of post caesarean section infections reported during the FY out of the 268 caesarean sections performed. The World Health Organization stipulates that this parameter of quality should be less than 10% in any health facility that provides emergency obstetric care services. Based on this yard stick, Matany Hospital performance has been remarkable.

C. Availability of Qualified Staff

Table 8.3: Proportion of clinically qualified staff in the Hospital

FY FY FY FY FY Indicators 2010/11 2011/12 2012/13 2013/14 2014/15 1 Total staff 250 255 254 248 208 2 Qualified staff 107 124 125 128 120

3 Proportions of qualified staff 42.8% 48.6% 49.2% 51.6% 58%

There has been a progressive increase in the availability of qualified health workers in the Hospital over the last years. The Hospital Management Team made it a priority to improve the staffing norms in various departments in the Hospital. The other major contributor to this achievement has been a significant reduction of staff attrition. The majority of our staff faithfully served their contracts or bonding agreements to completion, and some of them even opted to renew/extend their contracts. The proportion of qualified staff is now 58 %, therefore the aim to have at least 45% of qualified staff in the Hospital has been achieved by far.

Graph 8.1

%age of qualified Staff

60% 58% 55% 52% 50% 48.6% 49%

45% 43%

40%

35%

30% 2010/11 2011/12 2012/13 2013/14 2014/15

Page 74 of 100 D. Patient Satisfaction

This survey addresses the Clinical outcome as perceived by the patient with regard to clinical effectiveness, namely: improvement, loss of pain, humanity of care (i.e. staff attitude and patient involvement in care), organisation of care in terms of flow of clients and waiting time before seeing clinician, healthcare environment (e.g. toilet facilities, beddings and bathrooms). Also assessed is overall impression, whether patient is satisfied and willing to come back.

Based on the above indicators, for Matany Hospital, overall satisfaction rate (In & Out patients) slightly increased from 96% to 96.3%. Humanity of care increased from 97.1 to 98.4% indicating that majority of the staff were kind. Fewer patients were involved in care which dropped from 95.8 to 90.4%. The environment of Matany Hospital was rated with 98.5%. Patients appreciated the general cleanliness of the Hospital. Regarding the Total Patient Satisfaction Rate, Matany Hospital scored 96.3% in 2014/15 as compared to 86.5% in 2013/14.

Table 8.4: Patient satisfaction levels per core areas

Satisfaction Satisfaction Satisfaction Criteria commented Comment rate 2012/13 rate 2013/14 rate 2014/15 Clinical outcomes It is a good development if (Improvement after 95 96 96.3 patients feel that they have care) improved after care received Humanity of care Most of the staff were kind 100 97.1 98.4 (Kindness) Patient involvement in Need to involve patients more in 90.5 95.8 90.4 care their care The healthcare Patients appreciate the general 100 97 98.5 environment cleanliness in the Hospital Did not change. There is Waiting time (less than 83.4 76 76 continuous team work needed in one hour) order to improve

E. Medication safety

Drug prescription is one of the quality indicators of clinical care provided by the Hospital. Consideration is given to appropriate prescription (poly pharmacy, antibiotic rate, injection rate), dispensed drugs in relation to prescribed drugs (added up to the scores for appropriate prescription). According to WHO standards, average number of drugs prescribed < 2.6, antibiotics as a percentage of total drugs prescribed < 20% (Uganda <40%), Injections should be <15% of drugs prescribed. All (100%) prescriptions should have history and objective examination recorded, and all prescribed drugs actually dispensed. Since FY 2003/04 a regular monitoring system was re-vitalized in order to get information on prescription practises in OPD among Medical Officers and Clinical Officers. This has served a great purpose to regulate poly-pharmacy, in order not to deviate from the WHO/MoH standard recommendations. The polypharmacy rate increased from 2.28 in 2013/14 to 2.37 in the last year though it remained below the WHO recommendation of 2.6. During FY 2014/15 the average diagnoses per OPD patient was 1.2 (graph 8.4).

The percentage of outpatients getting an antibiotic in a prescription was ranging between 36.1 – 68.7 % throughout the FY. There is need to remind our Clinicians regularly to take note and regulate their prescription practices in order to minimise poly-pharmacy and antibiotic use. Monthly prescription trend for antibiotics and Non Steroid Anti Inflammatory Drugs (NSAIDS) are indicated in graphics 8.2 and 8.3, respectively.

Page 75 of 100 Graphic 8.2 Prescription of Antibiotic in OPD during FY 2014/15

Matany Hospital OPD: % of prescriptions with antibioticduring FY 2014/15 75.0 68.7

60.0 50.2 45.4 52.1 45.0 41.3 44.4 36.4 38.4 37.9 36.1 38.1 36.9 30.0

15.0 WHO recommends <20% ( MoH-Ug recommends <40%) 0.0 Jul- Aug Se p O ct N ov D e c Jan- Feb Mar Apr May Jun- 14 15 15

Graphic 8.3 Prescription of NSAID in OPD during FY 2014/15

Percentage of antinflammatory drugs prescribed to OPD patients during FY 2014/15 16.00% 13.92% 14.00% 13.16% 12.56% 12.00% 11.94% 10.93% 10.95% 9.64% 10.00% 7.79% 8.90% 8.05% 8.00% 9.06% 7.40% 6.00% 4.00% 2.00% 0.00% Jul-14 Aug Sep Oct Nov Dec Jan- Feb Mar Apr May Jun- 15 15

Almost all the drugs prescribed were available in OPD pharmacy during the year under review. Free malaria drugs were received, thanks to the regular information from JMS on availability. The previous challenge of irregular supplies of ARVs, is now stable, since Medical Access is supplying these drugs to the Hospital.

Graphic 8.4 Average numbers of Diagnoses made for a patient in OPD during FY 2014/15

Average number of diagnoses per OPD patient during the FY 2014/15 1.6 1.5 1.4 1.3 1.2 1.2 1.2 1.2 1.1 1.2 1.0 0.9 1.0 0.9 0.8 National Standard 0.8 0.8 Figure < 1.5% 0.6 Jul-14 Aug Sep Oct Nov Dec Jan- Feb Mar Apr May Jun- 15 15

Page 76 of 100 Table 8.5: Summary of Quality rates per indicator

Years FSB MDR RR IRCS STAFF SATIS DRUGS rate rate rate rate rate rate rate 2010/11 1.08 0.31 95.7 1.55 43 20 97 2011/12 1.46 0.46 96.9 0.37 48 16 90 2012/13 1.64 0.4 96.2 0 49 100 96.5 1.98* 2.2* 2013/14 95.2 0 52 96 96.5 1.32 0.6 2014/15 0.17 0.34 95.2 0 58 96.3 100

* with HEV impact

Performance Indicators

Matany Hospital is a major contributor to the health care outputs in Karamoja region and neighbouring Teso. Annually, the Hospital performance is assessed on core hospital functions; quality of care and efficiency of resource utilization. Hospital performance can be measured through some indicators developed by Uganda Catholic Medical Bureau (UCMB). These indicators can be used to rank different hospitals on basis of their out puts; and to monitor the performance of the same hospital over subsequent years.

Matany Hospital provides several health services to the people and these services can be seen as outputs. The main outputs of a hospital include; the number of patients seen in OPD, admitted in the wards, the number of mothers who attended Antenatal Care, Immunizations done and Deliveries conducted throughout the period under review.

Giving a weight to each of the above outputs, five outputs are measured against a term of reference (Op = 1 outpatient contact), UCMB has produced an aggregated indicator of outputs called Standard Unit of Output (SUO-OP). SUO-OP is calculated using the following formula:

SUO-OP = ( 15 x no. IP) + ( no. OP) + (5 x no. deliveries) + (0,2 x no. of immunizations given) + ( 0,5 x ANC visits)

In a similar way SUO-IP Standard Unit of Output per Inpatient) can be calculated. Starting from SUO-OP/IP and knowing the total expenditure of the Hospital, the income from patients user fees, the number of qualified staff, the bed capacity, the workload of OPD, PHC Department and wards, it is then possible to calculate other indicators called SUO-OP per staff (productivity of staff), cost per SUO-OP, cost per SUO-IP, median user fees per SUO-OP, median user fees per SUO-IP. These indicators can be used to measure the accessibility, the equity, the efficiency and the quality of Matany Hospital.

Hospital accessibility is measured looking at its utilization and therefore SUO-OP is the best indicator. During 2014/15 the SUO-OP showed a slight improvement as compared to the previous FY (see Graph 8.5). This is explained by the fact that there was a increase of the number of inpatients and deliveries.

Page 77 of 100 Graph 8.5: SUO-OP as measure of accessibility.

Matany Hospital SUO-OP from FY 2010/11 300,000 271,948 255,011 229,174 250,000 212,209 214,994 200,000 150,000 100,000 50,000 0 FY 2010/11 FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15

Another useful indicator of accessibility is the Cost Recovery rate from fees (CRR) that is the percentage of expenditures (recurrent cost) covered with money coming from user fees: in Matany Hospital for the FY 2014/15 this was 13%. According to UCMB the accessibility is good when this value ranges between 25-30%. Our CRR is far below average for the UCMB Health Network; this is an indicator of good service access and equity to the rural poor. This task of providing one of the most subsidised health services in the country is becoming more difficult in the present circumstances where resource mobilisation is an up-hill task for the Hospital Management Team.

Measuring equity: a hospital is equitable when people who are really in need, i.e. vulnerable groups: children, pregnant women, are served more and more. Three indicators are used: median user fees per SUO-OP, utilization of services by pregnant women and immunizations given to the population. Graph 8.6 indicates median user fee per SUO-OP and SUO-IP in the previous five years while no. of immunizations given and Antenatal Care Clinic workload are discussed in Chapter 6. The graphic indicates that the Hospital remained equitable although there was an increase both in the Median User fee per SUO- OP and SUO-IP. It was impossible for the Hospital to keep the recurrent costs/SUO as low as previous years since inflation and rising costs had their impact. It is important to note that no patient is turned away from accessing services; the Hospital has a Samaritan Fund which is used to care for those patients who are identified as not being in position to meet the cost of user fees.

Graph 8.6: Median user fee per SUO-OP and SUO-IP over the last 5 years

Matany Hospital Median User Fee per SUO-OP and SUO-IP since FY 2010/11

20,000 15,429 19,216 16,000

12,000 9,675 9,898 9,268

UGX 8,000

4,000 645 655 613 1,018 1,267 0 FY 2010/11 FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15

M edian User fee per SUO-OP M edian User fee per SUO-IP

Page 78 of 100 Considering no. of qualified staff and total cost of the Hospital, two other indicators, measuring the efficiency, SUO-OP per staff (productivity or technical efficiency) and Cost per SUO-OP (economic efficiency) can be calculated.

Graph 8.7 indicates the SUO-OP per staff and cost per SUO-IP since FY 2010/11. The graphic reveals that the SUO-OP per staff (productivity) has increased from 1,658 (for the previous) year to 1,792 (this year). This is an indicator that more patients in the Hospital were cared for including more deliveries; thus the productivity of our staff increased.

Cost per SUO-IP decreased slightly. In conclusion, our staff were more productive as compared to the previous year because we saw slightly more inpatients as compared to the previous year.

However this indicator does not take in consideration the quality of service as a single patient might have e.g. to be taken to theatre for surgical toilet, etc. several times thus consuming working time for our staff and resources but still counted to be just one patient. It has also to be mentioned that such indicators do not take into consideration the severity of the conditions of admitted patients.

Graph 8.7: SUO-op per staff, Cost per SUO-OP and SUO-IP (technical efficiency indicators)

Matany Hospital Cost per SUO-op and SUO-ip since FY 2010/11 250,000 194,910 183,382 200,000 166,217 166,995

150,000 119,973 100,000

50,000 12,093 12,864 10,997 11,041 7,998 0 2,428 2,057 1,833 1,658 1,792 FY 2010/11 FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15

SUO-op per staff Cost per SUO-op Cost per SUO-ip

Page 79 of 100 CHAPTER NINE

HEALTH TRAINING INSTITUTION

St. Kizito Hospital - Matany School of Nursing and Midwifery is situated in North-Eastern Uganda located in Matany sub-county, Napak District, Karamoja Sub - Region. It is 40 km from Moroto Municipality and 14 km from Napak District Headquarter. It begun in October 1984 with Certificate course in Nursing which extended its services in May 1993 when it started Diploma in Nursing course; this was suspended with the introduction of Certificate in Midwifery Training course in May 2010.

The school capacity was determined at 90 students due to the available space both for accommodation and classrooms, and availability of qualified tutors as guiding indicators. Due to demand for midwives in the region, the capacity has increased to 109 students. However, the school with other development partners including Government strive to increase gradually the school’s capacity from 90 to 120, thus aiming at an increase of 30%. This depends on the staff development over the years, and other capital development plans to be realised.

The school is managed by the Hospital Management Team, as one of the main departments of St. Kizito Hospital Matany which is fully owned by the board of Trustees of Moroto Catholic Diocese. The HTI has a Statutory Committee of the BoG which handles the school issues.

The types of courses at the school:

Table 9.1: Types of courses

Number of Number of Number of No of students No of students Success Course Students Students Students Total sat for final passed final rate New Intake 2ND Year 3RD Year exams exams CN 20 15 23 58 15 15 100% CM 13 19 19 51 19 19 100% TOTAL 33 34 42 109 34 34 100%

This FY 2014/2015 the Students Population was: 109

Students’ numbers female and male:

CN May 2013 = 23 (Female: 18, Male: 05) CN May 2014 = 15 (Female: 12, Male: 03) CN May 2015 = 20 (Female: 12, Male 08) CM May 2013 = 19 (Female) CM May 2014 = 19 (Female) CM May 2015 = 13 (Female)

Page 80 of 100 ACADEMIC PERFORMANCE

Student success rates according to grades

Graph 9.1: Showing certificate in nursing and midwifery students’ performance in grades

40

30

20

10

0 2010 2011 2012 2013 2014 distinctions 02013 credits 14 19 37 31 26 passes 30234 failed 00000

Looking at the above grading pattern according to the various intakes, there is improvement in the academic performance and practical skills as the grading changes from pass now to credits and few distinctions and there is need to maintain and improve for better performance.

Table 9.3: showing the success rate in the last five years

Course 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 CN/CM New admissions 38 35 43 35 33 Lost during the year 01 01 03 03 01 Referred during the year 00 00 00 03 00 Success Rate 100% 96% 100% 100% 100% st Fail at 1 attempt 00 01 00 00 00 nd Fail 2 attempt 00 00 00 00 00

In November 2014 thirty three Candidates, CN/CM 2012 May Intake sat for UNMEB State final examinations; fifteen CN and eighteen CM, all performed well. The eighteen CM candidates are the third group of student midwives since the inception of the midwifery program in the HTI. They sat for UNMEB State Final Examinations and all performed well with the following grades, 2 distinctions and 16 credits. The fourth and fifth sets are continuing well with the course. The CN candidates were fifteen they all passed with the following grades 1 Distinction, 10 Credits and 4 Passes.

This FY 2014/2015, the HTI management identified the following key priority areas as vital, and therefore all activities within the year were geared towards fulfilment of these priorities.

1. To strengthen the quality of training 2. To strengthen the academic performance, professionalism, moral discipline and to improve practical skills of the students 3. To strengthen students’ leadership skills 4. Maintenance of HTI physical infrastructure so as to reduce costs 5. To improve the use of the ICT

Page 81 of 100 1.1 Strengthen the quality of training: During the previous year the tutor-student ratio was 1:38, the students are taught theory and practical skills. The hospital management has reinforced the teaching staff with three Clinical Instructors and seven Preceptors who have contributed a lot in training of the students besides the three qualified Tutors and the tutor-student ratio currently is 1:36.

The Hospital Management Team and HTI Team planned to carry out the following activities:

 Identifying staff for tutor training: There is still need to identify more staff for tutor training particularly for Midwifery courses. The identification of capable students to be clinical instructors is ongoing and there is career guidance so that these staff with time go for upgrading course and become tutors.

 Short courses for administrative staff: Refresher courses to be organised for capacity building, so that these staff have updated skills in service delivery at the HTI.

 Identifying ways of attracting Hospital Staff to work at Matany HTI: The work schedule is made more attractive than the present and the management to review the allowances.

1.2 Strengthen the Clinical Area Supervision

This is in order for the students to perform better at the practical sites, and have their practical skills improved for quality and safe care of the patients. It is also coupled with the needs to produce future Nurses and Midwives with highly professional and technical standards that can meet the present health demands of our region, nation and the other nations respectively. Therefore the HTI Management sought the need to achieve the above priority area by undertaking the following actions:

 Identifying and mentoring more student nurses and midwives who are capable of instructing and taking up the clinical instruction activity after their qualification.  Involving actively the departmental leadership at the practicum site in training and supervising students when in the clinical area (This is on-going).  Involving the Preceptors who are supervising the students while at the practicum site (on-going).  Involvement of community leaders, members and neighbouring health facilities in specialized skills acquisition (on-going).  Recruitment especially of Midwifery Tutor by the Recruitment Team.

Reflecting on the numbers of referred students and those who left the training in the last three financial years; the detailed information has been described at the table below.

Table 1: Number of lost and referred students in the last three financial years

Course CN & CM 2011/2012 2012/2013 2013/2014 2014/2015

Lost during the year 04 02 03 01

Referred during the year 00 01 03 00

Page 82 of 100 The loss and referred students during the last Financial Years was attributed to gross breaches of HTI rules and regulations many of which involved ethical, professional, and moral issues. This resulted in a number of HTI Welfare/Disciplinary meetings and decisions that were painful for the students, their families and the School management.

FY 2014/2015 had one student lost during the year due gross negligence of a mother in labour and continuously demonstrating unethical behaviour contrary to the Midwifery profession, in spite regular attempts made to help her transform.

To achieve the above the teaching Staff continues to do the following:  Detailed teaching of Nursing Ethics and moral standards of the profession to the incoming students and revision with the continuing students.  Use collective effort by the HTI and Clinical Teams to remind students about professional standards and strengthen their ethical codes of conduct both in class and clinical area.  Introduction of teacher referees for each class, promotion and strengthening of guild leadership has helped a lot in guidance and counselling.  Involvement of family members/guardians in solving their problems

1.3 Strengthen maintenance of HTI physical Infrastructure:

Renovation of the existing buildings is being done in stages and gadgets have been put in place to monitor electricity and water so that wastage is minimised. Regular reminder of students on care of all the properties; the school rules and regulations were revised and are valid to date. The plan to renovate was not implemented in Financial Year 2014/2015 due to lack of finance. There is hope that all will proceed on well while lobbying for funds.

1.4 Strengthen counselling and guidance of students:

This is ongoing by the tutors. From time to time some facilitators were invited to give inputs which promote good moral behaviours and spirituality. Students were encouraged to actively and regularly participate in spiritual activities, associations such Young Christian Student (YCS), Christian Young Missionary Group (CYMG) and St. Peter the Apostle Society (SPA). Regular recollection days were organised, educative and spiritual films shown so as to boost their moral.

1.5 Improve the use of ICT

Purchase of more computers to enable each student easy access for practice and acquisition of computer skills. Power point presentation for teaching the students is in progress since this is one of the teaching methods.

Computer literacy has been introduced and is ongoing; the students are examined on this subject and the marks are included on their school transcripts.

Table 9.5: Indicators of faithfulness to the mission:

Faithfulness to Mission 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 Indicator ACCESS (utilization rate) 93% 124% 100% 100% 100% EQUITY (fee per student) 1,468,881 1,553,312 1,553,312 1,477,132 1,275,528 EFFICIENCY (expenditure per 1,483,083 1,696,440 1,859,207 1,697,228 1,696,639 student) QUALITY (success rate) 100% 96% 100% 100% 100% QUALITY (Tutor/Student ratio) 1:50 1:56 1.56 1:38 1:36

Page 83 of 100 The above table shows the HTI’s faithfulness to the mission in relation to the four key indicators compared to the last financial years.

Access: An indicator that looks at the capacity of the school and determines its usage. The number of students has increased because of two concurrently running programs the number has gone beyond the targeted capacity of 90 students to 109. There have been extra beds fitted in the hostels. This explains the 100% utilization rate.

Equity: This looks at the average fee per student. The fees did not increase. As some students were internally supported by the Hospital this indicator has even dropped and thus the HTI was more equitable.

Efficiency: This looks at the average recurrent cost per student. The Hospital continues to support the school in feeding, supplies and maintenance, through bulk purchases and storage of food stuff and other items which are usually a bigger component in students’ cost. It is noted that efficiency has remained constant in spite of inflation and general rising of prices.

Quality (students’ success rate): This has been 100% as in the previous financial years.

Quality (Qualified Tutor-Student ratio): This ratio stands at 1:36 as the tutors are now three in number. Quality has improved because of the increase in the number of the tutors, Clinical Instructors and Preceptors at the Clinical area.

The evolution of the staff establishment of the HTI:

Table 9.6: Staff establishment

Staff Establishment 2010/11 2011/12 2012/13 2013/14 2014/15 Qualified Tutors 2 2 2 3 3 Qualified Clinical Instructors / Mentor 0 1 0 0 0 Unqualified Clinical Instructors 8 2 2 2 3 N° qualified teaching Staff lost in the year 1 0 0 0 1 Attrition rate qualified teaching Staff 0 0 0 0 1 N° qualified teaching Staff recruited during 0 0 0 0 0 the year N° unqualified teaching Staff employed 3 0 0 0 1 during the year N° unqualified teaching Staff lost during the 4 0 0 0 1 year Attrition rate unqualified teaching Staff 0 0 0 0 1 Support Staff 12 10 10 10 10 N° of Hospital. Staff Members providing 3 4 3 3 0 lectures in HTI Ratio part-time vs. full-time qualified Tutors 0 4:2 3:2 3:3 0

The two Tutor students who had completed their course added to the number of qualified tutors. This has contributed greatly to the reduction of the high tutor – student ratio from 1:38 to 1:36; it is our wish to continue identifying and mentoring more staff to be trained as Tutors in order to meet the recommended WHO Tutor – Student Ratio of 1:20 or UCMB Tutor – Student Ratio of 1:30.

Page 84 of 100

Governance and Management of the School

St. Kizito Hospital Matany School of Nursing and Midwifery is governed and managed as one of the main departments and cost centre of the Mother Hospital. The title of the school management has been changed to Statutory Standing HTI Committee.

In regard to the continuous management of the HTI, the Principal Tutor and entire teaching staff were involved in the following:

 Formulation and implementation of monthly clinical and class room teaching time tables. This entails class room teaching, progressive clinical and academic assessments, examinations, and organising/attending internal and external academic seminars, extra-curricular activities. All these activities are on-going.

 Discussing briefly main issues of the school on daily basis. Having meetings scheduled fortnightly with teaching staff, supportive or administrative staff and quarterly meetings with In-charges of the wards and relevant departments of the Hospital to discuss professional, ethical training and moral issues. The minutes of these meetings are kept and read during subsequent meetings for better decision making, implementation, monitoring and evaluation. This is ongoing.

 Conducting meetings with Guild Executive and the entire student body on regular basis to strengthen guild constitutional policies, remind students of HTI rules and regulations and to encourage leadership qualities among the student guild and generally to solve any arising problem in the school.

 Teaching staff participate in staff development programs such as training, attending seminars, technical workshops, and conferences. This is arranged as organised by the programme managers.

 Coordinating with the different stakeholders like Hospital Management Team, MoES/UNMEB, MoH/UNMC, Diocese, and District as far as the school issues are concerned.

School finances:

The budget of the school is approved together with the Hospital budget through the BoG. In the table below the different types of sources for the school income during FY 2014/2015 are shown.

Table 9.7: Source of income for the Health Training School

Serial Source of income for the Income during No. Health Training School FY 2014/15 1 Student Fees' Collection 61,392,730 2 MOH-DP Bursary Account 28,973,970 3 Bursaries from Donors 20,656,400 Student Payments for other costs (regi- 4 12,127,600 stration / exams / specialised training …) 5 PHC Conditional grants to School 28,009,492 6 Other School Income (for services) 1,507,700 Gap, which needed to be financed from the 7 51,491,800 Hospital / Donors Total: 192,032,092

The school being one of the departments of the Mother Hospital gets management support for its finances from the Hospital finance department; this is done through timely update of

Page 85 of 100 the school management of its financial situation. The school accounts are audited as part of the Hospital account.

Income and Expenditure

The sources of income of the HTI are mainly external donation and bursaries which take about two third of the total income. Sustainability is still a challenge to the Institution so heavily supported by Donors.

Income

Graph 9.2: Sources of Income for the HTI, FY 2014/15

27% 31%

1%

15% 11% 15%

School Fees Bursaries from Donors Bursaries MoH / DP PHC CG Other Income From Hospital Funds/Donors

Expenditure

Graph 9.3: showing HTI Expenditure in the FY 2014/2015

5% 1% 3% 47%

34%

6% 4%

Employment Cost Admin. cost Utility & Property Teaching Cost Transport Maintenance Capital Devt.

Internally, the School receives unconditional administrative, financial support, in-kind services from the mother Hospital. Much of its supplies are obtained from the Hospital main store besides purchases, transport and storage processes and all repairs and building done by the Hospital Technical Department. The Hospital takes care of 50% of students’ medical treatment bill and treats the NMTS staff free. The management of Matany Hospital takes care of staff career development and sponsors a good number of students.

Page 86 of 100 The school receives support from the Local Governments of Napak and Moroto Districts through involvement in interviews, community activities and Family Planning Clinical Practice for our students. The HTI is continuously benefiting from spiritual formation of the students from the faith- based organisations within and without Moroto Diocese. It has also enjoyed a lot of support from the Diocesan Health Office both administrative and training.

Externally, the HTI is supported by the following partners:

 UNFPA: Sponsoring some midwifery students of May 2011, 2012, 2013 and 2015 Intakes. At the same time equipment for training and imparting skills to the students.  CUAMM-UNICEF: sponsoring some students (nurses)the last group were CN 2013 May Intake  FAWE: Sponsoring both Nursing and Midwifery students May 2015 Intake.  Saints Project Baylor-Uganda: sponsoring midwifery students the last group were in May 2013 and May 2014 Intakes.  Government of Uganda: gives PHC-CG.  UCMB: Offers administrative and technical support to the HTI by organising workshops, trainings, meetings, and technical advice during support supervision.  MOES-UNMEB: This supports the HTI, through organisation of workshops, training, meetings, support supervision, verification of documents and examinations.  MoH-UNMC: Supports the HTI through workshops, meetings, support supervision, verification of documents and quality assurance.  JHPIEGO: Organizing trainings for the teaching staff on effective Clinical teaching.  Other partners and friends: Give services in-kind, goods and donations.

The HTI is fortunate to have the above partners who have faithfully continued to support it. It hopes to train quality and highly competent professional Nurses and Midwives to serve this most underprivileged region of Karamoja, neighbour districts and the entire country. b) Other training activities of the Health Training Institutions(s):

Despite our limitation in staff the HTI was able to carry out the following:

 Participation in some continuous professional medical education sessions organised by the Hospital on updated specific topics that are essential during the period of their training.

 HTI team decided that each class is exposed to community activities for a period of four weeks in the whole period of training.

 Family Planning Clinical Practice: in St. Kizito Hospital Matany and Moroto Regional Referral Hospital.

 Involvement in both internal and external academic seminars.

 Admission ceremony and swearing in of the student guild committee members.

 Participation in extra-curricular activities: sports; music, dance, drama (MDD), and others

 Participation in the UNMEB examinations both Promotional and State Finals.

Page 87 of 100 Point of Action for FY 2014/2015

The achievements as compared to the annual plan are as follows:

In summary, the HTI was able to register great strides in the area of academic performance as was seen in the recent state final examinations results. However, the following could still place the HTI at a better position in future:

 Training more Tutors and recruitment of more Clinical Instructors to meet the WHO recommendation of ideal standard, tutor-student ratio of 1:20 or UCMB recommended ratio of 1:30.

 Obtaining some more textbooks in specific subjects like Nursing, Midwifery, Pharmacology, Medicine, Surgery, Sociology, Psychology, Primary Health Care, Paediatric, Personal Community Health, Mental Health, Nursing management and administration.

 Putting in place more strategies for resource mobilisation for major renovation of the infrastructures and sustainability of the training school activities.

 Frequent self assessment exercise for the HTI team to improve in the management of the school

 Training more than one HTI team member in preparation of various HTI reports and strengthening clinical supervision of students.

Annually carry out the student satisfaction survey of all finalists

Page 88 of 100 CHAPTER TEN

SUMMARY, CONCLUSION AND RECOMMENDATION

Conclusion

Matany Hospital is the only Hospital in Napak District and it is well integrated in the community. The Public Health Department functions as Head of the HSD Bokora and collaborates with the District Health System. The Organisation and management of the Hospital is clearly described in Chapter three with the organisational structure. The Hospital relies heavily on external donations and its sustainability is therefore compromised. The infrastructure of the Hospital is well maintained facilitating quality care. It is renowned that the staff are well motivated and committed to the care of the patients which is serving as a model for future generation of nurses and midwives being trained in the annexed HTI.

1) Achievements and Failures

The Hospital achievements are spelt out in the Faithfulness to the mission report below, based on performance indicators. In general it was noticed that out patient attendance and antenatal care declined slightly, while admissions, immunisations and deliveries increased.

2) Faithfulness to the Mission report ( performance indicators)

Each year management prepares a report with performance indicators, demonstrating faithfulness to the Mission for which the Hospital was set as a health institution of the Roman Catholic Church. All the Hospitals under UCMB are reporting on these indicates which are: Accessibility, Equity, Efficiency and Quality.

 Is the Hospital more accessible especially to the vulnerable groups?

OPD attendance and antenatal visits have reduced compared to the previous year. Hopefully the first line treatment of VHTs in the communities has helped patients at the onset of illnesses like malaria, cough and diarrhoea. It is noticed that private clinics and drug shops are on the rise within the District and it is not known whether qualified people are actually running them. Admissions, immunisation and deliveries in the Hospital were higher than the year before.

Table 10.1: Accessibility trend indicators over the past five years

Year 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 OPD plus special clinics 72,495 67,668 65,380 57,866 78,175

OPD Attendance (new) 46,429 43,458 37,612 31,055 29,675 Admissions 12,606 11,620 10,117 9,290 9,556 Deliveries 922 967 952 1.060 1,164 Antenatal 2,522 2,731 4,602 5,006 4,859 Immunisation 22,461 34,214 24,891 35,950 41,733 TOTAL SUO 271,948 255,011 229,174 212,209 214,994

Table 10.1 above gives a comparative analysis of service utilization over a period of five years; OPD attendance (new) has decreased by 1,380 = 4.4%, and antenatal attendance by 147 = 2.9%. The good screening in OPD reduced the number of admissions and the presence of VHTs working in the community is felt. Admissions increased by 269 = 2.9%

Page 89 of 100 as well as deliveries by 104 = 9.8%. Total immunisations increased by 5,783 = 16.1% as there were special immunisation days in the year.

 Is the Hospital more equitable/affordable?

The trend of the user fee / SUO over the last 5 years as evidenced by the data in the report and shown in below graph 10.1, refers to the amount that a patient has to pay per hospital standard unit of output. If services are equitable, then the fee per SUO must remain low, so that even the poorest of the poor can afford. Equity for Matany Hospital had an increase of 249 from the previous year and is now 1,267. The user fees/SUO has thus increased by 24.5%. (The average in the UCMB network is much higher by 5,103). The services provided by Matany Hospital remained for many years constant equitable (between 600 and 700) as the services were highly subsidised, while the recurrent cost/SUO was continuously rising year after year. This trend could not be maintained any longer although services continue being highly subsidised. There was a slight fees adjustment during the year under review but also a good number of patients who could pay cost recovery rates were admitted.

Graph 10.1: Equity/Accessibility trend over the past five years

Trend of Equity over 5 years 1500 1,267 1200 1,018 900 645 655 613 600 300 Fees/SUO 0 2010/11 2011/12 2012/13 2013/14 2014/15

 Is the Hospital more efficient?

The SUO/staff (Staff productivity and the Cost (hospital expenditure)/SUO as evidenced by the data in the report show that Staff’s Productivity has increased by 8.1% (134) that is from 1,658 (for the previous year) to 1,792 (this year). (see graph 10.2 overleaf). This is an indicator that Matany Hospital strives to guarantee higher quality services. The seasonal intake of admissions did not occur due to early treatment in the community by VHTs. This indicator has also to consider, that in spite of the recurrent cost/SUO which has increased by 24.5% remains a factor not being controlled by the Hospital.

Graph 10.2: Trend of efficiency over the past five years

Trend of technical Efficiency over 5 years 3,000 2,428 2,500 2,057 2,000 1,833 1,658 1,792 1,500 1,000 SUO/Staff 500 0 2010/11 2011/12 2012/13 2013/14 2014/15

 Is the Hospital offering care of better quality?

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Quality care is measured by the trend of indicators like FSB rate, Recovery rate, Post C/S infection rate, MMR in the Hospital, % of staff who are qualified. These indicators were evidenced by the data in the report. Graph 10.3 followed by a table on the quality indexes are shown below.

Graph 10.3: Trend of quality indicators over the past five years

Quality indicators over the past 5 years 100 80 60 40 20 0 2010/11 2011/12 2012/13 2013/14 2013/14 2014/15 - HEV Recovery Rate Maternal deaths Fresh still births C-S inf. rate %age of qual. staff

2010/11 2011/12 2012/13 2013/14 2013/14 2014/15 Recovery Rate 95.7 96.9 96.2 95.2 95.2 95.2 23 Maternal deaths 3 8 6 7 4 HEV! 21 Fresh still births 10 19 16 14 2 HEV! C-S inf. rate 1.55 0.37 0 0 0 0 %age of qual. staff 43 48 49 51.6 51.6 57.69

Special comments on Maternal Deaths and Fresh Still Births

During FY 2014/15, four maternal deaths occurred in the Hospital. Three of them died because of postpartum haemorrhage while one died of disseminated intravascular coagulopathy secondary to severe PET. Maternal death audits were done as per the Ministry of Health recommendation using the standard guidelines. Each of the events was reported to the District Health Office and Ministry of Health HMIS data bank. Below Graph 10.4 shows this scenario.

Graph 10.4: Trend of quality indicators over the past five years

Maternal Deaths over 5 years 25 23 20 15 10 8 6 7 5 4 3 0 2010/11 2011/12 2012/13 2013/14 2013/14 2014/15 with HEV without HEV

Total still births were 35 out of 1,164 total births. This is equivalent to a still birth rate of

Page 91 of 100 3.3%. Fresh Still births were 2 which is 0.17% of total deliveries. Macerated still births were 14 which is 1.32% of total deliveries.

Graph 10.5: Trend of quality indicators over the past five years

Fresh Still Births 25 21 20 19 16 15 14 10 10

5 2 0 2010/11 2011/12 2012/13 2013/14 2013/14 2014/15 with HEV without HEV

3) Contribution to the HSSP and MDG

The contribution of Matany Hospital to the national progress in achieving the MDGs is rather challenging but possible. The success of this contribution depends on the fulfilment of MDG-8; building partnerships for sustainability. The current economic crises besetting much of the developed world must not be allowed to decelerate or reverse the progress that has been made so far. Let us build on the successes we have achieved, and let us not relent until all the MDGs have been attained.

 MDG 1: Eradicate extreme poverty and hunger Matany Hospital has had a long standing corporate responsibility every other year in providing food hand outs to extremely vulnerable persons in the community and to the patients. This initiative was initially partly supported by WFP, but the Hospital must now find other partners to support this cause. ISP has been a leading partner in providing food support to the hospital. IDEA has also helped to provide this support through the so called “Akoro” and “Milk Project”.  MDG 3: Promote gender equality and empower women Matany Hospital has a Nursing and Midwifery Training School which provides a chance for young females to pursue further studies in nursing and midwifery. This empowers women.  MDG 4; Reduce child mortality The Hospital provides highly subsidised services to children. The average user fee for children is 2,761/= UGX. Expanded programme on Immunisation is free. The Hospital provides integrated management of childhood illness for all children and has an intensive therapeutic feeding centre for malnourished children. The nursery unit on maternity ward cares for neonates with neonatal complications.  MDG 5: Improve maternal health; The Hospital provides maternal health services like antenatal, delivery and postnatal services. There has been a slight decrease in antenatal attendance but an increase of hospital deliveries in FY 2014/15. Ambulance services are also provided for free for pregnant mothers. EMTCT has been provided to all HIV+ mothers. Adolescent health services are also offered.

 MDG 6: Combat HIV/AIDS, Malaria and other Diseases

Page 92 of 100 The Hospital runs an ART clinic since 2005 with a cumulative number of clients of 1,800. Treatment of malaria and other diseases is provided. The Hospital with the help of CUAMM received a GeneXpert machine in October 2014, which has made Matany Hospital a diagnostic centre for MDR tuberculosis.  MDG 7: Ensure environmental sustainability The Hospital has contributed to environmental sustainability through the artificial forest plated around the hospital. This is a model forest in the area considering the fact that the climate in Karamoja is semi arid. Other technologies like water harvesting and recycling of waste water with a record recovery of about 70% of the water are available  MDG 8: Develop a global partnership for health; The current economic crises besetting much of the developed world must not be allowed to decelerate or reverse the progress that has been made so far. Let us build on the successes we have achieved, and let us not relent until all the MDGs have been attained.

4) Sustainability

Matany Hospital sustainability is a very critical and urgent issue. The main threats to sustainability come from the place where we are situated, from National and Global health and economic policies, lack of proper financing of health services, and human resource situation. Sustainability is threatened locally by the harshness of the region and its isolation mainly because of the distances (almost 500km from main suppliers of medical goods and extremely poor access due to dilapidated road network, at least 140km from the Hospital to Soroti), lack of available trained personnel in the region and therefore the Hospital has to sponsor almost all needed cadres in order to guarantee the services. In a region where the Hospital is the main employer and the rest of the population survives on an extremely low income making it is unadvisable (because it would compromise our mission of making services accessible to the poor) to increase user fees for service which this year registered the local recovery/recurrent cost as low as 13 %. National and Global Policies regarding the creation of new districts and not yet fully operational Regional Referral Hospital makes service delivery difficult and more cumbersome financially for our hospital. The PHC Conditional Grant and all other support from government has not matched the increased demand for service added to this component of the HSD which Matany Hospital heads and must partially cover financially. The global economic crisis is having a strong impact on the progressive decline of external donations and considering the high dependence of this Hospital on external donations this becomes of high concern in near future. The widespread corruption is known to external donors and the withdrawal of support is already a reality which surely will affect health services especially to the most vulnerable people. The isolation of a region like Karamoja is not attractive to Staff; hence retention of Staff is a challenge.

Critical Issues:

Requiring local and internal policy  Full cost recovery of services provided especially for patients seeking private services, those referred or self referred from other districts.

Requiring managerial intervention from HSD and District:  Outreaches to hard to reach settlements not availed with basic services  Role of NGO’s in the region involved in health  Secondment of Staff or preferably financial contribution to the wage bill of the Hospital

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Requiring lobby and advocacy and partnership at district level:  Increase financial support in form of grants based on performance  Improvement of access to Hospital by advocating for better and well maintained roads facilitating access of ambulances to health units thus saving lives

Requiring attention/intervention of UCMB  More involvement of PNFP in planning and decision regarding health  Tax exemption issues for medical goods and for generating electricity through diesel generators  NSSF deductions issues regarding expatriates  Secondment or preferably salary payment of Tutors for NMTS and Medical Doctors to hard to reach areas.

Summary of Recommendations:

To Hospital Management:

 Need to continue applying cost recovery of services’ fees structure to patients asking for private services.  Continue effort of identifying and develop essential cadres  Improve departmental supervision in order to guarantee efficient utilisation of resources in the respective departments.  Mentorship of staffs to ensure quality service delivery at all points of health services delivery.

To HSD/District:

 Strive for better cooperation and sharing in planning and resource allocation  Follow referral system and maintain vehicles at H/C’s for transport of emergencies. Vehicles allocated to Health Centres are often out of service  More participation at Board meetings and Hospital activities on the side of District Officials  District Health Department must recognise the role played by Matany Hospital in health delivery in the District and ensure that the challenges faced by Matany Hospital are a priority in its problem list; all possible effort must be made to advocate and lobby for Matany Hospital at the District level.  The PHC Department in the Hospital must guarantee continued support supervision to the lower level health units in the HSD. Support from the District to continue this delegated service is expected.

To UCMB:

 Liaise with Government on issues of financial constraints and sustainability  Liaise with national insurance agencies on behalf of Expatriates serving in PNFP’s  Build capacity of the Hospitals in the net work to enable them do resource mobilisation. The Catholic Medical Bureau should also inform the various health facilities of the available opportunities at the national and international level, besides policy guidance.

To MOH:

 More support of PNFP institutions, especially those upcountry with the lowest fees recovery, offering highly subsidised services  Sharing of resources on basis of outputs and performance

Page 94 of 100 Conclusion St. Kizito Hospital operates with one goal: that of making the loving tender touch of Christ for the sick and the poor perceivable here and now, so that they may see, and believe, in Him, their Origin and Destiny. We rejoice with and for all those who have encountered the Lord within the walls of the Hospital; we know that often we have made this encounter more difficult with our shortcomings and fragility: we ask pardon for it. Above everything else, we desire to remain faithful to the task, entrusted to us by the Church, of serving the sick: we are grateful to all those who made and who will make this task possible.

We thank God our Almighty Father for having brought us safely to the end of this Financial Year. A lot more has been achieved and is not documented in this report.

We hope that the contents of this report will help to inform those who worked with us during the year towards the achievement of our mission.

They are:

 the Board of Governors of St. Kizito Hospital - Matany  the Health Authorities of the District and the Country  the Local Government  the Diocesan Authorities

We thank them for having entrusted us with the task of serving the people of Karamoja and of Bokora Health Sub District in particular.

Page 95 of 100 ANNEX 1 - Napak District with Health Units

Ngoleriet Lopeei HC II HC III

Lokopo Kangole HC III HC III Matany BOKORA HEALTH Hospital SUB-DISTRICT Morulinga HC II

Apeitolim HC II Nakicumet HC II

Lotome HC III

Lorengechora Namendera HC III HC II

Iriiri HC III

Amedek HC II

Nabwal HC II

Page 96 of 100 ANNEX 2

Members of the Board of Governors: (Following the Constitution of the Hospital)

Voting Members

1. Mr. Paul Abul, Chairman 2. Fr. John Bosco Mubangizi, Ag. Parish Priest, Matany Catholic Church 4. Fr. Sylvester Hategekimana, Provincial of the Comboni Missionaries 5. Sr. Alzira Neres, Provincial of the Comboni Missionary Sisters 6. Sr. Dinavence Tushabomwe, DHC Moroto Diocese 7. Dr. Pierluigi Rossanigo, Med. Tec. Advisor Moroto Diocese 8. Dr. James Lemukol, DHO Napak District 9. Mr. Joseph Lomonyang, LC V Napak District 10. Mr. Dominic Lochoro, LC III Chairman, Matany Sub County 11. Mr. Anthony Lemukol, Sub County Chief Matany 12. Mrs. Rose Lowanyang – Representing HSD, Kangole HC III 13. Representative of Kalongo Hospital (Sister Hospital) 14. Dr. Peter Lochoro, Country Representative of CUAMM

Members, holding offices in the Hospital

15. Br. Günther Nährich, Administrator/CEO (Secretary of the BoG) 16. Dr. John Bosco Nsubuga, Medical Superintendent 17. Sr. Rosario Marinho, out going Senior Nursing Officer Sr. Hellen Atekit, in coming Senior Nursing Officer 18. Sr. Nataline Mowo, Principal Tutor of the NMTS 19. Head of the Public Health Department (held by Medical Superintendent)

Members of the Hospital Management Team

1. Dr. John Bosco Nsubuga, Medical Superintendent (Chairperson HMT) 2. Br. Günther Nährich, Administrator/CEO (Secretary of the HMT) 3. Sr. Rosario Marinho / Sr. Hellen Atekit, Senior Nursing Officer 4. Sr. Nataline Mowo, Principal Tutor NTS 5. Head of the Public Health Department (held by Medical Superintendent)

Members on the NMTS Statutory Committee:

1) Fr. John Bosco Mubangizi, Ag. Parish Priest, Matany Catholic Church (Chairperson) 2) Mrs. Rose Lomonyang, DM Kangole HC III (Board Member) 3) The Sub-County Chief, Mr. Anthony Lemukol (Board Member) 4) The Assistant DHO Napak District, MCH/Nursing, Sr. Regina Narus 5) The DEO Napak, Mrs. Joyce Nakoya 6) The Diocesan Education Secretary 7) The CEO, Br. Günther Nährich (Ex-officio) 8) The PNO, Sr. Rosario Marinho / Sr. Hellen Atekit (Ex-officio) 9) The PT, Sr. Nataline Mowo (Ex-officio)

Page 97 of 100 ANNEX 3

MATANY HOSPITAL ANNUAL FINANCIAL REPORT Item Actual Cumulative Difference Codes Description of financial Item cumulative of last with last year the year 2014/15 FY 2013/14 1XXXX INCOME User Fees' Collection 272,439,130 216,100,950 56,338,180 PHC Conditional grants to Hospitals 537,666,660 529,372,125 8,294,535 PHC Conditional grants to School 28,009,492 28,784,957 (775,465) ( HTI - Non - wage ) Other School Income (incl. Sch. fees) 164,022,600 136,189,483 27,833,117 PHC Conditional grant for HSD ( Non- 35,000,000 35,194,103 (194,103) wage ) Donations of funds/goods for capital 195,900,000 140,272,160 55,627,839 development Donations of funds for recurrent cost 701,267,703 759,581,030 (58,313,326) Donations of goods and services 152,075,559 377,220,607 (225,145,048) Value of Drugs received through EDP 23,691,957 75,646,673 (51,954,716) (in kind) Value of Lab. Reagents & 3,606,208 12,211,340 (8,605,132) Consumables received (in kind) Income for projects(HIV/Aids, Malaria, 301,197,959 223,558,610 77,639,349 P Tuberculosis etc) Other Income 242,688,621 173,258,762 69,429,859 TOTAL INCOME 2,657,565,890 2,707,390,800 (49,824,911) EXPENDITURES: 21 EMPLOYMENT COST 211101 Staff Salaries and wages 938,346,276 863,154,281 75,191,995 211103 Hous/bic/overtime&other all. 22,741,100 21,217,700 1,523,400 211103 Night/safari all. 8,522,000 8,420,000 102,000 211103 Duty/Resp./Acting all. 17,975,672 15,731,672 2,244,000 211103 Lunch all. 43,845,000 40,146,000 3,699,000 211103 Cost for interns - 211103 Cost for student field trips - 212101 XXX NSSF XXX 77,007,532 68,565,093 8,442,439 212101 P.A.Y.E 88,014,708 61,401,920 26,612,788 Staff health/ Social Health Insurance 1,906,600 1,515,000 391,600 213001 (Medical expenses) Incapacity, death benefits & funeral 411,850 800,000 (388,151) 213002 expenses Retrenchment cost / Licence and Staff 11,370,494 8,214,013 3,156,481 213003 Insurance Sub Total 1,210,141,232 1,089,165,679 120,975,552 2XXX HOSPITAL BOARD COSTS Sub Total - -

Page 98 of 100 ADMINISTRATION COSTS FY 2014/15 FY 2013/14 Difference 221001 Advertising and Public Relations 600,000 1,959,000 (1,359,000)

Workshop/seminars 520,000 520,000 221002 - 221003 Staff training - 221004 Recruitment cost - 221005 Hire of venue - 221009 Welfare & Entertainment 3,373,000 5,113,500 (1,740,500) 221011 Printing and stationery 31,844,060 30,195,153 1,648,907 Other office expenses (small office 335,800 333,500 2,300 221012 equipment ) 221013 Bad debts - 221014 Bank charges 2,719,142 963,800 1,755,342 221015 Financial & related costs - Information Financial Management - 221016 System Recurrent cost 221017 Subscription 6,031,032 3,250,000 2,781,032 221018 Exchange loses / ( gains) - 222001 Tel./fax./postage/courier 7,079,283 9,316,300 (2,237,017) Information and communication 10,715,500 10,715,500 222003 technology (ICT) 223004 Guard and security services - 224002 Uniforms & protection clothing 2,518,456 6,305,698 (3,787,243) 225001 Consultancy charges 8,932,000 5,900,000 3,032,000 227001 Transport all. - Sub Total 74,668,272 63,336,951 11,331,321 PROPERTY COST 223001 Cleaning of ward/dormitories 38,421,316 47,583,292 (9,161,976) 223001 Cleaning/slashing of compound - 223005 Electricity - 223006 Water - 228001 Repairs and upkeep of buildings 37,214,379 62,387,174 (25,172,795) 223xxx Rents and rates - Sub Total 75,635,695 109,970,466 (34,334,771) TRANSPORT AND PLANT COST 226001 Insurance for vehicles 1,850,445 1,509,250 341,195 License for property, vehicles , - - 226002 equipment etc 227002 Air travel - - Carriage, Haulage, Freight & Transport 12,080,610 13,228,500 (1,147,890) 227003 Hire 227004 Fuel 78,603,670 81,491,550 (2,887,880) 228002 Maintenance and repairs - 228002 Tyres and spares 327,403 25,558,102 (25,230,699) 228003 Operation/maintenance of generators 65,478,593 70,455,473 (4,976,880) Sub Total 158,340,721 192,242,875 (33,902,154) SUPPLIES AND SERVICES 221007 Newspapers and publications 377,250 (377,250) 221008 Computer Supplies - - 228004 Maintenance of equip. and supplies 830,000 3,010,000 (2,180,000) 22xxxx Equipment and supplies - - - Sub Total 830,000 3,387,250 (2,557,250)

Page 99 of 100 MEDICAL GOODS AND SERVICES FY 2014/15 FY 2013/14 Difference 223007 Foodstuff and firewood 54,245,871 83,859,627 (29,613,756) 224001 Medical drugs 190,776,302 209,144,928 (18,368,626) 224001 Drugs received through EDP (in kind) - Value of Lab. Reagents & 60,287,470 81,333,095 (21,045,625) 224001 Consumables received (in kind) 224002 Beds and beddings 2,518,456 6,298,198 (3,779,743) Maintenance of medical tools and - 1,335,000 (1,335,000) 228004 equip. Donations of goods and services ( by - - 282101 hospital ) 22400X Medical supplies 204,766,174 223,646,894 (18,880,720) 224xxx Medical tools and equipment 63,291,587 166,414,847 (103,123,260) Sub Total 575,885,860 772,032,589 (196,146,730) PRIMARY HEALTH CARE Support supervision (together with - xxxx outreaches) xxxx Outreach services 15,198,400 20,946,100 (5,747,700) xxxx Drugs & sundries for LLUs 11,654,063 8,356,201 3,297,862 xxxx Planning and meetings 188,000 1,556,000 (1,368,000) xxxx Training of TBAs 3,343,000 8,241,000 (4,898,000) xxxx Hospital Based PHC 57,525,677 83,962,925 (26,437,248) Sub Total 87,909,140 123,062,226 (35,153,086) CAPITAL DEVELOPMENT 311101 Land - Major maintenance and upkeep of 210,734,276 152,272,656 58,461,620 312101 buildings 312102 Residential building - Transport Equipment ( motor vehicles, - 312201 motorcycles ) 312202 Machinery & Equipment (non-medical ) - Medical Equipment (eg Precision & - 312202X optical equip etc) 312203 Furniture & Fittings - Cultivated Assets (Breeding stock -fish - 312301 & poultry, diary cattle etc) Depreciation (all categories) ( this can - 231XXX placed under expenses category )

Other capital expenditure / - 231007 Depreciation cost - Staff Development costs (see page 4 15,606,500 32,175,099 (16,568,599) 221003 for definition) Sub Total 226,340,776 184,447,755 41,893,021 TRAINING SCHOOL TOTAL ANNUAL

COST (see explanations) Sub Total 190,188,657 192,247,135 (2,058,478) TOTAL EXPENDITURE TOTAL 2,599,940,353 2,729,892,926 (129,952,575) Balance (Income less Expenditures) 57,625,537 (22,502,127)

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