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

Annual Analytical Report Financial Year 2015/16

St Kizito Hospital Matany st 1 November 2016

Endorsement of Report

This annual analytical report for St. Kizito Hospital Matany covering the period from 1st July 2015 to 30th June 2016 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. Günther NÄHRICH ______

Chief Executive Officer of St. Kizito Hospital Matany

Date: 1st November 2016

This is to acknowledge that I have received this annual analytical report for St. Kizito Hospital Matany covering the period from 1st July 2015 to 30th June 2016. I have read it and endorse its authenticity and representativeness of the position of the Hospital in the year under report

Paul ABUL ______

Chairperson of the Board of Governors

Date: 1st November 2016

Page 2 of 101 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 CHAPTER THREE, GOVERNANCE AND MANAGEMENT 24 ORGANOGRAM 24 THE BOARD OF GOVERNORS 25 MANAGEMENT 31 CHAPTER FOUR, HOSPITAL HUMAN RESOURCES 33 CHAPTER FIVE, HOSPITAL FINANCES 38 INCOME 39 EXPENDITURE 40 CHAPTER SIX, HOSPITAL SERVICES 47 A: OUT PATIENT DEPARTMENT 47 SPECIAL OPD CLINICS 49 HIV AND AIDS SERVICES 51 B: INPATIENT WARDS 57 ORGANISATION AND MANAGEMENT, UTILISATION 57 MATERNITY WARD 60 C: OPERATING THEATRE 64 D: DIAGNOSTIC SERVICES 65 LABORATORY 65 IMAGING SERVICES 67 PHARMACY 68 CHAPTER SEVEN, HOSPITAL SUPPORT SERVICES 70 CHAPTER EIGHT, QUALITY AND PATIENT SAFETY 73 QUALITY IMPROVEMENT ACTIVITIES 73 QUALITY INDICATORS 74 PERFORMANCE INDICATORS 78 CHAPTER NINE, HEALTH TRAINING INSTITUTION 81 CHAPTER TEN, SUMMARY, CONCLUSION, RECOMMENDATION 90 FAITHFULNESS TO THE MISSION 90 ANNEX 1 - DISTRICT WITH HEALTH UNITS (Map) 97 ANNEX 2 - MEMBERS OF BoG, HMT and NMTS STAT. COMMITTEE 98 ANNEX 3 - ANNUAL FINANCIAL REPORT 99

Page 3 of 101 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 N / MTS Nursing / 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 101 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 Sr. Anita Consept. Tutor Br. Günther Nährich Administrator / CEO Lowanyang Lucy Dipl. Nurse/Midwife Lokongo Santine Internal Auditor Amulen Rebecca Diploma Nurse Ogwango Samuelle Accountant Nabukwasi Sofia Diploma Nurse Lorot John Bosco Kapel Accountant Among Mary Registered Nurse Otim David A/C Assistant Br. José Eduardo DN, I/C Pharmacy Ngorok Magdalen Senior Cashier Achilla Lilly Diploma Nurse Nawot Monica Internal Cashier Adiao Grace Diploma C. Nurse Ariam Juliana Assist Cashier Okello Eunice Diploma Nurse Loyep Stephen HR-Officer Tunyany Jacinta Certificate Nurse Loput Johnson HMIS Officer Aluko Grace Certificate Nurse Olupot Jonathan HMIS/Data Mgt. Assistant Abucho Babrah Certificate Nurse Alany Patricia IT-Assistant Tino Peace Certificate Nurse Nakiru Magdalen Secretary Ogwang Alex Certificate Nurse Sagal Prassedde Secretary, NMTS Loukae Gabriel Certificate Nurse MEDICAL OFFICERS Isone Mary Certificate Nurse

Dr John Bosco Nsubuga Gynaecologist / Med.Sup. Okudet Paula Enrolled Nurse Dr Borghi Emanuela Senior Medical Officer Achia Esther Certificate Nurse Dr. George Pellis Surgeon Apio Rebecca Certificate Nurse Dr. Deusdedit Kateregga Medical Officer Okot Kennedy Certificate Nurse Dr. John Ssembuusi Medical Officer Aloyo Agnes Certificate Nurse Dr Patrick Sali Medical Officer Aloyo Scovia Certificate Nurse Dr Longora John Paul Medical Officer Adongo A. Grace Certificate Nurse PARAMEDICALS Amoding Jennifer Certificate Nurse Oyaya Samuel Ochieng Clinical Officer Acom Evalyn Certificate Nurse Maraka Aloysius Clinical Officer Anyakun Hillary Certificate Nurse Otim Tonni Clinical Officer Nagendo Malisa Certificate Nurse Awas Roseline Clinical Officer Apio Loyce Certificate Nurse Amei Simon Peter Laboratory Technician Lomina Daniel Certificate Nurse Walter Ebong Laboratory Technician Emuat S. Peter CN/Dark Room Att. Bakar Fatuma Laboratory Technician Acom Rita Certificate C. Nurse Iluji Stephen Laboratory Technician Adela J. Florence Certificate C. Nurse Lokawa Paul Laboratory Assistant Opus Stephen Certificate C. Nurse Kodet Christine Laboratory Assistant Akech Martha Certificate Midwife Atirok Abraham Laboratory Assistant Adongo Sarah Certificate Midwife Modo David Laboratory Assistant Atero Lucy Certificate Midwife Locham Augustine Ophthalmic Assistant Alungo Salome Certificate Midwife Awas Patrick Orthopaedic Officer Akello Hellen Certificate Midwife Apono Mark Physiotherapist Aliat Esther Certificate Midwife Ayepa Alfonse Anaesthetic Attendant Lotukei A. Grace Certificate Midwife NURSING STAFF Nakiru Lucy Certificate Midwife Atekit Helen Ag PNO Akiriat Betty Certificate Midwife Sr Nataline Mowo Principal Tutor Napeyok Paulina Certificate Midwife Sr Gladys Licoru A. Ag. Principal Tutor Aleper Esther Certificate Midwife

Page 5 of 101 Awoyo Immaculate Certificate Midwife Akung Betty Cleaner Ayoo Teddy Certificate Midwife Longoli Maria Cleaner Okuvuru Victoria Certificate Midwife Kodet Magdalen Cleaner Lomilo Paul Dental Attendant Achilla Lucy Cleaner Otyang Charles N. Dark Room Att. Pedo Agnes Cleaner Lotukei Anjello Dark Room Att. Achia Giovanna Cook Adiaka Rosemary Nursing Assistant Alinga Amalia Cook Agaro Sylvia Nursing Assistant Akello Beatrice Cook Akinyi Jennifer Nursing Assistant Logiel Agnes Cook Akol Lucy Nursing Assistant Apuun Lucy Cook Awas Mary Goretti Nursing Assistant Ngole Jacinta Cook Jaka Valentine Nursing Assistant Amuron Hellen Cook Karane Josephine Nursing Assistant Angella Magdalen Cook / Caterer Lochoro Hellen Nursing Assistant Lokoel Agnes Cook Sagal Florence Nursing Assistant Nake Cecilia Cook Keem John Senior Nursing Aid Aleper Dina Cook Akumu Lucy Senior Nursing Aid Nauga Cecilia Cook Nachuwa Mary Senior Nursing Aid Longok Valentine Cook Yeno Maria Senior Nursing Aid Ojao Angelline Cook Angella Molly Nurse/Aid, SW Lotukei Agnes A. Pastoral Care Giver Nawal Jane Nurse/Aid, ChW Pulkol John Laundry Attendant Anero Betty Nurse/Aid, TB Ward Lokiru Raphael Laundry Attendant Achuka Angelina Nurse/Aid TB Ward Aleper Emanuel Incinerator Attendant Kodet Jenifer Nurse/Aid, OPD Abura Alice Watchwoman Namoe Margaret Nurse/Aid, TB Ward Angolere Mario Watchman Amodoi Josephine Nurse/Aid, CHW Losur Stephen Watchman Epur Scholastica Nurse/Aid Koryang Isaac Watchman Logiel Rose Nurse/Aid Omuke Stephen Watchman Aleper Agnes Theatre Attendant Elasu Stephen Watchman Lokwi Florence Theatre Attendant Lomeri John Compound Zoe Martin Theatre Attendant Teko Peter Compound SUPPORT STAFF Lochan Matteo Compound Sr. Ruaro Giovanna RN, Domestic Officer Lokol Enok Compound Atim Magdalen Assist Store Keeper, GS Lokut Marko Compound Namoe Rose Assist Store Keeper, GS Longoli Simon Compound Alumo Luigina Assist Store Keeper, GS Lodungokol Marco Compound Santina Yeno Assist Store Keeper, GS Keem Marco Compound Adupa Janet Cleaner Lomilo Simon Compound Aboka Agnes Cleaner Ichumar Peter Mortuary Attendant Aisu Anna Cleaner Lobur Joseph Mortuary Attendant Chero Anna Cleaner Achia Anna Tailor Ngorok Scola Cleaner Lolem Lucy Tailor Kiyonga Agnes Cleaner Nakong Lucy Assist Tailor Koryang Angellina Cleaner Loma Alice Tailor Lokoryo Dorothy Cleaner PUBLIC HEALTH DEPARTMENT Longole Theresia Cleaner Achia Deborah Incharge PHD / SNO Lopwanya Veronica Cleaner Longole Mary Diploma Midwife Napeyok Lucy Cleaner Ngiro Martin Health Educator Neno Betty Cleaner Lokwang Anthony Health Inspector Akol Alice Cleaner Imalany Ambrose H. Inform. Assistant Lomongin Clementina Cleaner Alinga Mary Gina Vaccinator Agilu Evalyn Cleaner Mudong Martina Vaccinator

Page 6 of 101 TECHNICAL DEPARTMENT Owilli Sylvio Mechanic / Driver Gruska Peter Incharge, Carpenter Sagal Samuel Joel Mechanic / Driver Teko Raphael Proc. Adv., S. Driver Lokut Matthew Mechanic / Driver Achilla Matthias Carpenter Lokiyo James Metal worker Sagal Michael Carpenter Aleper Gabriel Plumber / Mason Lokwii Joseph Carpenter Olupot J. Joseph Plumber Eliau Julius Electrician / Driver Lokiru Peter Porter Maruk Augustine A. Electrician / Driver Loburo Peter Porter Otyang Paul Electrician / Metal Worker Ngorok Eliya Porter Logiel Thomas Mason Amei Domenic Casual Worker Lokiru Mark Mason Loli John Casual Worker Mubakye Patrick W Mason Loteng Philip Casual Worker Lajul Robert Mason Lotukei Michael Casual Worker Onyait Christopher Mason Logiel Pasquale Store Keeper Loit Abraham Mason Lochen Sisto Support Staff Lotee Paul Mason Iiko Michael Support Staff Lomongin Daniel Mason Lowakori Marko Support Staff Iriama Philip Mechanic / Driver Ngorok J.B Support Staff Koriang Paul Mechanic / Driver Moru Paul Support Staff Omaswa Francis Mechanic / Driver

We do remember all those who help us in sustaining our health services 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, Belluno; ‘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.

Our special vote of thanks goes 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 for what it is known, namely a model for dedicated and compassionate service.

Page 7 of 101 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 macerated. 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 foetuses 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 101 EXECUTIVE SUMMARY

Description of the Hospital and its environment

St. Kizito Hospital Matany is located within in North-Eastern Uganda, bordering 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, ), and deals with an average annual admissions of about 9,000 inpatients and 23,000 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 Town Board.

The Hospital entirely depends on the inhabitants of this Trading Centre for its support staff and a most of its 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 /, 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, medical technologists and others, are conducted within the hospital. The Hospital is contributing to the health manpower development in Uganda.

Page 9 of 101 Achievements / improvements that have been made in FY 2015/16

Key planned activities Status of achievement Complete the process of accreditation of the Baseline line assessment, first training and Laboratory into SLAMTA first assessment done One staff completed a Masters of Science in Health Services Management; one staff got Send some staff for training like Hospital a certificate in Records and one MO is management, records management, surgery following a Masters in Surgery at Makerere University The quality assurance committee meets Intensify activities of the quality assurance twice a year and follow up its committee recommendations Staff development 9 nursing staff sent for further Staff at different school, Lacor, Nsambya, training , Rubaga Procurement and installation of new autoclave Equipment arrived, still to be installed and theatre lights Hospital acquired a new lorry It is in service New transformer was installed Functional Connection to the national grid (UEDCL) completed Acquired two overhauled generators In use Started construction of patients’ kitchen Still on going Employed a human resource officer Present Employed an internal auditor Present Start the Electronic Patients’ Records This delayed but will be effected in 2016/17 Management System Major Renovation of NMTS if funds are made Work in progress in the hope that the available pledged funds from OPM arrive As funding was not forthcoming it is hoped Modernisation of X-Ray equipment, phase 2 to have a new X-Ray machine within FY 2016/17 Funds are now available and intervention Rehabilitation of patients/attendants kitchen will be completed within FY 2016/17 Was completed by the end of 2015 and the Complete Extension of Laboratory old Laboratory was renovated Complete “Oxygen generating room”, and start Equipment arrived and the installation to be oxygen production with piping system to the carried out in early FY 2016/17 various wards.

Challenges encountered are: limited financial resources and manpower which did not allow achieving all the planned activities.

Important recommendations/plans for the coming year 2016/17

 Complete the process of accreditation of the Laboratory into SLAMTA  Send some staff for training as Public Health Nurse, Pharmacy Assistants, Theatre Assistants, Computer Science, Social Work, Laboratory Technician  Start the Electronic Patients’ Records Management System within FY 2016/17  Conduct cancer screening in the Hospital  Continue major renovation of NMTS if funds are made available  Modernisation of X-Ray equipment, phase 2 – new equipment is hoped to arrive in 2016/17  Rehabilitation of patients/attendants kitchen (as funds are now available)  Building of a new staff house with six units  Complete “Oxygen generating room”, and start oxygen production with piping system to the various wards.

Page 10 of 101 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 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 8,665 In-patients with a decrease of 10.3% from the previous year, and the total new and re-attendant outpatient consultations during the FY were 23,473 showing a decrease of 36.4% as compared to the previous year. In the special Clinics of the Hospital 39,542 patients were seen and thus the total of all out patient contacts was 63,015 compared to 78,175 which constitutes a decrease of 24.1%. Deliveries in the Hospital have decreased by 46 (4%), while antenatal attendance has increased by 1,536 (31.6%), 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 8,729 (20.9%) 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 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 101 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 101 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 23,291 148,283 148,283 for the year under report) Total expected deliveries B (5/100) * A 1,165 7,414 7,414 (5% of population) Total Assisted deliveries in C 1,165 5,163 5,163 Health Facilities Tot. Assisted deliveries as D (C/B)* 100 100% 69.64% 69.64% % of expected deliveries E Children <1 year (4.3%) (4.3/100) * A 1,002 6,376 6,376 F Children < 5 years (20.2%) (20.2/100) * A 4,705 29,953 29,953 Women in child - bearing G (20.2/100) * A 4,705 29,953 29,953 age (20.2%) H Children < 15 years (46%) (46/100) * A 10,714 68,210 68,210 I Orphans (10%) (10/100) * A 2,329 14,828 14,828 Suspected tuberculosis in J (A) * 0.003 70 445 445 the service area

Table 1.2 TOP TEN CAUSES OF OPD ATTENDANCES IN BOKORA HSD FY 2013/14 FY 2014/15 FY 2015/16 Malaria 85,132 Malaria 59,397 Malaria 27,846 RTI 43,647 RTI 40,477 RTI 15,071 Diarrheal D'ses 11,360 GID Diseases 5,528 Mild acute Malnutrition 3,046 Eye conditions 7,965 Diarrheal D'ses 5,283 Diarrhoea acute 2,834 GID Diseases 6,141 Skin Diseases 4,808 Pneumonia 2,301 Skin Diseases 6,107 Pneumonia 2,850 Eye conditions 2,025 Intest. Worms 4,759 Intest. Worms 2,711 Gastro intestinal Disord. 1,917 Pneumonia 4,690 ENT 2,694 Urinary tract Infect. 1,787 UTI 4,204 Injuries 2,144 Skin diseases 1,715 ENT 3,263 UTI 1,128 Injuries 1,631

Page 13 of 101 Graph 1.1: Top 10 diseases in Bokora Health Sub District during FY 2015/16

TOP TEN CAUSES FOR OPD ATTENDANCES IN BOKORA HSD FY 2015/16

Skin Injuries Eye UTI diseases 3% conditions GID 3% 3% 3% 3% Malaria Pneumonia 46% 4%

Diarrhoea acute 5% M ild acute malnutrition RTI 5% 25%

Malaria is still the leading cause of OPD attendance over the years. However numbers of out patients has generally decreased over this FY 2015/2016 which we attribute to increased work done by the VHTs to treat common illnesses like diarrhoea, fever and cough at household level. Besides that an increase in malaria testing that has registered 34 percent in FY 2015/16 has improved in excluding a sizeable number of cases that were usually considered to be having malaria clinically. There are also more small private clinics and drug shops opened where it is presumed that patients also seek services from there. The migration of the communities to the fertile areas where there are no social services resulting in limited accessibility to the health units also contributes to this reduction. Generally there has been marked drop in proportions in a number of the top ten OPD attendance in the HSD. Compared to the top ten causes of OPD attendance in FY 2014/2015 less progress has be made in tackling malnutrition in the Health Sub District with improved screening of malnourished children at health facility making mild acute malnutrition (MAM) among the top five causes of OPD attendance.

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 101 Graph 1.2: Distribution of malnourished children admitted in Matany Hospital ITFC

Distribution of Cases admitted to Matany Hospital ITFC per Health Center FY 2015/16

10% Matany 6% 1% Iriiri 43% Lopeei 2% Amudat 10% Katakwii Nakapiripirit 2% Kangole Lotome 1% 1% Kotido 12% Lorengecora 12% Lokopo Total admitted Children: 166

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 was among the top ten causes of admissions in FY 2014/2015 but the number of malnourished children admitted in Hospital ITFC has fallen from 278 in FY 2014/15 to 166 in 2015/16 equivalent to 40 percent reduction. The significant reduction in admissions is mainly attributed to accessibility to supplementary feeding to all identified moderately malnourished children in all health centres by Andre Food Consult before they deteriorate to SAM. Despite of the above reduction in admissions the prevalence of malnutrition in the district remains high as revealed in the food security assessment carried in July 2015 and mass screening conducted in October the same year. The food security assessment in July 2015 before harvest revealed a high prevalence of GAM rate above 10 percent, with 2 percent SAM threshold levels and mass screening done in October just after harvest showed GAM rate at 8.6 percent and SAM 0.8 percent. According to World Food Programme food security assessment report of 2015 Napak district is reported to be with the highest prevalence of malnutrition in Karamoja region. This persistent trend is particularly worrying given the different interventions carried in the past years with less noticeable changes.

The situation is expected to worsen after December like in other previous years as a result of too little rains and practically little 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 101 CHAPTER TWO

HEALTH POLICY AND DISTRICT HEALTH SERVICES

COMMUNITY HEALTH DEPARTMENT

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 MoH with a purpose of achieving improved health for all in the HSD.

Bokora Health Sub-District comprises of 8 Sub-Counties (i.e. Matany, Iriri, Lokopo, Lopeei, Ngoleriet, Lotome, and Lorengecora including one town council located in Lorengecora. It was in July 2010 that Napak District was curved out of Moroto District which covers the area of Bokora HSD. There are 14 Health Units, 1 Hospital (Matany), 6 health centre IIIs (Iriiri, Lorengecora, Lopeei, Lokopo, Kangole and Lotome) and 7 health centre IIs (Amedek, Nabwal, Morulinga, Ngoleriet, Namendera, Nakicumet and Apeitolim).

A good number of districts in Uganda created significant number of health facilities in the past however Napak district is one of those that did not and at this time when the district is expanding the number of its health centres, it is incapacitated with a ban on creation of new health centre IIs in the country. The district has Namendera, and Nakicumet already operationalised despite of the ban and these health centres do not receive medicines nor other logistics from government including funds to run them and it strains the HSD and DHO’s office in borrowing the needed items for these health centres. Two new health centres are planned to be operationalised; Naturumrum in Iriiri and Kailikong in Lopeei in the next FY 2016/17. Nakayot area poses a great challenge to health service delivery with many people settled in the place but far from the nearest health centre. Unfortunately the area is still a place of conflict between wild life authority and the settling communities. A community Based Organization, Clide is offering some services there. Iriiri Health Centre III is planned to be elevated to HC IV since a third of the district population is settled in Iriiri Sub County. Matany Hospital and Kangole Health Centre III are Private Not for Profit health units under UCMB which offer highly subsidised health services.

Access to care is affected by; high illiteracy rate, lack of business and working opportunities, poverty, changing weather patterns and long distances walked particularly in hard to reach areas.

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 23,291 2. Morulinga HC II 8 km 10 km ( 21 Km during 1. Lokopo HCIII Lokopo the rainy season) 21,761 80 km (120 km during 2. Apeitolim HC II the rainy season)

1. Nawaikorot HC II 15 km Ngoleriet 18,183 2. Kangole HC III 10 km

Page 16 of 101 17 km (50 km during Lotome Lotome HC III 11,834 the rainy season)

1. Iriri HC III 45 km 2. Nabwal HCII 70 km Iriiri 3. Amedek HC II 53 km 42,817 4. Nakicumet HC II 18 km 5. Namendera HC II 78 km 11 km (37 km during Lopeei Lopeei HC III 13,676 the rainy season)

Lorengecora 1. Lorengecora 37 km 11,333 2. Lorengecora T.C 37 km 5,389 Total Bokora HSD 148,283

Table 2.2: Population figures for year 2015/2016: (Bokora HSD population from Census 2014, total population NAPAK DISTRICT = Bokora Health Sub-District = 148,283)

% of the Age group Target Population Remarks population For DPT-HEP B + Hib, Infants < 1 Yr. 4.3% 6,376 measles, polio coverage Children < 5 Yrs 20% 29,657 For Polio campaign (NIDs) Women 15 to 49 Yrs 23% 34,105 For TT coverage Pregnant Women 5% 7,414 For TT coverage >6 months to <5 years 19.2% 28,470 For Child days 1 – 15 years 48.4% 71,769 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. 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. The 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 been carrying outreach activities to Apeitolim, Lotome, Lorengecora and Kangole Health unit to offer integrated HIV care services which include; HCT, EID,CD4 testing and TB/HIV co management. With the new policy on HIV care services MoH accredited HC IIIs to run HIV Clinics, Matany Hospital transferred clients to Iriiri, Lotome and Kangole HCs as a strategy to minimise poor adherence to treatment however the Hospital still gives assistance to these health centres in caring for HIV patients.

Page 17 of 101 Although the strategy was aimed at improving adherence, loss to follow patients on ARVs has continued to rise and according to ART clinic records at the end of June 2016 there are 557 active or regular cases, deceased 79, PMTCT 1, Lost to follow up 993, transferred 402 and those stopped treatment by 5. Baylor and CUAAM do support a few components of HIV care but the problem of Lost to follow up particularly those residing in our catchment area requires new appropriate interventions to address it.

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

5. Through the peripheral health units and VHTs the following activities have been carried in the HSD; 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.

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 2 2 1 1 3 1 1 1 0 17 100% by Government SCO IRIIRI HC III 2 1 2 1 2 3 1 1 3 1 1 0 1 19 111% (Govt) KANGOLE HC III 1 0 1 0 2 0 1 0 3 1 1 1 0 11 65% (Cath. Church) LOKOPO HC III 1 0 1 0 2 3 1 0 3 1 0 0 0 12 71% (Govt) LOPEI HC III 1 0 0 1 1 2 1 0 3 1 1 0 0 11 65% (Govt) 1 LORENGECORA 0 1 1 2 2 1 0 3 1 0 1 0 13 76% HC III (Govt) SCO LOTOME HC III 1 0 0 0 1 4 1 0 4 1 1 1 0 14 82% (Govt) SCO HC II standard by 0 0 1 0 1 1 0 2 0 0 0 0 5 100% Government Nawaikorot 0 0 1 0 5 1 0 0 4 1 0 0 0 12 240% HC II (Govt)

Amedek HC II 0 0 1 0 2 1 0 0 1 0 0 0 0 5 100% (Govt) Morulinga HC II 0 0 1 0 3 1 0 0 3 0 0 1 0 9 180% (Govt) Apeitolim 0 0 1 0 2 4 1 0 1 1 0 0 0 6 120% HC II (Govt.) Nabwal HC II 0 0 0 0 2 2 0 0 1 0 0 0 0 5 100% (Govt.) Nakicumet HC II 0 0 1 0 1 1 0 0 1 0 0 0 0 4 80% (Gov’t) Namendera 0 0 0 0 2 1 0 0 2 0 0 0 0 5 100% HC II (Gov’t) TOTAL (current 7 2 10 3 22 21 8 1 32 8 4 4 1 123 85% staff) Qualified 5 4 3 2 -3 -2 5 -1 0 5 2 2 -1 21 15% Staffing Gap Total (ideal 12 6 13 5 19 19 13 0 32 13 6 6 0 144 100% staffing)

Page 18 of 101 In overleaf 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 services continue to be incorporated in these integrated outreaches. These ART outreaches are mainly in Apeitolim and Lorengecora health centres in the HSD. This has led to an increase in accessibility to HIV care and some improvement on adherence to treatment by clients. Mass Hepatitis B screening and vaccination started in April 2016. A total of 13,541 people have been tested with 1,352 turning positive and those that have been immunised are 11,369. Treatment of those with Hepatitis B will be organised by the Ministry of Health. The Queen Elizabeth Diamond Jubilee Trust has supported Cataract and trichiasis surgeries in the Health Sub District using Door to door mobilisation and screening strategy. Cataract surgery targeted Ngoleriet and Lopeei Sub Counties. Lid rotation surgeries have been conducted in all the Sub Counties and it is planned to end in December 2016. Out-reaches to hard to reach areas have continued with support from CUAMM. The District recruited new health workers during the FY. Matany Hospital received 4 seconded staff, who were formerly employed by the Hospital.

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 2015/16 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’ 2006 2007 2008 2009 2010 2011/ 201 2013 2014 2015 Target Supervision /07 /08 /09 /10 /11 12 2/13 /14 /15 /16 2015/16 No. of visits to 84 96 96 96 96 100 120 117 112 118 144 Government units No. of visits to 12 12 12 12 12 11 12 12 12 12 12 Diocesan units Total visits to all 96 108 108 108 108 111 132 129 124 130 156 units Total no. of the units 9 9 9 9 9 11 11 11 13 13 13 Average visits per 12 12 12 12 12 12 12 11.7 9.5 10 12 unit

Page 19 of 101  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 streets and Kenya towns. 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. Following activities were carried out: Immunisations of 1,004, Deworming of children: 894, Antenatal visits: 394, children assessed for malnutrition: 856 and VHTs supervised were 18. 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 still 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 some improvement registering 6,587 first antenatal visits and 4,924 deliveries in 2015/16. The increase in maternal health services has been a combined effort of the district and implementing partners. UNIC.EF through CUAMM is paying 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. Each sub-county has an average 8 outreach posts run by the health unit staff and some of the Field Health workers attached and facilitated by the 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 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 Target BCG 89% 97% 100% 98% 109% 143% 100% DPT3 113% 119% 100% 100% 118% 163% 85% MEASLES 104% 115% 100% 100% 100% 190% 95%

TT2+ P 87% 124% 50% 50% 57% 58% 50%

TT2+ NP 23% 53% 27% 50% 45% 47% 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. The population figure of the district is not well certain since there different figures used coupled with the timing of the previous census which was conducted at the time when many people had gone outside the district but keep coming back making projections difficult. There are also settlements that have high numbers of children of immigrants from

Page 20 of 101 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.

The Hospital through its community health department contributes to the National development plan and sustainable development goal 3 of “ensuring healthy lives and promotion of well-being for all at all ages” substantially in the region. 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.

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 department collaborates with frontline health workers in form of Village health teams, 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 are 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. 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. The district did not conduct this mass drug distribution in FY 2015/2016 because the prevalence of lymphatic filariasis and trachoma had gone down.

 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. Annual eye surgical camp continues to be conducted in Matany Hospital and in the FY 2015/2016 a total of 589 patients under went lid rotation with

Page 21 of 101 support from Queen Elizabeth Diamond Jubilee Trust and 97 cataract surgeries. Lid rotation contributed 82% of all the operations while cataract surgeries contributed 14%. The rest included; trabs, intraocular surgeries, aniridia etc.

Table 2.7: Primary Eye Care

2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 No. of uncomplicated cases treated 1,833 1,563 692 1,039 1,045 1,470 No. of cases operated 275 137 394 333 455 686 No. of cases referred 18 16 8 6 8 6

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 2015/2016

Ophthalmic Assistant Workload during FY 2015/2016 including static clinic and outreaches Eye disease No. Eye Surgery No. Normal eyes 18 LID Rotation 589 Allergic eyes 154 CAT 97 Acute red eyes 30 TRAB 5 Cataract 226 Enucleation 0 Glaucoma 55 Foreign body removal 0 Corneal scars 84 Retina 0 Active trachoma 456 Other intraocular 0 Non active trachoma 137 Eviscerations 0 Ocular trauma 37 Carcinoma/pterygium 0 Refractive errors 42 EZIA (Aniridia) 0 Other diseases 231 Others 19 Total eye diseases 1,470 Total eye surgery 710 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 2015/16.

The table below shows a summary of cases reported since 2013/14 to 2015/16

Table 2.9: Notifiable Diseases during FY 2013/2014 to 2015/2016

FY 2013/14 2014/2015 2015/2016 Cases Cases Cases Disease Deaths Deaths Deaths reported reported reported Cholera 0 0 0 0 0 0 Bacillary Dysentery 1,533 0 961 0 1,108 0 Measles 5 (suspects) 0 3 (suspects) 0 3(suspects) 0 AFP/Polio 0 0 0 0 0 0 Bacterial meningitis 14 9 15 0 15 0 Meningococcal Meningitis 00 1 0 1 0 Malaria 86,241 65 59,397 67 61,524 62 Neonatal tetanus 0 0 2 1 2 1 Plague 0 0 0 0 0 0 Typhoid 425 1 196 3 278 2 Yellow fever( suspects) 7 0 0 0 0 0 VHF 0 0 0 0 0 0 Guinea Worm 0 0 0 0 0 0 Animal bites/ Susp. rabies 402 0 480 1 354 1 Chicken pox 92 0 421 0 287 0 SARI 0 0 0 0 0 0 Maternal Death 0 7 + 16 0 4 0 2 due to HEV Perinatal Death 0 15 0 45 0 20 Hepatitis E (HEV) 1,494 (suspects) 31 177 (suspects) 0 20 (suspects) 0

Page 22 of 101 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 that had continued in FY 2014/15 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. The introduction of Hepatitis B vaccination was started in April 2016 with social marketing at the market premises by the hospital team and there is good uptake of vaccination.

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 modern 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  Creation of new health centre 11s which are not recognised by central government

Plan for next Financial Year 2016/17

 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 in future when possible.  Eye-Surgeon to continue with the annual surgical camps and support Facial cleanness to prevent trachoma.  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.  Improve follow up of TB patients and supervise TB control activities.  Strengthen the epidemic preparedness and response activities.  The hospital could initiate new interventions to address the problem of lost to follow up for ART services

Page 23 of 101 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 catch- Support Staff Diagnostic support staff. infrastructure, ment area; and students departments Cleaning and Equipment HSD services Pharmacy Domestic and Grounds; and activities Department Transport

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 101 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 2015/16 there were four BoG meetings.

Table 3.1 BoG meetings

No of Dates of Board Reports presented / Key issues handled / decision Members meetings taken present Results of Patient Satisfaction and Drug Prescription 30/07/2015 1 14 Survey 2 Personnel Issues 3 Financial Issues – Budget FY 2015/16 4 PHC – brief report 5 NMTS – brief report AOB - False reports on Fees-increase, attendants 6 request for help in spite of being helped Feedback on Sensitisation of community leader in 12/11/2015 1 16 Napak District on Hospital updates 2 Report on user fees increase and its effects 3 Faithfulness to the Mission Report 4 Audit Report FY 2014/15 5 NMTS – brief report 6 PHC - brief report 7 AOB - Visit of the First Lady on Monday, 19th October 2015 - Hospital Accreditation for 2016 to UCMB network 03/03/2016 1 Possible support by OPM 13 2 Strategic Plan Jul 2016 to Jun 2021 3 Financial Issues – budget performance 4 NMTS – brief report 5 PHC - brief report 6 AOB - TB support and MDR Drugs supply 10/06/2016 1 Strategic Plan for Jul 2016 to Jun 2021 13 2 Hospital Budget FY 2016/17 3 NMTS - brief report 4 PHC - brief report 5 AOB - Cancer Screening in October 2016

During the BoG meeting of 30th July 2015 the results of the Patient Satisfaction and Drug Prescription Survey carried out in May 2015, were shared. 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.

Page 25 of 101 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 2015/16 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.

The main issue discussed during the BoG meeting of 12th November 2015 was the Feedback on Sensitisation of community leaders in Napak District on Hospital updates and new user fees presented by the MS. This had been recommended by the BoG meeting of July following increase of user fees in April 2015. Some individuals were also using the opportunity to tarnish the reputation of the Hospital. The sensitisation program was conducted between 31st Aug – 9th Sept 2015. The objectives of the sensitisation were: to get a feedback from the community about the new fees structure, sensitise the community about the financial situation of the Hospital, how the services can be sustained and updates about other developments in the Hospital. There is still a misconception that patients should get treatment free of charge. Leaders understood that the fees were not as high as they had thought considering also the high quality of service that patients receive. They appreciated that the Hospital is still concerned about the poor through its different payment structures. Emphasis was put on service first then negotiated payment for those with insufficient funds. Other issues discussed were the free ambulance services for pregnant mothers and neonates (for which they were grateful), new organisation of OPD, new prescription practices in OPD, new laboratory machines, health centres’ issue etc. In close conjunction with the first topic, the Administrator presented in various Graphics the impact on the increase of user fees versus OPD and Inpatient attendance by comparing the figures of the same period with the previous year. It was obvious that both Inpatient and OPD attendance dropped. OPD numbers dropped on average by 36.6% while IP Attendance dropped on average by 14.8%, while income both for IP (46.5%) and OPD (58%) increased. The HMT looked at these figures and suggests that children and pregnant mothers, as well as chronically ill patients need to be more supported than other patients or those with more income, who can afford cost recovery rates. The Samaritan Fund is fed from outside donations and cares for fees for destitutes and those who cannot afford. The next agenda point gave highlights on the Faithfulness to the Mission Report 2014/15. It was noted that there was a slight reduction of OPD and ANC attendance. All the other indicators showed positive trends. These included more inpatients, more deliveries, and more immunisations. The general performance using the Standard Unit output (SUO) has as well improved by 2.9%. One member commented that UCMB try to sustain their services in spite of many challenges. The HMT struggles to maintain the spectrum of services in spite of the challenges concerning their sustainability. Now is the time that stakeholders come to the Hospital’s aid. The same situation is coming up again as in 1996, when UCMB was advocating to government that our PNFP Hospitals needed support. Government has to once again be informed that the time has come which makes it almost impossible to keep

Page 26 of 101 up all our services due to widening financial gaps and more assistance is needed in order to avoid that health services are reduced. The fourth agenda point dwelt on the Audit report for the year ended 30th June 2015. The board was informed about the three main areas, namely the financial position as at 30th June 2015, the financial performance and the statement of Cash flows. In general it was noted that the financial position was a bit better than the previous year. The Principal Tutor gave in the next agenda point the Faithfulness to the Mission Report of the NMTS for FY 2014/15. She showed that the number of students had increased from the target population of 90 in the last four years and was at 109 students as of 30th June 2015. One student was lost during the reporting period due to gross neglect of a mother who was in labour. During FY 2014/2015 there was stability in discipline and good academic performance hence no student was referred. The fee per student continued to be affordable and thus the indicator for equity favourable. This applies also for efficiency as the average recurrent cost per student remained stable as compared to the previous year in spite of inflation and general rising of prices. The success rate remained 100% which has been maintained for the last four years. Also the equality rate, this is qualified Tutor : student ratio has improved and is now by 1:36. The WHO standard Tutor-Student Ratio is at 1:20 while UCMB accepts a Tutor – Student Ratio of 1:30. Finally the MS gave the report on PHC activities:  The District conducted a mass nutrition screening for children below five years between 27th - 31st October 2015. In Matany Sub county 3,800 children were screened of which 17 were found to have severe acute malnutrition with seven coming from Morulinga parish. These were referred for care in Health Centres.  Kangole and Lotome satellite ART clinics were operationalised. Transfer of patients from Matany ART Clinic to these clinics started in September and was completed in October. However the Matany ART clinic team will continue conducting support supervision to these Health Units until December 2015.  The District has had four eye surgical camps. In Nakicumet, Morulinga, Lokopo and Lopeei Health Centres. The camps were funded by an NGO-CHRISTIAN BLIND MISSION (CBM). VHTs did the mobilisation and surgery was done by CBM surgeons. The Hospital Ophthalmic Assistant was involved in the exercise.  The HSD was involved in the national mass immunisation campaign against measles from 3rd-5th October 2015. Napak District scored 102% and Matany Sub County 115%. The planned HPV vaccination was not given. It was rescheduled to sometime in November2015.  There is a midwife to midwife mentorship going on in the HSD. The mentorship involves senior midwives of the District, mentoring the junior ones in the different facilities. CUAMM is coordinating this project.  JHpiego has been organising trainings of midwives on different obstetric emergencies at Iriir Health Centre. They have had trainings on helping mothers survive, helping babies breathe, obstructed labour and PET. The CUAMM Country Representative commented, that CUAMM could help to have more ART outreaches, especially to HC II’s in order to eliminate mother to child transmission of HIV everywhere. Under AOB following was discussed:  Visit of the First Lady on Monday, 19th October 2015 The Administrator briefly informed the house about the visit of the First Lady. In February 2015 the Hospital received some drugs from the First Lady’s office and took the opportunity to inform her about our challenges. In June 2015 she invited the HMT for a meeting. Requests were made for the NMTS, Tax exemption for the importation of a four wheel drive lorry, and a burns programme. In August she met the MS in Kampala. She then expressed that she wanted to come. Her visit was on the 19th October. She first visited the

Page 27 of 101 NMTS and then Maternity. In a power point presentation she was informed about sustainability issues and projects which were accomplished in the previous two years. We informed her also that the main challenges are the recurrent costs which are difficult to find. She stated clearly that government cannot commit itself for paying salaries, which is the highest item for recurrent costs. In her remarks, she commended us for the good services and the way the Hospital is organised and maintained. She perceived the big struggle we are having to sustain our services and requested one of her secretaries to follow up. - A general renovation of the NMTS was requested and a BoQ presented. It is hoped to receive this FY about 50% of the requested funds and the other 50% in FY 2017/18. The house was informed that the students showed great proficiency and self confidence when they presented to the First Lady some health talks while she was visiting the NMTS. This was very impressive. Karimojong applicants to the NMTS continue to get priority according to the mission of the HTI.  Hospital Accreditation for 2016 to UCMB Network The Hospital Administrator passed the Accreditation Certificate around which was received during the 2nd Hospital Managers Technical Workshop on the 7th October 2015, organised by UCMB.

It was interesting for the Board, during its meeting on the 3rd March 2016, to hear from the MS about the various encounters he had with the First Lady since February 2015 and how it led to a Memorandum of Understanding between the OPM and Matany Hospital. It will be a three year support. Each year 500 Million UGX are expected to support mainly the Nursing Training School major renovation, new infrastructure, and support in form of sponsorships for nursing students and staff development (N.B.: However until September 2016 no funds were received so far). The major topic discussed during this BoG meeting was the need to formulate a second Strategic Plan for the period Jul 2016 to Jan 2021. First the monitoring and evaluation indicators of the soon ending Strategic Plan over the past five years were discussed. Most of the targets were met. Then the proposals of the staff for the next five years strategic plan were presented. As way forward a small committee to develop the first draft for the next Strategic Plan was chosen comprising of the CEO, MS, Ag PNO, PT, DHO and DHC- Advisor. Next agenda point discussed was the Budget Performance report. The budget figures FY 2015/16 were compared to the actual income and expenditure figures from July 2015 to January 2016. The figures were balancing well. Members commented the income of higher user fees. This was expected and is also needed. Now the cost recovery rate from user fees in relation to recurrent costs was during these 7 months by 17.27%. In FY 2011/12 the percentage was by just 7.77%. The Principal Tutor gave her brief report in updating the board about the current student population. She further informed about the 100% success rate during state final examinations of the 42 nursing and midwifery finalists out of which 36 passed with Credits. Two CM May 2014 Intake students failed their re-sit of promotional exams and were referred. Referral is recommended by UNMEB as to give some weak students more time to become good professionals. In the PHC Report the MS informed members that Napak District is one of the 13 districts with the highest prevalence of Hepatitis B. Government decided to vaccinate all individuals 13years and above against hepatitis in these districts. Napak received its hepatitis B vaccines in November 2015 for mass vaccination. Last year the District recruited health workers who received appointment letters in February 2016. They are to be posted soon. Hospital expects 4-5 staff to be seconded to Matany. Government is planning to introduce Community health extension workers who will replace VHTs. CHEWs will be based at parish level and have to undergo training for one year. They will provide more services than VHTs.

Page 28 of 101 The PHC Supervisor, Sr. Achia Deborah completed her Bachelor’s degree in Nursing in December last year. She resumed her duties in February this year. Another issue discussed was concerning outreaches – there is need to do something for our communities but MoH has strong reservations to create more HUs. It may take some time until new LLHU can be established, hence outreaches need to continue. It is feared that these outreaches are only on a project basis and therefore funding unpredictable. Nabwal Maternity Centre: Staff house construction was stopped by UWA. 16,000 people are estimated to be living there. A borehole donated by Water Aid was destroyed by UWA. The District Chairman and RDC have had several discussions on this issue at higher level and continue to follow up this issue with the MPs, who need to take this up at national level. Three meetings have already taken place. Fertile land is gazetted. Nakayot, Nabwal and area before Apeitolim were requested to be considered for settlements. Let people stay where they are, e.g. Alakas. It seems field offices of UWA were not informed – The efforts of the District to give water to these people, planning for HUs, Schools and agricultural programmes in the green belts should not be in vain. AOB - TB support and MDR Drugs supply There are still challenges to follow up MDR patients. The project has not enough resources to follow them up. The RRH Moroto was requested to put up a small MDR Unit where these patients can be kept. The MS informed the house about the challenges to follow up MDR patients. There is a MDR panel in the Hospital tasked to make contact tracing, assess the homes, link to nearest HU’s etc. It is very difficult to follow up these patients. Currently we have got six patients followed up by Matany Hospital. Even from Moroto we follow up a patient. The MS shared also the difficulty to access MDR drugs. It is CUAMM facilitating to pick the drugs from NMS. NMS communicated recently that they cannot support a PNFP Hospital and therefore orders for MDR TB drugs should be channelled through Moroto RRH. These bureaucratic barriers cannot be accepted. It is obvious that NMS needs an authorisation from the Director General of Health so that supplies can be directly sent to Matany. During the BoG meeting on the 10th June 2016 the first draft of the Strategic Plan was the major topic discussed. Members commented, gave recommendations and tasked the Strategic Plan Committee to get the opinion of other stakeholders and present to the next BoG meeting a final draft. The Administrator presented the budget in the usual format, an excel sheet with three columns. The first with the figures of the budget of the current FY 2015/16, the second column the projects actual figures for 2015/16 based on the first three quarters performance and lastly the budget figures for the coming FY 2016/17. The Principal Tutor presented her short report. She informed that the various programmed teaching and learning activities of the school are going on well. The third year students (both Nurses and Midwives) have completed one month Field Attachment period at Kangole H/C III. It was a rich experience for the students because during this period they were exposed to the reality of what takes place in a lower level health facility setting during service delivery. The community of Kangole appreciated the services offered by our students to them. She then informed about the current student population. The new intake May 2016 has 25 midwifery students and 19 nursing students. Further she informed about the current number of teaching staff as well as administrative staff. New in our NMTS is a Warden. The School Administration saw it necessary to have a school warden, as the new students are accommodated in the Teaching Centre. The dormitory of the school is currently undergoing a major renovation. This is hoped to be completed in two months time. The MS informed members in his PHC report, that

Page 29 of 101  Currently there is a Health Facility Quality of Care Improvement Assessment going on in the Health Sub-District. Some staff of Napak District were trained and are currently carrying out the assessment in 14 Health Centres plus the Hospital. The DHO was to schedule a meeting for the dissemination of the findings during the assessment exercise.  Napak District seconded recently four additional staff to the Hospital.  In November 2015 Hepatitis B vaccines were received, but without test kits. In April 2016 test kits were received; testing and vaccinations started. During May 2016 there were 111 out of 1,064 people found positive. As many people are turning up for testing and vaccination it was resolved that daily 50 people are tested and vaccinated.  Ophthalmic surgical camps were conducted in Lokopo and Ngoleriet. Due to many surgical camps Trachomatous Trichiasis Cases are almost eliminated. Cataract operations were also performed. After having received the alarming situation about Hep B members asked for more information about the disease. Another member wished to know how much the treatment of Hep B is costing. Possibly some can afford and we need to have it available for those who can afford. The monthly cost for these ARV drugs is about 600,000/- UGX per month. The duration of the treatment is six months! The community leaders need to be made aware of this so that it can be taken to a higher level for action. Under AOB, the MS informed about a planned Cancer Screening in October 2016, which is supported by AFRON (Oncology for Africa) in connection with UWOCASO (Uganda Women’s Cancer Support Organization). In September 2016 community leaders etc. will be informed about it and announcements made in churches and over the radio, etc.

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 long been vacant and was held for many years by the PNO. Since July 2015 a Human Resource Officer was employed by the Hospital. Job descriptions and employment manual are available for all cadres and clearly spelt out in their appointments.

General Staff assemblies are regularly held.

The Hospital recognised the need for the internal system management /process Auditor. This position is covered by an IT Officer. He was sent for studies for a Master of Science in Health Service Management and is expected to return to the Hospital in August 2016. Amidst many other tasks, he will keep an eye on the following together with the Accounts personnel:

 The Internal stock management processes  The internal control procedures  Follow up on record keeping of all supporting documents for all transactions in the year

Page 30 of 101 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.

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 Monthly contributions are regularly 1 PAYE Yes submitted Monthly contributions are regularly 2 NSSF Yes submitted 3 Local service tax Yes Payment is done annually 4 Annual operational licence Yes Obtained with the help of UCMB Staff are continuously reminded to 5 Practicing licence for staff Yes register with professional bodies Timely compiled, scrutinised and 7 Monthly HMIS Yes submitted to various stakeholders UCMB statutory requirement 1 Analytical Report end of FY 2015/16 Yes This is currently in progress 2 External Audit end of FY 2015/16 Yes Was done in the 37th week in 2016 3 Charter Yes still valid 5 Contribution to UCMB for the year 2016 Yes Paid before March 2016

HMIS 107 PLUS financial report / th 6 Yes Submitted on 30 July 2016 quality indicators ending FY 2015/16

Report Status of staffing as of end of th 7 Yes Submitted on 20 July 2016 FY 2015/16 8 Manual of Employment Yes still valid 9 Manual of Financial Management Yes still valid Report on Undertakings and Actions of Timely submitted before the 31st 10 Yes the year August 2016

Page 31 of 101 Accreditation status with UCMB

Matany Hospital fully accomplished the 10 statutory requirements and hospital undertakings set by the Uganda Catholic Medical Bureau and was awarded a certificate of accreditation for FY 2016/17 with 90% score attained and valid until 31st December 2017. During the Hospital Managers Technical Workshop II organised by UCMB for early October it is hoped to once again receive a new Accreditation Certificate. 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 2016 to June 2021 was discussed during the BoG meeting of 16th September 2016. 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 15th September 2016 with its Theme: “Provide comprehensive sustainable health services that ensure healthy lives, uphold client satisfaction and respect human dignity”.

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

Advocacy, Lobby and Negotiation

The Hospital has been involved in several advocacy endeavours. The Hospital was visited by the First lady on 19th October 2015. Several challenges facing the Hospital were discussed like dwindling funding to the Hospital, shortage of critical health cadres, sustainability issues, 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.

From 31st August – 9th Sept 2016 the Hospital conducted a sensitization program of community leaders (politicians, elders and health workers) in all sub counties of Napak District on Hospital updates and new user fees. The objectives of the sensitisation were: to get a feedback from the community about the new fees structure, sensitise the community about the financial situation of the Hospital, how the services can be sustained and updates about other developments in the Hospital. 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 started drafting a new strategic plan for 2016-2021 which among other purposes will be an advocacy tool for the Hospital.

Page 32 of 101 CHAPTER FOUR

HOSPITAL HUMAN RESOURCES

Introduction

During FY 2015/16 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 2016 was 221. 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 2012/13 200 196 174 170 160 149 155

120

80 78 80 59 59 66

40

0 2012 2013 2014 2015 2016 Total: 255 254 248 208 221

Non Karimonjong Personnel Karimonjong Personnel

Graphic 4.1: Levels of Employment at Matany Hospital since 2012/13

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 33 of 101 Present situation (June 2016)

The expatriate staffs include; the Administrator (CEO), 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 slightly decreased. However in absolute figures we have employed additional six qualified staff but at the same time more support staff, thus in total 0.7% less qualified staff as seen in below graphic.

%age of qualified Staff 60.0% 57.7% 57%

55.0% 51.6% 49% 50.0% 48.6%

45.0%

40.0% 2011/12 2012/13 2013/14 2014/15 2015/16

Graphic 4.2: Percentage Trend of Qualified Staff since 2011/12

During 2015/16 there was an increase in the absolute numbers of qualified staff, however as the total number of staff increased the percentage has slightly dropped as seen 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 2011/12 – FY 2015/16

end end end end end June June June June June 2012 2013 2014 2015 2016 MEDICAL OFFICERS 8 (1) 7 7 7 7(1) ALLIED MEDICAL PROFESSIONS 15 (8) 13(7) 14(7) 14(9) 16(10) NURSING STAFF 78 (53) 80(38) 77(36) 70(43) 69(42) ADMINISTRATIVE STAFF 9 (5) 11(4) 12(6) 14(7) 15(11) PHC STAFF 37 (37) 37(37) 36(36) 3(3) 6(6) TECHNICAL STAFF 43 (32) 41(29) 39(29) 36(30) 38(30) SUPPORT STAFF 46 (46) 47(45) 46(43) 47(44) 53(42) SCHOOL STAFF 15 (10) 14(10) 13(9) 13(9) 13(9) KHRDCH STAFF 4 (4) 4(4) 4(4) 4(4) 4(4) TOTAL 255 254 248 208 221 ( .) = Karimojong Personnel 196 174 170 149 155 Non Karimojong Personnel 59 80 78 59 66

Page 34 of 101 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 2012/13 and 2014/15.

Table 4.2 Staff turnover

Staff FY FY FY FY FY Cadres Establishment 2011/12 2012/13 2013/14 2014/15 2015/16 Total staff 286 255 254 254 208 221 Enrolled cadres 139 124 125 128 120 126 (all combined) Enrolled staff lost 24 55 25 32 36 Turnover rate 21.2% 44.1% 19.8% 25.3% 28.6%

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% 28.6% 30.0% 19.8% 25.3% 20.0% 21.2%

10.0%

0.0% FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 FY 2015/16

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.

Since 1st July 2015 the Hospital has employed a Human Resources Officer who was sponsored for a three year Bachelor Course. 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 35 of 101 During FY 2015/16 there was an increase of the number 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 competitive salaries to the employees in order to compete favourably for the job market. However during FY 2015/16 there was no salary increase effected as the financial situation of the Hospital is still worrying. 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 and therefore 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. Intrahealth-Uganda has supported the Hospital with sponsorship of some staff who have gone back to school for further training. They will be bonded to the Hospital after studies. 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) Medical ethics 2) Alcoholism 3) Specimen rejection criteria 4) Counselling of discordant couples 5) Obstructed labour 6) Common Skin conditions 7) Tb Spine and Matany TB infection control protocol 8) Typhoid perforation 9) Cholera

Page 36 of 101 10) Records Management and data quality 11) Adolescent HIV/AIDS 12) Integrated management of Malaria 13) Hepatitis B

The Staff are also informed about quarterly review data and briefed on Hospital performance. Staffs 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 Training Course sent for of training Source of funding be effected training (years) post-training) Master of Science in Health 1 1 Hospital 3 Year3 Services Management, 1* Diploma in Nursing, 1* 4 1 1/2 Hospital 2 years Diploma in Midwifery, 2* 3 1 1/2 Intrahealth 2 years Diploma in Public Health, 1* 1 1 Intrahealth 2 years Diploma in Medical Laboratory 1 3 Hospital 3 years Technology, 1* Bachelor in Economics and 1 3 Hospital 3 years Statistics, 1* Plumbing, Craft II 1 1 Hospital 3 years Training to start in 1st Quarter of FY 2016/17 Bachelor in Medicine and 1 5 Hospital (partly) 5 years Surgery, 1* Diploma in Computer Science 1 3 Hospital (partly) 3 years Certificate in Pharmacy and 2 2 Intrahealth 2 years Health Supplies Management, *2 Certificate as 2 2 Intrahealth 2 years Theatre Assistant, 1* Diploma in Social Work , 1* 1 2 Hospital 2 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 continues investing 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 remuneration.

Page 37 of 101 CHAPTER FIVE

HOSPITAL FINANCES

This Financial Year the Hospital managed to balance income and expenditure with a positive balance of 133,802,027/= UGX. In this amount are the funds included which are advanced for the building of a six partition staff house. Hence it remains still a big challenge for the Hospital Administration to make sure that the running costs are covered. Fortunately external donations increased while the support to the salaries for staff working in the HIV/Aids Clinic stopped as the programme of USAID-Sustain reduced its support and shifted towards the support of the Laboratory. 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 in April 2015 showed its effect. 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 have come up more private clinics and drug shops and one wonders if they have all their official licences and trained health personnel to their operations. VHTs continue to have a good impact on the population in treating simple health conditions. The number of admission decreased as well. The PHC Conditional Grant was received 100%. Various types of external donations increased, while external donations for capital development remained stable and fewer donations were received in kind. Government support in terms of Essential Drugs has further slightly reduced during this financial year while other income for sales and services has increased by about 43 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, FY2011/12 to FY 2015/16

FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 FY 2015/16 INCOME UGX UGX UGX UGX UGX User Fees 167,002,700 140,422,290 216,100,950 272,439,130 366,737,426 PHC CG Hospital ¹ 487,649,667 557,348,975 529,372,125 537,666,660 536,474,193 PHC CG School ¹ 21,673,318 - 28,784,957 28,009,492 29,517,040 PHC CG HSD ¹ 46,543,538 30,296,650 35,194,103 35,000,000 35,000,000 Other School Income 200,070,535 217,344,462 136,189,483 164,022,600 190,606,550 External Donations 171,757,658 213,799,340 140,272,160 195,900,000 194,163,706 Funds (Cap. Dev’t) External Donations of 943,674,606 725,252,055 759,581,030 701,267,703 969,929,599 Funds ² External Donations 170,436,843 155,142,921 377,220,607 152,075,559 82,201,470 Goods/Services Value of EDP Drugs 79,791,928 113,536,037 75,646,673 27,298,165 21,589,271 received Received in kind for Not reported as 384,625,986 amount distorts 235,769,950 301,197,959 58,924,383 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 ³ 203,072,940 184,516,715 173,258,762 242,688,621 285,593,559

TOTAL 2,876,299,719 2,400,529,312 2,707,390,799 2,657,565,890 2,770,737,197

Page 38 of 101 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 34.6%. This is mainly attributed to more 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%. The general support towards the Nursing & Midwifery Training School increased as compared to last year by 16.2%. Bursaries from Government and Development Partners have reduced. External donations for recurrent costs have increased by 38.2%, due to the faithful support of the various support groups and benefactors and 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 remained almost the same. The value of essential drugs allocated from Government decreased slightly as compared to the previous year.

Graph 5.1 – INCOME SOURCES AND TRENDS

INCOME DETAILS & TRENDS FY 2011/12 - 2015/16

1,200,000,000

1,000,000,000

800,000,000

600,000,000

400,000,000

200,000,000

0 Ot her External Ext ernal Ext ernal Value of Received in PHC CG PHC CG PHC CG Other User Fees School Don. (Cap. Donat ions Do nat ions EDP Drugs kind for Ho sp it al ¹ School ¹ HSD ¹ Income ³ Income Dev’t) of Funds ² Goods/Servi received HIV / A IDS

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 FY 2015/16 366,737,426 536,474,193 29,517,040 35,000,000 190,606,550 194,163,706 969,929,599 82,201,470 21,589,271 58,924,383 285,593,559

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

User Fee / SUO

1,900 UCMB network: Average Fees/SUO during FY 2015/16 = 5,793 1,731 1,600 1,267 1,300 1,018 1,000 655 613 700 400 FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 FY 2015/16

Page 39 of 101 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 per SUO must remain low, so that even the poorest of the poor can afford. Equity for Matany Hospital had an increase of 464 from the previous year. The user fees/SUO increased by 36.6%. 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 was fully felt during FY 2015/16. Another factor for higher user fees income was due to a higher number of patients (as members of insurance schemes) who could pay cost recovery rates. In spite of this the Hospital supports the poor and destitute by treating them free of charge, debiting the Samaritan Fund.

Expenditure

Table 5.2: Trend of Expenditure over the last 5 years, FY2011/12 to FY 2015/16

FY 2011/12 FY2012/13 FY2013/14 FY2014/15 FY2015/16 Expenditure UGX UGX UGX UGX UGX Employment Cost 1,070,688,081 978,620,282 1,089,165,679 1,210,141,232 1,272,733,923 Administration Cost 70,828,920 91,605,002 63,336,951 74,668,272 88,239,244 Property Cost 49,077,983 71,097,033 109,970,466 75,635,695 77,111,948 Transport and Plant 249,939,842 160,911,299 192,242,875 158,340,721 157,211,109 Cost Medical goods and 605,227,717 540,047,196 681,874,764 519,121,533 471,683,899 medical Supplies Non-medical goods/ 104,140,959 139,300,752 93,545,075 57,594,327 51,494,803 suppl. PHC Activities 188,570,409 120,381,923 123,062,226 87,909,140 51,479,662 Major maintenance and 192,998,410 154,105,324 152,272,656 210,734,276 215,135,097 upkeep of buildings Staff Development 81,931,000 75,068,587 32,175,099 15,606,500 58,709,200 Cost Training School Cost 190,972,052 199,071,283 192,247,135 190,188,657 193,136,286 TOTAL 2,804,375,373 2,530,208,679 2,729,892,926 2,599,940,353 2,636,935,171

Comment: Employment Costs have increased as there were a few more qualified staff employed during FY 2015/16. 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 remained stable as fuel prices fuel prices were steady. 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 during FY 2015/16 the Field Health Workers salaries that were paid by the Hospital since the early 80- ties were laid off during FY 2014/15. 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. The major intervention was the extension of the Laboratory. Staff Development costs have increased as more staff were sent for higher courses. Management believes in developing its own staff. The cost for the Nursing and Midwifery Training School has slightly increased.

Page 40 of 101 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 Trans- Med. Non- PHC Capital Admini- Property ment port & goods & medical Activi- Develop NMTS stration Cost Cost Plant services supplies ties ment F Y 2 0 11/ 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 FY 2014/15 1,272,734 88,239 77,112 157,211 471,684 51,495 51,480 273,844 193,136

Graph 5.4 – Trend of Efficiency over the last five years

Trend of economic Efficiency over 5 years 12,000 10,509 9,747 9,999 10,000 8,431 8,121 8,000

Recurrent Costs/SUO 6,000

UCMB network: Average Recurrent Cost/SUO during FY 2014/15 = 15,240 4,000 2011/12 2012/13 2013/14 2014/15 2015/16

Comment: Efficiency is a measure of recurrent cost per unit output (SUO). In 2015/16, the cost per SUO increased to 9,999 as compared to the previous year of 9,747. This is an increase of 252 or 2.6% cost per output. In spite of cost containment and proper use of resources the economic efficiency has increased, and is attributed to inflation and rising costs.

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

Financial Year Result

FY 2015/16 ended with a positive balance of 133.8 million UGX. This is attributed due to the faithful support of the various support groups and benefactors as well as the continuation of CUAMM support mainly to the Maternal to Child Health component in the

Page 41 of 101 Hospital and the NMTS. The USAID-Sustain Project stopped its salary support and shifted in supporting the activities of the Laboratory with equipment, and some staff salaries. Another intervention from the side of the Hospital 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. 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 remained stable. Its support through Development Partners to the Hospital in the form of Essential Drugs has however slightly decreased. 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? 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 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 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 FY 2015/16 UGX UGX UGX UGX UGX OPD Adult & children 1,908 1,775 2,927 3,790 6,741 IP Maternity 5,205 4,123 4,777 10,135 17,776 IP Paediatric 959 915 1,396 2,434 5,744 IP Surgical Ward 32,538 29,647 32,108 52,229 60,470 IP Medical Ward 13,774 15,894 20,448 42,142 61,428 IP TB Ward 6,123 5,260 7,748 19,091 25,872

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 fees adjustment in FY 2014/15. Therefore the additional income from user fees was 34.6% as compared to the 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 16.84%. In FY 2015/16 it was at its highest ever, namely 16.84%. In spite of the higher cost recovery rate Matany Hospital services are not sustainable and can be only maintained from donations, government support and of well wishers.

Page 42 of 101 Table 5.4: Cost Recovery Trend in the period FY 2011/12 to 2015/16

FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 FY 2015/16 UGX UGX UGX UGX UGX Total User fees (a) 167,002,700 140,422,290 216,100,950 272,439,130 366,737,426 Total Recurrent 2,177,184,125 2,149,903,502 1,861,226,431 2,230,135,810 2,111,108,280 (incl. staff Expenditure (b) development Cost) Cost Recovery Rate = 7.77 7.54 9.69 12.91 16.84 (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 2015/16 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. Finally the fees adjustment in April 2015 has certainly also had its impact on lower patient attendance.

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

FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 FY 2015/16

UGX UGX UGX UGX UGX Maternity Ward 32 beds 32 beds 32 beds 36 beds 36 beds Cost per bed 6,653,608 5,824,158 6,050,123 6,041,099 8,404,804 Average Cost per inpatient 123,143 107,917 102,762 111,299 149,714

Cost/SUOop 255,011 229,174 212,209 214,994 211,870 Paediatric Ward 112 beds 112 beds 112 beds 88 beds 88 beds Cost per bed 2,706,502 2,957,272 3,032,294 4,163,946 4,077,601 Average Cost per inpatient 49,649 61,065 76,164 76,594 91,282

Cost/SUOop 255,011 229,174 212,209 214,994 211,870 Surgical Ward 41 beds 41 beds 41 beds 41 beds 41 beds Cost per bed 3,191,193 3,629,280 3,899,209 4,777,033 6,629,408 Average Cost per inpatient 174,317 221,041 227,297 240,955 264,635

Cost/SUOop 255,011 229,174 212,209 214,994 211,870 Medical Ward 41 beds 41 beds 41 beds 41 beds 41 beds Cost per bed 4,044,340 4,704,914 4,722,047 4,872,256 5,667,765 Average Cost per inpatient 98,760 133,588 171,179 177,725 223,226

Cost/SUOop 255,011 229,174 212,209 214,994 211,870 TB Ward 58 beds 58 beds 58 beds 44 beds 44 beds Cost per bed 1,371,153 1,398,700 1,494,001 2,315,322 2,332,332 Average Cost per inpatient 143,810 150,509 198,288 262,283 310,978

Cost/SUOop 255,011 229,174 212,209 214,994 211,870 Cost per OPD activity 7,257 7,621 7,217 7,631 12,162

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

Above table 5.5, 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

Page 43 of 101 showed a steady rise. The cost per OPD activities has risen by 59%. This difference is explained that the Hospital did not reduce the number of staff in spite of lower patient attendance. Due to cost containment efforts of the Hospital Management, the recurrent and also the total costs for FY 2015/16 did increase between just 1.4-2.8 %. The PHC Conditional Grant (PHC CG) which remained constant for a couple of years 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% 22.79% 19.82% 20.0%

0.0% FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 FY 2015/16

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% to 14.3% Antibiotic is needed 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% to 4% Antibiotic is needed Acute diarrhoea in children < 5 years 137,000 8,000 plus 1,000 if 5.8% to 6.6% Antibiotic is needed

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 44 of 101 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 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 FY 2015/16 Table 5.7 UGX UGX UGX UGX UGX Total Local 370,075,640 364,939,005 389,359,712 515,127,751 515,127,751 Revenues (a) Total Recurrent 2,149,903,502 1,981,581,563 2,230,135,810 2,111,108,280 2,177,184,125 (incl. Expenditures (b) staff development Cost) Sustainability 17.21 % 18.42 % 17.46 % 24.58 % 29.96 % 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 24.58 29.96 17.21 18.42 17.46 20.00

0.00 FY 11/12FY 12/13FY 13/14FY 14/15FY 15/16

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 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 FY 2015/16 UGX UGX UGX UGX UGX Total Local 1,198,165,227 1,128,990,535 1,122,400,220 1,303,518,460 1,465,518,039 Revenues (c) Total Recurrent 2,149,903,502 1,861,226,431 2,230,135,810 2,111,108,280 2,177,184,125 Expenditures (b) Sustainability 55.73 60.66 50.33 62.21 67.31 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

80 67.31 55.73 60.66 62.21 60 50.33 40

20

0 FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 FY 2015/16

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 2015/16.

Page 45 of 101 External Audit

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

 Complete engraving of all Hospital Assets  Internal Auditor to check monthly stock balances  Continue updating the Fixed Assets Register

The previous audit recommendations were mostly complied with which was stated in the Management Letter for FY ended June 2015 and others were recommended as a way forward.

Procurement

The Procurement Committee in the Hospital is the HMT. The Hospital Administrator serves as Procurement Officer. Since July 2015 a Procurement Advisor, holding a Diploma in Procurement and Logistics Management is employed. He carries out most of the purchases, which are beforehand authorised by the HMT/Administrator. The needs of the various departments are listed and brought for verification to the Administrator. The procurement procedures in the Hospital are very clear and have been satisfactory. However there is need of writing a Procurement Manual. Major procurements during FY 2015/16 were the purchase of an Oxygen Pant in order to reduce the cost of logistics and purchase of Oxygen cylinders and Oxygen concentrators. A new autoclave for the Theatre was also obtained and the old theatre lights replaced with modern cold light illumination.

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. A meagre emergency fund of the Hospital cannot be invested as at times government funds delay and there is need to always have some liquid funds available for operations. 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. With the increase of prices of daily commodities the Hospital feels the need of an imminent

salary increase which 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

 Have the next five year Strategic Plan approved by the BoG

 Continue keeping structures well maintained

Page 46 of 101 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 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 2015/16 the total number of OPD attendances was 23,473 a reduction of 26.7% visits as compared to the previous year. Although Matany Hospital is not a referral Hospital in the region, it was observed that 31.8% of the patients were from outside the catchment area.

Graph 6.1: Illustration of OPD attendance during financial year 2015/2016

Matany Hospital OPD Attendances during FY 2015/16 5,000

4,000 3,376 3,000 2,244 1,903 1,964 1,664 1,736 1,716 2,000 1,525 1,483 1,594 1,493 1,398 1,000 196 149 149 119 136 191 59 74 107 106 54 0 37 Jul-15 Aug Sept Oct Nov Dec Jan-16 Feb Mar April May Jun-16

Total Attendances Re-attendances

Page 47 of 101 Table 6.1: Trend of Out-patient Attendance in the period 2008/09 to 2015/16

OPD Department FY FY FY FY FY FY FY FY

08/09 09/10 10/11 11/12 12/13 13/14 14/15 2015/16 New attendance 36,264 40,905 46,429 43,458 37,712 31,055 29,675 22,096 Adults 20,766 20,964 23,215 21,726 20,407 17,470 16,704 13,907 Children 15,498 19,941 23,214 21,732 17,305 13,585 12,971 8,189 Re-attendance 3,102 3,146 2,339 1,832 1,640 2,019 2,336 1,377 TOTAL 39,366 44,051 48,768 45,290 39,352 33,074 32,011 23,473 OPD plus 55,644 64,490 72,495 67,668 65,380 57,866 78,175 63,015 special clinics

The number of outpatients compared to last year dropped by 26.7%. 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. There are also several small private clinics and drug shops that keep opening up in trading centres. Slight adjustments of user fees in April 2015 may also have had an impact on OPD attendance. 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 reduced by 41%. More patients were seen in the eye and physiotherapy clinics compared to last year. However the number seen in dental, orthopaedic, gynaecological and surgical clinics reduced.

Graph 6.2: OPD attendance Trends over the last five years

OPD attendance trends over the last five years 80,000

60,000

40,000

20,000

0 FY 11/12 FY 12/13 FY 13/14 FY 14/15 FY 15/16

New attendance Adults Children Special Clinics Reattendants Total Table 6.2: List of Top ten OPD diagnoses in Financial Years 2013/14 to 2015/16

FY 2013/14 FY 2014/15 FY 2015/16 1 Malaria 9,392 1 Malaria 9,089 1 Malaria 6,490 2 RTI 7,079 2 RTI 4,676 2 Pneumonia 3,802 3 GID 2,562 3 GID 2,326 3 GID 1,367 4 Eye Conditions 1,474 4 Pneumonia 1,217 4 UTI 1,070 5 Diarrhoeal Diseases 1,535 5 UTI 1,186 5 Diarrheal Diseases 620 6 Skin Diseases 1,158 6 Skin Diseases 882 6 Injuries 528 7 UTI 1,476 7 Eye conditions 809 7 Eye conditions 505 8 Pneumonia 1,168 8 Diarrheal Diseases 760 8 Skin diseases 493 9 STDs 614 9 Injuries 663 9 Sexual transm. Infect. 354 10 Hypertension 586 10 STDs 576 10 Hypertension 276

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 get drugs from NMS but well buffered by IRC which ensures that they have a constant supply of anti-

Page 48 of 101 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, diarrheal diseases and injuries have risen in ranking. Hypertension has also increased despite having dropped last year from the top 10 OPD diagnoses. User fees for hypertensive patients are highly subsidized to improve adherence since they are in chronic care. Hygiene related conditions are still prevalent in the community.

Graph 6.3: Top ten causes for OPD Attendance in Matany Hospital during FY 2015/16

Top ten causes for OPD Attendance in Matany Hospital during FY 2015/16

Sexually transm. Eye conditions Infections 3% Skin Dis 3% Hypertension Injuries 3% 2% 3% Malaria Diarrheal D'ses 42% 4% UTI 7%

Gastro-Intestinal Disorders 9% Pneumonia 24%

Graph 6.4: Top ten causes for OPD Attendance in Bokora HSD during FY 2015/16

TOP TEN CAUSES FOR OPD ATTENDANCES IN BOKORA HSD FY 2015/16

Skin diseases GID 3% Injuries UTI Eye conditions 3% 3% 3% 3%

Pneumonia Malaria 4% 46%

Diarrhoea acute 5% Mild acute malnutrition RTI 5% 25%

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, pneumonia and diarrhoeal diseases contribute the 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 0.8%. The VCT, eye and surgical clinics remain the busiest.

Page 49 of 101 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. The work load is reducing over the years.

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 2012/13 2013/14 2014/15 2015/16 1 Tooth extraction 403 377 299 119 2 Dental fillings 154 76 80 45 3 Scaling and polishing 62 9 16 1

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 8.5%. A total of 1,567 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 admitted. Tables 6.4 and 6.5 below show the orthopaedic and physiotherapy rehabilitative work load during the year 2015/16.

Table 6.4: Orthopaedic procedures done from FY 2011/12 to FY 2015/16

No of patients Orthopaedic procedures done 2011/12 2012/13 2013/14 2014/15 2015/16 1 Plaster ( POP) 494 446 664 501 461 Open reduction and internal 2 141 182 177 200 205 fixation 3 Others 1,282 1,191 1,972 1,051 901

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

Condition No of patients

handled 2011/12 2012/13 2013/14 2014/15 2015/16 1 Trauma 954 1,191 1,366 1,210 1,098 2 Degenerative 289 261 43 53 125 3 Congenital 41 40 51 53 30 Infectious 4 162 184 problems 83 71 99

Page 50 of 101 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 and Tepes, 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 4,394 clients were tested which was an increase of 40.7% compared to the previous financial year. HIV positive clients were 240 (5.5%). The number of individuals with discordant results reduced by 42.3% from 26 to 15. Counselling discordant couples remains a big challenge as few accept the results.

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.

HCT services have been extended to hard to reach areas through outreaches. Staff in the clinic have been trained in adolescent HIV care since it is a new special group in HIV care.

Table 6.6: HIV Counselling and Testing (by gender and age group) and Relationship to Cotrimoxazole Prophylaxis and TB Detection

No of No of No of No of individuals individual Individual No of individual Individuals Total Category 5- <15 0- <2 yrs 2 - <5 yrs yrs 15 – 49 yrs >49 yrs M F M F M F M F M F H1-Number of Individuals counselled 80 65 1,331 1,989 372 352 4,189 H2-Number of Individuals tested 51 50 48 46 80 65 1,331 1,989 372 362 4,394 H3-Number of Individuals who recei- 51 50 48 46 80 65 1,331 1,989 372 362 4,394 ved HIV test results H4- Number of individuals who received HIV results for the first time 0 0 2 1 8 8 1,214 1,790 133 123 3,279 in this financial year H5-Number of Individuals who tested HIV positive 0 0 0 0 0 0 101 92 20 27 240 HG-HIV positive individuals with suspected TB 0 0 0 0 0 0 78 46 19 10 153 H7-HIV positive cases started on Cotrimo- xazole preventive therapy (CPT) 0 0 0 0 0 0 101 92 20 27 240 H8-Number of Individuals tested before in this financial year (re- testers) 22 12 54 49 73 66 338 383 61 57 1,115

Page 51 of 101 No of No of No of No of No of individuals individual Individual individual Individuals Total Category 15 – 49 0- <2 yrs 2 - <5 yrs 5- <15 yrs yrs >49 yrs M F M F M F M F M F H9-Number of individuals who were 732 Counselled and tested together as couple H10-Number of individuals who were Counselled and received results together 720 as couple H11-Number of individuals with 59 Concordant positive results H12- Number of individuals with 15 Discordant results H13-lndividuals counselled and tested for 19 PEP H14-Safe male Circumcision 0 0 0 1 0 1

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.

Table 6.7: Trend of HCT in the five Years (2011/12 to 2015/16)

2011/12 2012/13 2013/14 2014/15 2015/16 Positive Negative Positive Negative Positive Negative Positive Negative Positive Negative 334 3,534 276 5,805 224 7,311 288 2,836 240 3,590 Total 3,868 Total 6,081 Total 7,535 Total 3,124 Total 4,394 (8.7%+ve, (4.5%+ve, (2.97%+ve, (9.2%+ve, (6.7%+ve, 91.3%-ve) 95.5%-ve) 97%-ve) 90.8%-ve) 93.3%-ve)

Graph 6.5: Data of table 6.7. - Trend of HCT in five Years (2011/12 to 2015/16)

8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 - FY FY FY FY FY 2011/12 2012/13 2013/14 2014/15 2015/16 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.

Page 52 of 101 All the mothers were counselled and tested for HIV. The number of exposed infants tested for HIV by PCR below 18 months was 36 of which none tested positive. Follow up of exposed infants is still big challenge as mothers always migrate to other areas looking for food thereby interrupting care.

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 partners tested reduced by 20.1% compared to last FY. The number of HIV+ mothers who attended the post-natal clinic were only 3 out of 36 who tested positive during antenatal. 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.

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

EMTCT INDICATORS 2011/12 2012/13 2013/14 2014/15 2015/16 A12-pregnant women counselled, test and 1,572 1,595 2,067 1,653 1,315 received HIV test results A 13-HIV positive pregnant women given 68 31 21 15 36 cotrimoxazole for prophylaxis A15 HIV Positive Pregnant women 63 27 36 14 24 assessed for ART eligibility A16-pregnant women who knew their HIV(+) 15 22 31 18 12 status before the 1st ANC visit A 17-pregnant women SD NVP N/A 5 15 4 0 given ARVs for AZT - SD NVP N/A 11 15 0 0 prophylaxis (EMTCT) 3TC-AZT-SD NVP N/A 5 16 0 0 A 18-0thers Specify for regimens covered 0 1 14 152 36 (Option B+) A 19-Prenant women on ART for their own N/A 25 47 14 15 health A 20-Male partners tested and received HIV results N/A 872 776 776 620 in EMTCT 6.2.3 POSTNATAL 2011/12 2012/13 2013/14 2014/15 2015/16 P2-Number of HIV + mothers followed in 33 52 8 56 3 PNC 6.2.4 EXPOSED INFANT DIAGNOSIS (EID)

SERVICES E1-Exposed infants tested for HIV below 18 33 52 45 30 36 months (by 1st PCR) E2-Exposed infants testing HIV positive below 5 2 1 2 0 18 months E3-Exposed infants given Septrin for 27 22 13 21 32 prophylaxis 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.

Page 53 of 101 ANTIRETROVIRAL THERAPY

The ART clinic which was started in 2005 has a cumulative number of individuals ever enrolled in the clinic of 1,972. The number of new patients enrolled in HIV care last financial year was 113. The number of individuals active in the clinic is 854 of which 809 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 four lower level units in the HSD (Lorengechora, Lotome, Kangole and Apeitolim). However clinics in Kangole and Lotome were gradually handed over to the staff of the units but continued to get support supervision from Matany team. 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. 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 22 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 (2015/2016)

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 0 0 1 1 0 2 46 63 113 facility during the year Number of pregnant women enrolled into care during the 0 15 15 year. Cumulative Number of individuals on ART ever 25 11 19 18 15 17 775 1,092 1,972 enrolled in HIV care at this facility Number of HIV positive patients active on pre-ART 0 0 0 0 0 0 0 20 20 Care Number of HIV positive cases who received CPT at last visit 0 0 0 0 0 0 0 20 20 in the year. Number eligible patients not 0 0 0 0 0 0 0 0 4 started on ART Number of new patients started on ART at this facility during 0 0 1 1 0 2 40 55 99 the year.

Page 54 of 101 Number of pregnant women started on ART at this facility 0 15 15 during the year. Number of HIV positive patients assessed for TB at 4 3 7 5 13 15 267 402 716 last visit in the year Number of HIV positive patients started on TB 0 0 0 0 0 0 0 0 22 treatment during the year Net current cohort of people on ART in the cohort completing, 0 0 0 0 0 0 0 0 127 12 months during the year Number of clients surviving on ART in the cohort completing, 12 0 0 0 0 0 0 0 0 41 months on ART during the year Number of people accessing 0 0 0 0 0 3 1 5 9 ARVs for PEP

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. 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

2012/13 2013/14 2014/15 2015/16 Top five mental health No. of No. of No. of No. of diagnoses Patients Patients Patients Patients 1 Epilepsy 483 111 182 144 2 Depression 46 25 77 9 3 Alcohol and Drug abuse 202 8 25 29 4 Anxiety Disorders 136 22 15 5 5 Dementia 13 1 5 1

Page 55 of 101 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 from St. Benedictine Eye Hospital Tororo and Dr. Keith. During FY 2015/16, two surgical camps were conducted namely in November 2015 and April 2016 with a total of 165 Patients operated. Cataract is the main indication for surgery contributing 58.8% (97 patients) of all ophthalmic surgeries done. Ophthalmic Assistant performed 589 lid rotations in the year including outreaches within Bokora Health Sub- District.

The pathology mix for the eye conditions includes the following; allergic and bacterial conjunctivitis, cataract, eye trauma, ectropion, active trachoma infection with some cases of trachomatous trichiasis, corneal ulcers and scarring. Due to better hygiene in the community and the regular eye camps, trachomatous trichiasis has greatly reduced. Cases of glaucoma are not common among the catchment population.

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

2011/12 2012/13 2013/14 2014/15 2015/16 No. of uncomplicated cases treated 1,563 1,518 1,039 1,355 1,411 No. of cases operated 137 234 322 374 693 No. of cases referred 16 6 6 0 2

Utilisation of Ophthalmology services has increased by 4% compared to last year. The Hospital organised annual surgical camps conducted by the team from Ruharo eye centre, headed by Dr. Keith Waddel and the Benedictine Eye Care Centre.

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

Page 56 of 101 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.

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 8,665 patients were admitted, with children’s ward having the highest admissions and contributing 45.4% 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 445 patients for 2015/16. Matany Hospital treated 435 patients, a case detection rate of 97%. This is above the expected National Case detection rate of 70%. Napak district is ranked 14th in the country among the districts with high TB case detection rates but unfortunately has some of the highest loss to follow up or defaulters rates. There is need to devise ways of keeping patients on treatment till they complete. 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 25.6 to 19 days. In the past the Hospital implemented hospital based DOTS where patients were discharged after completing the intensive phase of treatment for two months. 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

Page 57 of 101 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.

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 2012/13 – 2015/16

Surgical Medical 2012/ 2013/ 2014/ 2015/ 2012/ 2013/ 2014/ 2015/ WARD WARD 13 14 15 16 13 14 15 16 (41 Beds) (41 Beds) Patients Patients 1,205 1,169 1,128 1,170 1,291 958 1,033 838 Discharged Discharged Duration of stay Duration of stay 12,521 18,949 16,024 21,888 10,174 10,699 10,963 10,458 (No. of days) (No. of days)

Avg. duration of Avg. Length of 11 16.2 14.2 18.7 7 11.2 10.6 10 stay (No. of days) stay (No. of days) Bed Occupancy Bed Occupancy 84% 127% 107% 146% 68% 71% 73% 70% Rate Rate Turnover Interval Turnover Interval 2.6 -3.4 -0.9 -5.9 4.4 4.45 3.9 5.4 (No. of days) (No. of days) Throughput per Throughput per 27 29 28 29 Bed (No. of 35 23 25 20 Bed (No. of pts) patients) Paediatric 12/13 13/14 14/15 2015/16 Maternity 12/13 13/14 14/15 2015/16 WARD (112 (102 (88 (88 WARD (32 (32 (36 (36 beds) beds) beds) beds) beds) beds) beds) beds) Patients Patients 4,859 4,026 4,217 3,677 1,973 1,635 1,790 1,800 Discharged Discharged Duration of stay Duration of stay 30,247 30,247 27,600 29,876 8,764 8,764 12,060 13,703 (No. of days) (No. of days) Avg. duration of Avg. duration of 6.2 7 6.5 8 4.4 5 6.7 8 stay (No. of days) stay (No. of days) Bed occupancy Bed occupancy 74% 81.2% 86% 80.20% 75% 157% 92% 89.4 Rate Rate Turnover Interval Turnover Interval 2.2 1.7 1.1 0.6 1.5 4.0 0.6 10.3 (No. of days) (No. of days) Throughput per Throughput per Bed (No. of 43 45 48 42 Bed (No. of 62 46 50 20 patients) patients) T.B Adults 14/ 15 2015/ 16 2012/ 2013/ OVERALL 12/13 13/14 2014/15 2015/16 WARD (44 (44 (284 (284 (250 (250 13 14 Indicators (58 Beds) beds) beds) beds) beds) beds) beds) Patients Overall 398 326 438 445 79.6% 77.4% 85.6% 81.2% Discharged B.O.R No. of patient Turnover 15,008 11,531 11,221 8,229 4.9 2.5 3.1 0.9 days interval Avg. Length of Throughput 38 35 25.6 19 34.4 32.7 32 32 stay (No. of days) per bed Bed Occupancy Avg. Length 70.9% 54.5% 69.8% 38.9% 8 9 8.1 10 Rate of stay Turnover Interval Total 15.5 29.6 11 17.7 82,544 80,190 77,868 84,154 (No. of days) Inpatient Days Throughput per Bed (No. of 7 6 10 10 patients)

Page 58 of 101 The general average length of stay increased from 8.1 to 10 days. Maternity ward, surgical and children’s wards increased their durations of stay. However Medical and TB wards reduced their average durations of stay. TB ward having the most significant reduction of 6.6 days. The bed occupancy rate decreased from 85.6% to 81.2%. Surgical ward still has the highest bed occupancy rate (146%) because the patients stay long (18.7 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 also explains why it has the least turn over interval of – 5.9 days. 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 17.7 days.

Table 6.13: Top 10 causes of admission

Cause of Admission Cases 1 Malaria 2,630 2 Pneumonia 1,146 3 Injuries 663 4 Liver di’ses 653 5 Anaemia 563 6 TB 495 7 Respiratory Di’ses 473 8 Skin Di’ses 465 9 Diarrhoeal di’ses 434 10 UTI 384

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 34% of in-patients. This is followed by Pneumonia and Injuries. 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 (% only among the ten) during FY 2015/16

Ten top causes of admission during the FY 2015/16

Gental Diarrhoeal Urinalysis UTI Diseases 3% Malaria 6% 5% 34% TB 6% Respiratory Infectious 6% Anaemia 7% Liver disease Pneumonia Injuries (all 15% 9% types) 9%

The Graphic 6.7 overleaf shows the top causes of mortality in Matany Hospital. Malaria is the leading cause of mortality, followed by pneumonia and anaemia. 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 59 of 101 Graph 6.7: Top causes of death during FY 2015/16

Five top causes of death during FY 2015/16 in Matany Hospital

Other types of Respiratory Malaria meningitis infections (other) 6% 18% Liver diseases 7% (other) 7% Pneumonia 13% Cardiovascular Diseases 8% Perinatal Anaemia Liver cirrhosis TB 8% conditions (All 13% 9% types) 11%

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 Malaria 35 2,630 1.33% 2 Liver Diseases 30 653 4.59% 3 Pneumonia 25 1146 2.18% 4 Anaemia 25 563 4.44% 5 Other cardiovascular Dis'es 15 120 12.50% 6 Premature baby 14 71 19.72% 7 Meningitis 14 66 21.21% 8 TB 13 345 3.77% 9 Respiratory Infections 12 473 2.54% 10 Other Neonatal conditions 9 41 21.95%

Comment: Perinatal conditions, meningitis and cardiovascular diseases have high case fatality rates. Perinatal conditions include; prematurity, respiratory distress, hypoglycaemia and neonatal sepsis.

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 1,386; an increase 7.5% from the previous financial year. However, the turn up for ANC fourth visit dropped from 800 to 759, a decrease of 0.5%. 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 increased from 38% to 45% this year. The percentage of mothers attending the 4th ANC visit in comparison to total antenatal attendance increased from 16.5% of last year to 20.5% this year. This is lower 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

Page 60 of 101 1,165 but 1,386 women attended the first ANC. This made the first ANC coverage of 119%. The distribution of insecticide treated mosquito nets has greatly attracted mothers to 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 has dropped. The number of post natal mothers seen was 582 which was a decrease of 23.9% from last year. Of the 1,118 mothers delivered in the Hospital, 52.1% returned for PNC. Continuous sensitisation 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 2011/12 2012/13 2013/14 2014/15 2015/16 A1- ANC 1st Visit 1,578 1,461 1,299 1,289 1,386 A2- ANC 4th Visit 263 259 601 800 759 A3- Total ANC visits new clients + Re-attendances 2,731 3,141 5,004 4,859 3,707 M- ANC Referrals to unit 26 128 194 158 131 A5- ANC Referrals from unit 10 0 0 18 44 POSTNATAL P1- Post Natal Attendances 831 419 663 765 582 P2- Number of HIV+ mothers followed in PNC 33 35 8 56 13 P3- Vitamin A supplementation 1,415 1,342 695 641 1,118 P4- Clients with pre-malignant conditions for breast 0 0 0 0 0

Comment: Postnatal attendances have reduced compared to last year.

Maternity Admissions:

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

Deliveries and Births indicators 2011/12 2012/13 2013/14 2014/15 2015/16 Total Admissions for delivery 967 952 1,060 1,164 1,535 Deliveries in unit 967 952 1,060 1,164 1,118 Normal delivery 684 612 815 852 833 Abnormal delivery (incl C/S) 283 340 245 312 285 Live birth in units 971 975 1,052 1,137 1,080 Babies born with low birth weight (<2.5Kgs) 135 162 149 139 139 Fresh Still births in unit 14 16 14 +7 16 27 due to HEV Macerated still births in unit 11 12 14 11 11 Newborn deaths (0-7days) 12 17 15 45 40 FSB died in hospital (FHS heard before del) N/A N/A N/A 2 3 Maternal deaths 8 6 7 +16 due 4 2 to HEV For Live Births Full term Normal wt 777 672 903 967 947 Full term Low birth wt 130 144 149 127 139 Premature 64 61 76 43 69 For Caesarean Sections Elective C/S 26 39 34 40 41 Emergency C/S 244 287 211 228 211 Total C/S 270 326 245 268 252 C/S as % of Total deliveries 27.9% 34.2% 23.11% 23.02% 22.54% Emergency C/S as % of all C/S 90.4% 88.04% 86.12% 85.07% 83.73%

During the Financial Year, the number of deliveries in the hospital was 1,118, with a decrease of 46 deliveries from the previous FY. 833 of the deliveries were by spontaneous vaginal delivery, while 252 were by caesarean section. The macerated still births were 11,

Page 61 of 101 while Fresh Still Births were 27. Only three mothers lost their babies in the Hospital, the rest (24) of the FSBs did not have active foetal heart beats at admission. The major causes of intra uterine foetal deaths are infections and antepartum haemorrhage. 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 2015/16 the Total Still Birth Rate was 3.3% (27), an increase of 1% compared to the previous year (2.3%). The fresh still birth rate in the hospital of babies admitted with foetal hearts was 0.26%.

Caesarean Sections

Graph 6.8: Trend of deliveries over the last five years

Norm. Delivery vs. CS over the last three years 1,200 1,060 1,120 1,118 967 1,000 952 852 833 800 815 684 612 600 400 326 270 245 268 252 200 - FY FY FY FY FY 2011/12 2012/13 2013/14 2014/15 2015/16

Total adm. Normal Caeserean for delivery Delivery Section

During FY 2014/15 the caesarean section rate as a percentage of total deliveries was 22.5%, 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.

The main indications for C/S were: 1. Obstructed labour 2. Foetal Distress

3. Ante partum haemorrhage

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

Page 62 of 101 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. During FY 2015/16, two maternal deaths occurred in the Hospital. One was a mother referred from Amudat hospital with a ruptured uterus. She died within three hours of admission. The second died due to encephalitis. She was admitted for seven days. 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 an obstetrician/gynaecologist to guarantee specialised care for mothers so as to minimise maternal deaths. The specialist plays a role in bed side teaching and mentorship of the midwifery trainees, midwives and junior doctors.

The high caesarean section rate (22.5%) 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.

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

Provenance of women who underwent CS 100%

80%

60%

40%

20%

0% Napak Moroto Kotido Katakwi Nak'pirit Others

FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 FY 2015/16

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.

Page 63 of 101 From the catchment population of (UBOS projection, 2015/16) for Napak District, the expected number of pregnancies was 7,496 with 7,191 births. The total number of supervised deliveries in the district was 4,924. Out of which 1,118 were in Matany Hospital while the remaining 3,806 were in the Lower level health units. Therefore Matany Hospital contributed 22.7% of the supervised deliveries. The overall percentage of supervised deliveries in Napak was 67.5%. Matany Hospital had a total of 3,707 ANC visits out of which 1,386 were first visits and 759 fourth visits. The total ANC visits in the district were 6,587 compared to 6,318 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 1,606)

No Top ten surgical procedures done Number of Patients Proportion % 1 Caesarean Section 252 17.1% 2 Skin Grafting 246 16.7% 3 Abscess Incision and Drainage 185 12.6% 4 Laparotomy 144 9.8% 5 Minor orthopaedic surgery 97 6.6% 6 Evacuations 68 4.6% 7 Herniorrhaphy 48 3.3% 8 External fixation 25 1.7% 9 Other minor procedures 344 23.4% 10 other major procedure 64 4.3%

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 2011/12 to 2015/16

2011/12 2012/13 2013/14 2014/15 2015/16 Major operations (incl C/S) 1,016 1,059 1,047 714 650 Emergencies 314 380 516 282 222 Emergency Op as % of total 30.1 57.3 49.3 39.5% 34.2% major operations Minor operations 1,128 1,024 1,226 1,432 956

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

Page 64 of 101 D: DIAGNOSTIC SERVICES

Laboratory

By the end of June 2016, the human resource in our Laboratory included four 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 past two years. These include; GeneXpert, chemistry analysers (Humastar 200 and Hemolyte), Hemacount and CD4 FACS count, PIMA and Selexon Poct for screening Hepatitis B. 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 2011/12 to 2015/16

FY FY FY FY FY Type of laboratory test 2011/12 2012/13 2013/14 2014/15 2015/16 Blood smear for Malaria parasites 19,298 18,708 19,127 14,752 12,054 Blood smear for other purposes 59 137 49 10 21 WBC Count (total and differential) 3,098 3,282 4,306 3,524 6,782 Sputum smears (specific MT/a specific) 4,515 2,638 3,998 3,797 2,449 Urethra, vaginal smears & pus smears 186 8,07 585 276 298 Haemoglobin estimations 5,425 7,828 9,343 11,316 9,285 PCV 1,557 0 0 0 11 Sickling Test 79 69 81 14 48 ESR 304 468 923 111 33 Blood grouping and X-Matching 5,327 6,291 7,705 7,823 7,887 Urine examination 3,695 2,773 3,972 4,230 3,182 CSF examination 315 126 89 143 142 Other body fluid examinations 93 0 0 288 28 Stool examinations 704 770 622 854 862 Widal test 1,168 1,997 2,137 782 595 VDRL 3,271 4,785 5,460 2,327 4,717 Serum Creatinine 672 1,177 1,158 1,295 1,422 Blood Glucose 284 214 472 794 265 Pregnancy test 608 963 588 630 527 HIV test 6,358 8,948 10,314 10,253 10,754 Hepatitis B. 1,594 1,961 2,033 2,368 4,722 SGOT 806 1,305 1,315 815 1,277 SGPT 806 1,305 1,315 802 1,478 Other 24,108 18,674 7,625 16,547 16,780 TOTAL 84,330 85,226 83,217 83,751 85,619

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.

Page 65 of 101 Graph 6.10: Average Laboratory Investigations requested per patient

Average Laboratory Investigations requested per patient since FY 11/12

120,000 100,967

100,000 89,893 84,330 82,432 83,463 80,000 60,410 55,121 60,000 41,566 40,238 32,138 40,000

20,000 2.1 1.4 1.6 2.0 3.1 0 FY 11/12 FY 12/13 FY 13/14 FY 14/15 FY 15/16

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 2015/16 each patient had an average of 3.1 investigations done.

Blood transfusions

Most blood supply to the Hospital was from Nakasero Blood Bank and 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. Two blood donation drives were conducted in September 2015 and January 2016. 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 2015/16 the total number of Blood Transfusion was 1,826 which was a decrease of 38.8% compared to the previous year (2,536).

Graph 6.11: Blood Transfusion Services

Blood Transfusion in Matany Hospital during FY 2015/16

250 224 220 216 208 200 179 162 143 150 128 126

100 78 77 65 50

0 Jul-15 Aug Sep Oct Nov Dec Jan-16 Feb Mar Apr May Jun-16

Total blood transfusions: 1,826

Page 66 of 101 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 2016, 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 and one Certificate Nurse. The number and quality of X-rays taken still remained high attributed to the competence of our personnel.

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

Year 2011/12 2012/13 2013/14 2014/15 2015/16 Chest 3,296 3,065 3,407 3,410 2,693 Plain Abdomen 106 156 159 150 118 Barium Enema 1 5 8 3 12 Barium Meal 12 33 30 47 36 Traumatology 1,321 1,562 2,278 2,004 1,788 Skeletal 854 814 863 904 1,049 Urogenital 0 0 0 0 0 TOTAL 5,590 5,635 6,745 6,518 5,696

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.

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 6,518 6,000 5,635 5,590 5,696 5,000

4,000

3,000 2011/12 2012/13 2013/14 2014/15 2015/16

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.

Page 67 of 101 Table 6.21: Ultrasound examinations done over the last five years in the Hospital

Year 2011/12 2012/13 2013/14 2014/15 2015/16 Obstetrics 1,415 1,208 1,442 983 1,462 Gynaecologic 968 849 911 855 981 Liver, Spleen 1,707 572 1171 2068 1,584 Abdomen 2,517 2573 3393 2061 2,289 Urogenital Organs 376 269 439 460 362 Heart 206 393 567 442 259 Tissue 348 388 910 759 526 TOTAL 7,537 6,484 8,833 7,628 7,463 No. of Patients 5,235 4,860 6,211 4,339 4,799

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 7,537 7,628 7,500 7,463 6,484 6,000

4,500

3,000 2011/12 2012/13 2013/14 2014/15 2015/16

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. The Hospital is under SPARS program and is being supervised by the Diocesan medicines supervisor. The assessment was done in April 2016 and Matany scored 80.2%. There are continuous quarterly assessments. Further improvement is foreseen.

Page 68 of 101 Table 6.22: The ten most used drugs in our Hospital are:

Injectables Tablets 1 Ampicillin Inj. 1g Paracetamol 500mg tab 2 Ampicillin INJ 500mg vial Folic/ferr.sulp. Tab 0.25/200mg 3 Gentamicin INJ 80mg/2ml Amoxyciline 250mg caps 4 Ceftriaxone INJ 1g vial Multivitamin tabs 5 Frusemide INJ 20mg/ml 2ml Ibuprofen 200mg tabs 6 Benzyl Penicillin INJ 1MIU(x-pen) Metronidazole 200mg- tabs 7 Cloxacillin INJ 500mg vial Ampicillin/Cloxacillin 500mg caps 8 Diclofenac INJ 75mg/3ml amp Vitamin B complex tab 9 Metronidazole IV 5mg/ml 100ml Cloxacillin 250mg caps 10 Dexamethasone INJ 4mg/ml vial Folic acid 5mg tabs

The total expenditure on drugs during this FY was of about 165,502,202/= UGX plus donated ARV drugs. The percentage of the ten top most used drugs on the total amount for drugs used is 43%.

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 69 of 101 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 fourteen employees. The Administrator/ CEO supervises the accounts department with one senior accountant, two Bachelor in Business Administration of which one is the Internal Auditor and one accounts’ assistant, three cashiers (two in OPD and one for the inpatient), the General Office with one secretary and one office attendant and the ICT Department with Technical Advisor (until Dec 2015) and an ICT Assistant. 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 instead 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. Most of FY 2015/16, 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 70 of 101

Table 7.1: Food distributed in FY 2013/14 - FY 2015/16

Amount Amount Amount Food specification distributed during distributed during distributed during FY 2013/14 (kg) FY 2014/15 (kg) FY 2015/16 (kg) Beans 16,500 14,400 12,500 Rice 4,727 4,318 5,179 Corn-meal / Maize 23,520 19,450 16,550 Vegetable Oil 2,833 2,386 1,961 Sugar 4,372 4,456 4,448 Dry Skimmed Milk 1,737 1,611 1,366

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 two years ago, 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 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. 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 to ferry Hospital supplies, drugs, surgical sundries, building materials, food, etc. mainly from Kampala (470 km one way). 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 38 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 2015/16 were: Completion of the extension of the Laboratory and annexed to it an oxygen generation room, major renovation of the Nursing and Midwifery Training School starting with the dormitories, showers and toilets, the sewerage system, etc. The building of a new staff house for six units was as well started. Various services to the public as income generating activity by this 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

Page 71 of 101 submersible pump linked to the Hospital generator by an underground cable, and another within the Hospital compound, with a solar panel operated submersible pump. A 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. The Hospital was connected to the National Electricity Grid in November 2015 but has been unstable.

 Recommendations

The weather condition in Uganda due to global warming has greatly changed in the past few years. The quality of the roads especially during rainy season is poor, which results 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. A missionary sister who served since January 2012 and was fully dedicated for pastoral care of the patients left in September 2015. A support staff who has been showing availability to pray and accompany the sick was thereafter involved in the pastoral care of the patients, closely supported by the above mentioned Pastoral Care Giver an the Parish Priest. In July 2016 a young man identified by the Parish Priest was sent for a ten week Clinical Pastoral Education Unit organised by UCMB and will hereafter strengthen the pastoral care in the Hospital. 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.

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

Activity / Indicator FY 2012/13 FY 2013/14 FY 2014/15 FY 2015/16 No. of patients visited or 5,504 8,025 9,431 17,998 counselled No. of patients baptized 2 3 12 18 No. of patients confirmed 0 0 0 0 No. of patients given Sacrament 1 0 0 1 of marriage No. of patients anointed 9 18 34 42 No. of patients for Holy n/a n/a n/a 71 Communion

Page 72 of 101 CHAPTER EIGHT

QUALITY AND PATIENT SAFETY IMPROVEMENT

During the FY2015/16, 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. 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) Patients’ satisfaction survey Improved client satisfaction of services provided Drug prescription survey Better prescription practices 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 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 Reduced neonatal deaths. Phototherapy started, new weighing scales, use of penguin suction bulbs. 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 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, Onsite mentoring of Hospital staff by several Improved service provided like data stakeholders like MoH, SUSTAIN, Baylor, management, logistics management. CUAMM, Medical Access, etc.

Page 73 of 101 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 2015/16 Explanation Recovery rates on discharge: Recovery patients in one year discharged 96.9 96.2 95.2 95.2 98.6 as clinically recovered from that Rate episode of disease (from all wards) following treatment. 2.17% Maternal death rates: is not a Maternal population based maternal 0.46 0.4 0.34% 0.1% death rate 0.66 mortality rate or ratio that you may often comes across. Fresh still 1.98% Fresh still birth rate: Fresh Still 1.45 1.64 0.17% 0.3% births have intact smooth skin births rate 1.32% not macerated. Early neo-natal deaths rate. Number of babies who died Early within the 7th day from birth Neonatal 1.45 1.43 1.42% 3.87% 3.58% 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 improved and is within acceptable standards if we consider the severity of medical cases reaching the Hospital.

Maternal deaths

During FY 2015/16, two maternal deaths occurred in the Hospital, giving maternal death rate of 0.1%. One was referred from Amudat Hospital with ruptured uterus. Second died because of severe pre-eclampsia. 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 increased to 0.3% from 0.17% in the previous FY. Hospital had 27 fresh still births with only three having had a foetal heart at admission in Hospital. 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 decreased from 3.87% to 3.58%. The Hospital had 40 ENND compared to 45 of the last financial year. Major causes of death were prematurity, birth asphyxia and neonatal septicaemia. Protocols were introduced on management of preterm babies. Perinatal death audits have been done. 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.

Page 74 of 101 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

2011/12 2012/13 2013/14 2014/15 2015/16 Explanation C/S infection c/s infection rate 0.37% 0% 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 252 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 2011/12 2012/13 2013/14 2014/15 2015/16 1 Total staff 255 254 248 208 221 2 Qualified staff 124 125 128 120 126

3 Proportions of qualified staff 48.6% 49.2% 51.6% 57.7% 55.01%

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 60.0% 57.7% 57.01% 55.0% 52% 50.0% 48.6% 49%

45.0%

40.0%

35.0%

30.0% 2011/12 2012/13 2013/14 2014/15 2015/16

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

Page 75 of 101 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 2013/14 rate 2014/15 rate 2015/16 Clinical outcomes It is a good development if (Improvement after 96 96.3 96.1 patients feel that they have care) improved after care received Humanity of care Most of the staff were kind 97.1 98.4 99.6 (Kindness) Patient involvement in Need to involve patients more in 95.8 90.4 96.5 care their care The healthcare Patients appreciate the general 97 98.5 100 environment cleanliness in the Hospital Did not change. There is Waiting time (less than 76 76 94.7 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 decreased from 2.37 in 2014/15 to 2.05 in the last year. It remained below the WHO recommendation of 2.6. The average number of diagnoses per OPD patient was 1.1 as seen in graphic 8.4. The injection rate reduced from 5.2% to 2.4%. All patients received the prescribed drugs giving a dispensing rate of 100%. This indicates good drug stocking levels.

The percentage of outpatients getting an antibiotic in a prescription was 25.6%. Antibiotics were given mainly for respiratory and skin conditions. Constant use of the Uganda clinical guidelines will help to control antibiotics use. Monthly prescription trend for antibiotics and Non Steroid Anti Inflammatory Drugs (NSAIDS) are indicated in graphics 8.2 and 8.3, respectively.

Page 76 of 101 Graphic 8.2 Prescription of Antibiotic in OPD during FY 2015/16

Matany Hospital OPD: % of prescriptions with antibioticduring FY 2015/16 60.0

50.0

38.8 40.0 35.4 30.5 32.3 31.9 28.7 28.6 28.8 27.0 30.0 26.5 23.2 23.7 20.0 WHO recommends <20% 10.0 ( MoH-Ug recommends <40%)

0.0 Jul-15 Aug Sep Oct Nov Dec Jan- Feb Mar Apr May Jun- 16 16

Graphic 8.3 Prescription of NSAID in OPD during FY 2015/16

Percentage of antinflammatory drugs prescribed to OPD patients during FY 2015/16 30.0%

25.0% 24.3%

20.0% 16.7% 17.5% 17.8% 14.9% 16.4% 15.0% 14.3% 12.0% 13.3% 14.2% 10.7% 12.5% 10.0%

5.0%

0.0% Jul-15 Aug Sep Oct Nov Dec Jan- Feb Mar Apr May Jun- 16 16

The number of NSAIDs prescribed increased over the previous year. They were used as pain killers. 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 2015/16

Average number of diagnoses per OPD patient during the FY 2015/16 1.6

1.4 1.4 1.3 1.3 1.3 1.2 1.3 1.3 1.2 1.1 1.1 1.1 1.1 1.0 1.0

0.8 National Standard Figure < 1.5%

0.6 Jul-15 Aug Sep Oct Nov Dec Jan-16 Feb Mar Apr May Jun-16

Page 77 of 101

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 57.7 96.3 100 2015/16 0.27 0.11 98.6 0 57.01 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 2015/16 the SUO-OP showed a slight decline as compared to the previous FY (see Graph 8.5). This is explained by the fact that there was a decrease of the number of inpatients and deliveries.

Page 78 of 101 Graph 8.5: SUO-OP as measure of accessibility

Trend of general performance using SUO

270,000 255,011 250,000 229,174 230,000 212,209 214,994 211,870 210,000 190,000

Total SUO SUO Total 170,000 150,000 2011/12 2012/13 2013/14 2014/15 2015/16

Another useful indicator of accessibility is the Cost Recovery rate from user fees (CRR) that is the percentage of expenditures (recurrent cost) covered with money coming from user fees: in Matany Hospital for the FY 2015/16 this was 16.84%. According to UCMB the accessibility is good when this value ranges between 25-30%. Our CRR is still 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 2011/12

30,000 26,241 25,000 19,216 20,000 15,429 15,000

UGX 9,898 10,000 9,268 UCMB Ø 5,793 FY 2015/16 5,000 655 613 1,018 1,267 1,731 0 FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 FY 2015/16

Median User fee per SUO-OP Median User fee per SUO-IP

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.

Page 79 of 101 Graph 8.7 below, indicates the SUO-OP per staff and cost per SUO-IP The graphic reveals that the SUO-OP per staff (productivity) has decreased from 1,792 (for the previous) year to 1,658 (this year). This is an indicator that fewer patients were seen in OPD and admitted in the Hospital. There were also fewer deliveries; thus the productivity of our staff decreased.

Cost per SUO-IP increased slightly. In conclusion, our staffs were a bit less productive as compared to the previous year because we saw fewer 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 reflect 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 2011/12 250,000 194,910 183,382 188,681 200,000 166,217 166,995 150,000 100,000 50,000 12,446 10,997 11,041 12,864 1,792 12,093 1,682 0 2,057 1,833 1,658 FY 2011/12 FY 2012/13 FY 2013/14 FY 2014/15 FY 2015/16

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

Page 80 of 101 CHAPTER NINE

HEALTH TRAINING INSTITUTION

St. Kizito Hospital - Matany School of Nursing and Midwifery is a full Board Vocational training School, located in Matany Sub-county, Napak District, Karamoja Sub – region. It was established in October 1984 and begun with Certificate in Nursing with a vision for quality training of health care Staff of high moral and professional standards. In May 1993 introduction of extension in registered nurse training course was implemented; which later was suspended in May 2010 with the introduction of Certificate in Midwifery training.

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 20 15 55 23 23 100% CM 24 13 17 54 19 19 100% TOTAL 44 33 32 109 42 42 100%

This FY 2015/2016 the Students Population was: 109

Student numbers as per gender:

CN May 2014 = 15 (Female: 12, Male: 03) CN May 2015 = 20 (Female: 12, Male 08) CN May 2016 = 20 (Female: 15, Male 05) CM May 2014 = 17 (Female) CM May 2015 = 13 (Female) CM May 2016= 24 (Female)

Page 81 of 101 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 2011 2012 2013 2014 2015 distinctions 20130 credits 19 37 31 26 36 pa sse s 02346 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 credits and few distinctions to Credits and Passes. There is need to maintain and improve for better performance. - Students who obtained credits were more in FY 2012/2013 compared to the last five years. In FY 2015/2016; there were 36 credits, 6 passes, no failure.

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

Course 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 CN/CM New admissions 35 43 35 33 33 Lost during the year 01 03 03 01 03 Referred during the year 00 00 03 00 03 Success Rate 96% 100% 100% 100% 100% Fail at 1st attempt 01 00 00 00 00 Fail 2nd attempt 00 00 00 00 00

In November 2015 forty two CN/CM 2013 May Intake Candidates sat for UNMEB State final examinations; twenty three CN and nineteen CM, all performed well. The nineteen CM candidates are the fourth group of Midwifery students since the inception of the program in the HTI. They performed well with the following grades, 18 credits and 1 Pass. The fifth and sixth sets are continuing well with the course. The CN candidates were twenty three they also passed with the following grades 18 Credits and 5 Passes.

This FY 2015/2016, 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. Sustainability of the quality of training. 2. Strengthen the clinical area supervision. 3. Maintenance of HTI physical infrastructure and to reduce costs. 4. Strengthen counselling and guidance of students. 5. Improve the use of ICT.

Page 82 of 101 1.1 Sustainability of the quality of training:

During the previous year the tutor-student ratio was 1:36, the students are taught theory and practical skills. The hospital management has reinforced the teaching staff with two Diploma nurses to teach in the school, two Clinical Instructors and eight Preceptors who have contributed a lot in training of the students besides the three qualified Tutors and the current tutor-student ratio remained at 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 Mentors is on-going together with career guidance so that the staff with time will go for upgrading courses and become tutors.

Short courses: Refresher courses shall be organised for both teaching and administrative staff in order to build their capacity and enable acquisition of updated skills for efficient 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 Karamoja region, Uganda and other nations respectively. Therefore the HTI Management sought the need to achieve the above priority area by undertaking the following actions:  Continue to identify and mentor more student nurses and midwives who are capable of instructing and taking up the clinical instruction activity after their qualification.  Orientation and induction courses for the mentors identified.  Regular meetings between the HTI and Staff at Practicum site to monitor and evaluate students’ performance.  Involving actively the Preceptors and departmental leadership at the practicum site in training and supervising students when in the clinical area (on-going).  Regular Clinical Teaching sessions in all the wards for better assessment of hands on skills (on-going).  Recruitment/training of 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 table 1.

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

Course CN & CM 2012/2013 2013/2014 2014/2015 2015/2016 Lost during the year 02 03 01 03 Referred during the year 01 03 00 03

The loss and referred students during the last three Financial Years was attributed to gross breaches of HTI rules and regulations many of which involved ethical, professional, and

Page 83 of 101 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 2015/2016 had three students referred to year one due to poor academic performance and three students lost during the year due to pregnancy, despite regular Counselling and Career Guidance attempts offered to help them concentrate in the training they have embraced.

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.  Invite various external opinion leaders to give Career Guidance to the students.  Use of collective efforts 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.  Guidance and counselling of students by teacher referees for each class, promotion and strengthening of guild leadership has contributed a great deal in creating a friendly environment of learning in the HTI.  Involvement of family members/guardians in solving their problems

1.3 Strengthen maintenance of HTI physical Infrastructure:

Renovation of the existing buildings has started this is being done in stages and gadgets have been put in place to monitor electricity and water so that wastage is minimised. Students are reminded continuously about care of all the properties; the school rules and regulations were revised and are valid till June 2018. There is hope that the started renovation work will proceed on well while lobbying for more 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 their spiritual and educative films shown to broaden their knowledge and critical thinking.

1.5 Improve the use of ICT

Purchase of more computers to enable each student easy access for practice and acquisition of computer skills. Computer literacy has been introduced and is ongoing; the students are examined on this subject and the marks are included in their academic school transcripts.

Teaching students using Power point presentations is in progress since this is one of the teaching methodologies encouraged for better understanding. Table 9.5: Indicators of faithfulness to the mission:

Faithfulness to Mission 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 Indicator ACCESS (utilization rate) 124% 100% 100% 100% 100% EQUITY (fee per student) 1,553,312 1,553,312 1,477,132 1,275,528 1,532,125

EFFICIENCY (expenditure per student) 1,696,440 1,859,207 1,697,228 1,696,639 1,742,716 QUALITY (success rate) 96% 100% 100% 100% 100% QUALITY (Tutor/Student ratio) 1:56 1.56 1:38 1:36 1:36

Page 84 of 101 The overleaf 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. Due to the rising costs of living, the fee has slightly increased compared to the two previous Financial Years. In spite this slight increment, students are ongoing with their training and no drop out due to lack of tuition fee has been registered thus the HTI has been 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 expenditure per student has slightly increased this could be attributed to the general rise 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 2011/12 2012/13 2013/14 2014/15 2015/16 Qualified Tutors 2 2 3 3 3 Qualified Clinical Instructors / Mentor 1 0 0 0 0 Unqualified Clinical Instructors 2 2 2 3 2 N° qualified teaching Staff lost in the year 0 0 0 1 0 Attrition rate qualified teaching Staff 0 0 0 1 0 N° qualified teaching Staff recruited during 0 0 0 0 0 the year N° unqualified teaching Staff employed 0 0 0 1 1 during the year N° unqualified teaching Staff lost during the 0 0 0 1 0 year Attrition rate unqualified teaching Staff 0 0 0 1 0 Support Staff 10 10 10 10 12 N° of Hospital. Staff Members providing 4 3 3 0 1 lectures in HTI Ratio part-time vs. full-time qualified Tutors 4:2 3:2 3:3 2:3 1:3

The number of the three tutors has contributed greatly to the reduction of the high tutor – student ratio to 1:36; at the same time Tutor-Student Ratio for the last three previous Financial Years remained stable. 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 85 of 101 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 and weekly evaluation of the activities implemented. 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 2015/2016 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 98,477,100 3 Bursaries 27,091,000 Student Payments for other costs (regi- 4 11,916,500 stration / exams / specialised training …) 5 PHC Conditional grants to School 29,517,040 6 Other School Income (for services) 5,358,900 Gap, which needed to be financed from the 7 47,763,050 Hospital / Donors Total: 220,123,590

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

Page 86 of 101 Income and Expenditure

The sources of income of the HTI are mainly school fees followed by external donations, PHC Conditional Grant and bursaries. Sustainability is still a challenge to the Institution as about 50% are still funds from other sources than direct school fees.

Income

Graph 9.2: showing HTI Income in the FY 2015/2016

Sources of Income for the HTI, FY 2015/16 22%

2%

51%

13% 12% School Fees Bursaries PHC CG Other Income From Hospital Funds/Donors

Expenditure

Graph 9.3: showing HTI Expenditure in the FY 2015/2016

5.0% 0.4% 1.6% 50.3%

31.8%

6.5% 4.5%

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

Internally, the School receives unconditional administrative, financial support or in-kind for services from the mother Hospital. Much of its supplies are obtained from the Hospital main store besides purchases, transport and storage processes. All the repairs and building are done by the Hospital Technical Department. The Hospital takes care of 50% of students’ medical treatment bill and treatment of minor ailments of the NMTS staff. The management of St. Kizito Hospital Matany takes care of Human Resource development of the staff; at the same time it offers sponsorship to some of the students who are bonded to serve in either the Hospital or the training school.

The school receives support from the Local Governments of Napak and Moroto Districts through involvement in interviews, community activities. In Moroto Regional Referral Hospital the students during the period of placement, learn get experience in Family Planning Clinical Practice and other specialized care of patients.

Page 87 of 101 The HTI is continuously benefiting from spiritual formation of the students from the priests of Matany Parish, faith-based organisations within and outside Moroto Diocese. It has also enjoyed a lot of support from the Diocesan Health Office in both administrative and training activities.

Externally, the HTI is supported by the following partners in development:

 UNFPA: - Sponsoring some midwifery students of May 2014, 2015 and 2016 Intakes. At the same time equipment for training and imparting skills to the students.  FAWE: - Sponsoring Nursing and Midwifery students May 2014, 2015 and 2016 Intakes.  Saints Project Baylor-Uganda: - Sponsoring midwifery students the last intake was in May 2014 and they shall finish their training in November 2016; this marks the end of Baylor sponsorship activities.  Government of Uganda financial support through 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 by organizing workshops, trainings, meetings, support supervision, verification of students’ documents and State Examinations.  MoH-UNMC: - Supports the HTI through support supervision, verification of documents and quality assurance and issuance certificates, Professional ID and Practicing License.  Millennium Promise: - Sponsoring one Certificate Nurse May 2014 and some of the Midwifery students of May 2016 Intake.  Intrahealth: - Sponsoring Midwifery students of May 2014, 2015, and 2016 Intakes  Other partners and friends: Give services in-kind, goods and donations.

The HTI has been privileged to have the above partners who have faithfully continued to support its activities in training quality and highly competent professional Nurses and Midwives to serve this most underprivileged Sub-region of Karamoja, neighbouring districts, the entire country and other nations. b) Other training activities of the Health Training Institutions(s):

Despite our limitation of under-staffing 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 planned implemented Field attachment of students to Lower Level Health Units for four weeks community exposure activities. This is to enable them understand the health needs of the people they are going to serve after completion of the training.

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

 Student involvement in both internal and external academic seminars.

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

Page 88 of 101  Participation in extra-curricular activities like sports; music, dance, drama (MDD), and others.

 Participation in Promotional and State Finals UNMEB examinations.

 Major renovation work of the infrastructures in the training school (in progress).

Point of Action for FY 2015/2016

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.  The HTI administration shall continue looking for avenues of acquiring 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 to complete the 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 89 of 101 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, admissions and deliveries declined, while antenatal care and immunisations 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, admissions and deliveries in the Hospital 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. Antenatal attendance and immunisation were higher than the year before.

Table 10.1: Accessibility trend indicators over the past five years

Year 2011/2012 2012/2013 2013/2014 2014/2015 2015/16 OPD plus special clinics 67,668 65,380 57,866 78,175 63,015

OPD Attendance (new) 43,458 37,612 31,055 29,675 22,096 Admissions 11,620 10,117 9,290 9,556 8,665 Deliveries 967 952 1.060 1,164 1,118 Antenatal 2,731 4,602 5,006 4,859 6,395 Immunisation 34,214 24,891 35,950 41,733 50,462 TOTAL SUO 255,011 229,174 212,209 214,994 211,870

Table 10.1 above gives a comparative analysis of service utilization over a period of five years; OPD attendance (new) has decreased by 7,579, and antenatal attendance increased by 1,536. The presence of VHTs working in the community gives a good impact. VHTs treat cough, diarrhoea and fever in the community which are the commonest illnesses seen in

Page 90 of 101 OPD. The community is mobile and more new settlements in hard to reach areas were established. This could have affected the health seeking behaviour of the community due to long distances from the Hospital and poor transport facilities. Admissions have decreased by 891 indicating the referral function of the Hospital. Deliveries have decreased by 46. Total immunisations have significantly increased by 8,729 which is the highest indicator compared to the last five years.

 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 464 from the previous year. The user fees/SUO increased by 36.6%. 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 was fully felt during FY 2015/16. Another factor for higher user fees income was due to a higher number of patients (as members of insurance schemes) who could pay cost recovery rates. In spite of this the Hospital supports the poor and destitute by treating them free of charge, debiting the Samaritan Fund.

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

Trend of Equity over 5 years 2000 1,731 1600 1,267 1,018 1200

800 655 613 400 Fees/SUO 0 2011/12 2012/13 2013/14 2014/15 2015/16

 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 decreased by 6.1 % (110) that is from 1,792 (for the previous year) to 1,682 (this year). This is because the SUO decreased due to less OPD attendances, admissions and deliveries. Hence the SUO/Staff is not as good as compared to last FY.

Graph 10.2: Trend of efficiency over the past five years

Trend of technical Efficiency over 5 years 2,500 2,057 1,833 2,000 1,792 1,658 1,682 1,500

1,000 SUO/Staff 500

0 2011/12 2012/13 2013/14 2014/15 2015/16

Page 91 of 101  Is the Hospital offering care of better quality?

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 2011/12 2012/13 2013/14 2013/14 2014/15 2015/16 - HEV Recovery Rate Maternal deaths Fresh still births C-S inf. rate %age of qual. staff

2012/13 2013/14 2013/14 2014/15 2015/16 Recovery Rate 96.2 95.2 95.2 95.2 98.6 23 Maternal deaths 6 7 4 2 HEV! 21 Fresh still births 16 14 2 3 HEV! C-S inf. Rate 0 0 0 0 0 %age of qual. staff 49 51.6 51.6 57.69 57.01

Special comments on Maternal Deaths and Fresh Still Births

During FY 2013/14, 23 maternal deaths occurred in the Hospital. Maternal death audits were done as per the Ministry of Health recommendation and none of the findings pointed to errors in the management and care given. The high number of maternal deaths was attributed to Hepatitis E outbreak in the region. Hepatitis E infection causes severe morbidity and high mortality among pregnant women. It was directly responsible for 16 maternal deaths. Ministry of Health was notified about this problem and sent a team to help with the containment of the epidemic. - During FY 2014/15 the HEV epidemic was almost over and therefore the number of maternal deaths reduced. During FY 2015/16 the number of maternal deaths further dropped to just two.

Page 92 of 101 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 2 0 2011/12 2012/13 2013/14 2013/14 2014/15 2015/16 with HEV without HEV

During FY 2013/14 total still births were 35 out of 1,060 total births. This is equivalent to a still birth rate of 3.3%. Fresh Still births were 21 which is 1.98% of total deliveries. Macerated still births were 14 which is 1.32% of total deliveries. Hepatitis E infection with liver failure contributed to 7 fresh still births. There were 14 FSBs without HEV infection during FY 2013/14. The number of hospital FSBs has reduced to 2 in FY 2014/15 and 3 in FY 2015/16.

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

Fresh Still Births 25 21 19 20 16 14 15

10

5 2 3 0 2011/12 2012/13 2013/14 2013/14 2014/15 2015/16 with HEV without HEV

3) Contribution to the HSSP and SDGs The Hospital provides health care services in accordance with the health sector component of the National Development Plan and National Health Policy II. It will strive to achieve the objectives and targets of the Health Sector Development Plan (2016-2020) of Government of Uganda. This continues to guarantee access for all people in its catchment area to basic health services, with special focus on social health protection for vulnerable groups (such as women, children, the elderly and poor).

Page 93 of 101 Through its programmes, the Hospital contributes to the attainment of the Health related Sustainable Development Goal of ensuring healthy lives and promoting wellbeing for all at all ages.

The Hospital contributed 17.3% of OPD attendance in the financial year 2015/16 in Napak District. Its role in improving maternal health is markedly significant with 22.7% of supervised deliveries and 20.4% of antenatal attendance in Napak District having been in Matany Hospital. The prevalence of HIV in Karamoja is increasing from 3.5% in 2006 to the current 5.3%. Matany offers ART services to its clients with 77.3% of clients in the district on ARVs being attended to in Matany Hospital. It also manages 91.5% of tuberculosis cases in the district. It is the only treatment centre for MDR-TB in Karamoja currently with patients coming from five districts of the region. The contact tracing and follow up of MDR -TB patients requires a lot of financial resources and a dedicated MDR TB panel. The Hospital has the single intensive therapeutic feeding centre to manage severe acute malnutrition in the district. The Hospital serves as the headquarters of Bokora HSD, supervising 13 lower level health units. The HSD carries out several functions including support supervision for which 156 supervision visits were carried out in 2015/16. It follows up 88 VHTs in Matany Sub County. Since more than 75% of the overall burden of diseases is preventable, Public Health Care remains the major strategy for delivery of health services in the catchment area. Great attention and support is given to health promotion, education, enforcement and preventive interventions such as immunization, promotion of sanitation and nutrition.

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 16.84 %. National and Global Policies regarding the creation of new districts make 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.

Page 94 of 101 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

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:

 Maintain all hospital infrastructure and complete renovation of NMTS.  Diversification of finance sources of the hospital.  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.

Page 95 of 101  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 network 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 supervision from the Karamoja area team.  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

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 96 of 101 ANNEX 1 - Napak District with Health Units

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

Lotome Apeitolim HC III HC II Nakicumet HC II

Namendera HC II Lorengechora HC III

Iriiri HC III

Amedek HC II

Nabwal HC II

Page 97 of 101 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. Divina Musimire, 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 (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. Hellen Atekit, Ag. Principal 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. Hellen Atekit, Ag. Principal 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. Hellen Atekit (Ex-officio) 9) The PT, Sr. Nataline Mowo (Ex-officio)

Page 98 of 101 ANNEX 3

MATANY HOSPITAL ANNUAL FINANCIAL REPORT Item Actual Cumulative Difference Codes cumulative of last year with last Description of financial Item the year FY 2014/15 year FY 2015/16 1XXXX INCOME User Fees' Collection 366,737,426 272,439,130 94,298,296 PHC Conditional grants to Hospitals 536,474,193 537,666,660 - 1,192,467 PHC Conditional grants to School 29,517,040 28,009,492 1,507,548 ( HTI - Non - wage ) Other School Income (incl. Sch. fees) 190,606,550 164,022,600 26,583,950 PHC Conditional grant for HSD ( Non- 35,000,000 35,000,000 - wage ) Donations of funds/goods for capital 194,163,706 195,900,000 - 1,736,294 development Donations of funds for recurrent cost 969,929,599 701,267,703 268,661,895 Donations of goods and services 82,201,470 52,075,559 - 69,874,089 Value of Drugs received through EDP 21,589,271 23,691,957 - 2,102,686 (in kind) Value of Lab. Reagents & 755,200 3,606,208 - 2,851,008 Consumables received (in kind) Income for projects(HIV/Aids, Malaria, P 58,169,183 301,197,959 - 243,028,776 Tuberculosis etc) Other Income 285,593,559 242,688,621 42,904,938 TOTAL INCOME 2,770,737,197 2,657,565,890 113,171,307 EXPENDITURES: 21 EMPLOYMENT COST 211101 Staff Salaries and wages 993,071,922 938,346,276 54,725,646 211103 Hous/bic/overtime&other all. - 211103 Night/safari all. 23,774,000 22,741,100 1,032,900 211103 Duty/Resp./Acting all. 10,110,000 8,522,000 1,588,000 211103 Lunch all. 21,738,754 17,975,672 3,763,082 211103 Cost for interns 48,666,500 43,845,000 4,821,500 211103 Cost for student field trips - 212101 XXX NSSF XXX 81,697,818 77,007,532 4,690,286 212101 P.A.Y.E 86,882,654 88,014,708 - 1,132,054 Staff health/ Social Health Insurance 213001 (Medical expenses) 3,251,300 1,906,600 1,344,700 Incapacity, death benefits & funeral 213002 expenses 1,420,000 411,850 1,008,150 Retrenchment cost / Licence and Staff 213003 Insurance 2,120,975 11,370,494 - 9,249,519 Sub Total 1,272,733,923 1,210,141,232 62,592,691

Page 99 of 101 ADMINISTRATION COSTS FY 2015/16 FY 2014/15 Difference 221001 Advertising and Public Relations 5,851,000 600,000 5,251,000 221002 Workshop/seminars - 520,000 - 520,000 221003 Staff training - 221004 Recruitment cost - 221005 Hire of venue - 221009 Welfare & Entertainment 6,810,700 3,373,000 3,437,700 221011 Printing and stationery 34,365,315 31,844,060 2,521,255 Other office expenses (small office 221012 428,000 335,800 92,200 equipment ) 221013 Bad debts - 221014 Bank charges 998,379 2,719,142 - 1,720,763 221015 Financial & related costs - Information Financial Management 221016 - System Recurrent cost 221017 Subscription 3,400,000 6,031,032 - 2,631,032 221018 Exchange loses / ( gains) - 222001 Tel./fax./postage/courier 14,546,588 7,079,283 7,467,305 Information and communication 222003 11,229,540 10,715,500 514,040 technology (ICT) 223004 Guard and security services - 224002 Uniforms & protection clothing 4,689,722 2,518,456 2,171,266 225001 Consultancy charges 5,920,000 8,932,000 - 3,012,000 227001 Transport all. - Sub Total 88,239,244 74,668,272 13,570,971 PROPERTY COST 223001 Cleaning of ward/dormitories 42,447,807 38,421,316 4,026,491 223001 Cleaning/slashing of compound - 223005 Electricity 17,846,119 17,846,119 223006 Water - 228001 Repairs and upkeep of buildings 16,818,022 37,214,379 - 20,396,357 223xxx Rents and rates - Sub Total 77,111,948 75,635,695 1,476,253 TRANSPORT AND PLANT COST 226001 Insurance for vehicles 1,850,445 - 1,850,445 License for property, vehicles , 226002 234,000 234,000 equipment etc 227002 Air travel 1,428,000 1,428,000 Carriage, Haulage, Freight & Transport 227003 8,647,500 12,080,610 - 3,433,110 Hire 227004 Fuel 101,081,840 78,603,670 22,478,170 228002 Maintenance and repairs - 228002 Tires and spares 11,868,684 327,403 11,541,281 228003 Operation/maintenance of generators 33,951,085 65,478,593 - 31,527,508 Sub Total 157,211,109 158,340,721 - 1,129,612 SUPPLIES AND SERVICES 221007 Newspapers and publications - - 221008 Computer Supplies 5,366,040 - 5,366,040 228004 Maintenance of equip. and supplies 950,000 830,000 120,000 22xxxx Equipment and supplies - - Sub Total 6,316,040 830,000 5,486,040

Page 100 of 101 MEDICAL GOODS AND SERVICES FY 2015/16 FY 2014/15 Difference 223007 Foodstuff and firewood 40,489,041 54,245,871 - 13,756,830 224001 Medical drugs 165,502,202 190,776,302 - 25,274,100 224001 Drugs received through EDP (in kind) - Value of Lab. Reagents & 224001 79,282,653 60,287,470 18,995,183 Consumables received (in kind) 224002 Beds and beddings 4,689,722 2,518,456 2,171,266 Maintenance of medical tools and 228004 - - - equip. Donations of goods and services ( by 282101 - - hospital ) 22400X Medical supplies 202,086,867 204,766,174 - 2,679,307 224xxx Medical tools and equipment 24,812,177 63,291,587 - 38,479,410 Sub Total 516,862,662 575,885,860 - 59,023,198 PRIMARY HEALTH CARE Support supervision (together with xxxx - outreaches) xxxx Outreach services 25,767,000 15,198,400 10,568,600 xxxx Drugs & sundries for LLUs 10,101,477 11,654,063 - 1,552,586 xxxx Planning and meetings - 188,000 - 188,000 xxxx Training of TBAs 2,945,000 3,343,000 - 398,000 xxxx Hospital Based PHC 12,666,185 57,525,677 - 44,859,492 Sub Total 51,479,662 87,909,140 - 36,429,478 CAPITAL DEVELOPMENT 311101 Land - Major maintenance and upkeep of 312101 211,033,559 210,734,276 299,283 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 4,101,538 4,101,538 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 221003 58,709,200 15,606,500 43,102,700 for definition)

Sub Total 273,844,297 226,340,776 47,503,521 TRAINING SCHOOL TOTAL ANNUAL

COST (see explanations) Sub Total 193,136,286 190,188,657 2,947,629 TOTAL EXPENDITURE TOTAL 2,636,935,170 2,599,940,353 36,994,817

Balance (Income less Expenditures) 133,802,027 57,625,537 76,176,490

Page 101 of 101