MEDICINES AND HEALTH SERVICE DELIVERY MONITORING UNIT. Raising the bar in healthcare

Transcription

1 MEDICINES AND HEALTH SERVICE DELIVERY MONITORING UNIT Raising the bar in healthcare ANNUAL REPORT 2011

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3 The ideals we cherish, our fondest dreams and fervent hopes may not be realized in our lifetime. But that is beside the point. The knowledge that in your day you did your duty, and lived upto the expectations of your fellow men is in itsely a rewarding experience and magnificent achievement. From a letter to Sheena Duncan, dated 1 April 1985 (conversations with myself; NELSON mandela) ANNUAL REPORT

4 Table of Contents VISION ROLE PEOPLE VALUES ACRONYMS DIRECTOR S FORWARD OUR ACHIEVEMENTS 0 PART 1: HUMAN RESOURCES FOR HEALTH: THE NATIONAL PICTURE PART 2: UN-REGISTERED CLINICS AND ILLEGAL NURSING SCHOOLS PART 3: HEALTH SERVICES DELIVERY EXTERNAL SUPERVISION PART4: INVENTORYMANAGEMENT; EQUIPMENT, INFRASTRUCTURE AND UTILITIES USE PART 5: DRUGS UTILIZATION AND MANAGEMENT PART 6: FINANCES UTILIZATION AND ACCOUNTABILITY PART 7: LEGAL FRAMEWORK IN THE HEALTH SECTOR PART 8: CHALLENGES FACED IN THE HEALTH SERVICES SECTOR PART 9: RECOMMENDATIONS MATRIX OUR WAY FORWARD APPENDICES APPENDIX 1: VANDALIZATION OF MOH CARS. APPENDIX 2; CONCLUDED COURT CASES BY THE UNIT APPENDIX 3: PHOTO GALLERY APPENDIX 4; SAMPLE DRUG AUDITS 2 ANNUAL REPORT 2011

5 OUR VISION A healthy Ugandan population supported by an effective and responsive health care system MISSION To monitor, support and sustain a national health care system that is efficient in operation; which provides affordable, high quality healthcare and is cognizant of the right to health and dignity of the people of Uganda. MHSDMU PROFILE MHSDMU has a dedicated and highly skilled multidisciplinary team to undertake its complex nature of activities and fulfill the mandate of securing better health service delivery for Ugandans. These professionals include doctors, pharmacists, auditors, lawyers, police detectives, policy analysts and public health practitioners among others. In addition to the in-house skills MHSDMU has, we also work in partnership with key stakeholders, systems and structures at all levels. These include national level stakeholders in the health sector such as Ministry of Health, Ministry of Finance, Public Service, IGG, IGP, Auditor General, local government structures, politicians, local leaders civil society organizations and people living in the communities. VALUES Working with all stakeholders to achieve results for the better health of the Ugandan people Accountability to the Government and the people of Uganda Open and constructive consultation with professionals, health providers, opinion leaders and community groups Being aware of our responsibilities and managing our own performance Using resources efficiently Working in a fair, professional and ethical manner Integrity Commitment and resilient Value for money Hard work. ANNUAL REPORT

6 ACRONYMS AMREF BOQ CAO CDC DHO DISO DPP FEFO GISO GoU HC HMIS HSD HRH IGG IGP JICA LC MDGs MHSDMU MOFPED MoH NDA NMS NRH OPD PNFP PPDA PSU RDC African Medical and Research Foundation Bill of Quantities Chief Administrative Officer Center for Disease Control District Health Officer District Internal Security Officer Directorate of Public Prosecutions First Expiries First Out Gombolola Internal Security Officer Government of Uganda Health Centre Health Management Information System Health Sub District Human Resources for Health Inspector General of Government Inspector General of Police Japan International Cooperation Agency Local Council Millennium Development Goals Medicines and Health Service Delivery Monitoring Unit Ministry of Finance, Planning and Economic Development Ministry of Health National Drug Authority National Medical Stores National Referral Hospital Out Patients Department Private Not for Profit Public Procurement and Disposal of Public Assets Pharmaceutical Society of Uganda Resident District Commissioner 4 ANNUAL REPORT 2011

7 DIRECTOR S FORWARD are numerous constructions both done by central and local government that are shoddy. During monitoring the underlying causes of such conduct have not been dealt with comprehensively. In addition numerous equipments in health centers have been lost. Our journey although short, it has exposed the Unit to positive realities and also challenges that our country faces in health sector. There are positive trends in medical supply chain. There is increase of medical stocks in all health centers.there has been increment in funding of medicines and medical supplies. Thanks to Ministry of Health and National Medical Stores for the effort that has been put in to streamline the supply of medicines. There is however a challenge of failure to supply all required items especially by big hospitals. There is need to address the factors that bog NMS down urgently so that all required medicines are supplied according to the need. The Medicines and Health Service Delivery Monitoring Unit has inspected over 250 health centers in about 50 districts with constraints notwithstanding. In the course of our work it became very clear that excellent health policies have been laid down to have appropriate mechanisms for implementation but these are not necessarily comprehensively effected. There The target of the Unit in the coming year is to work closely with The Ministry to ensure that there is effective monitoring of service delivery. The collaboration will also involve other regulators like professional bodies. The implementers ought to spend more time on ground to ensure that government programs are implemented. What has been lacking is to put more emphasis on activities or mechanisms that emphasize implementation and can yield results that benefit the common man directly. The issues like human resource management gaps, infrastructure mismanagement, gross corruption, attitude disorientation, unclear policies, superficial and inconsistent monitoring, weak or nonexistent regulation cannot be handled by the existing incapacitated regulatory bodies. The capacity they presently have does not match the magnitude of challenges in regulating the health sector. I am grateful to those that have played their role and have stayed the course despite the hardships. I thank those professionals that have inscribed ethics in their hearts and have sacrificed and given all to save lives in our health facilities when there is no apparent personal gain but the inner satisfaction and joy of doing right in the sea of wrong. ANNUAL REPORT

8 OUR ACHIEVEMENTS In working to achieve its three-fold objective of better health, better systems and better values MHS- DMU has registered remarkable success in less than two years. We have been able to cover over 250 health centers nationwide as a part of our monitoring and follow up work in just this past year. The districts visited include Gulu, Busia, Masindi, Buliisa, Mbarara etc. MHSDMU has made significant achievements which include but are not limited to: No. Achievement Examples 1. Recovery of stolen medicines Drug theft criminal rackets have been significantly reduced. Networks in the Western, Eastern and Central Regions have been broken. Reduction in theft of government drugs. 2. Recovery of government funds Across the border theft operations have been significantly reduced and in some cases completely broken down As of August 2011 the Unit has recovered over Shs 732,095,938 UGX through administrative re-imbursements and UGX 79,210,000through court fines. In addition, nearly 2 billion shillings (1, 87,000,000 billion UGX) is in the process of being recovered through government officials commitment to pay back money wrongfully obtained or which they could not account for. 3. Drug usage and management complaints among health centers countrywide have improved tremendously. 4. Prosecution of various crimes including; theft, embezzlement, criminal negligence across the country 5. Creation of a toll free and hot lines as an avenue for the public to register their concerns A relatively more sensitized and empowered population. Health workers in over 200 health centers have had interactive training on proper drug management procedures and documentation. 42 convictions Over 160 cases ongoing in courts and or pending investigations. Disciplinary actions through administrative means have been taken by local government Over 100 interactive radio talk shows done in over 10 languages (find out derby s complaints on different regions and the number of complaints. MHSDMU has contributed to national dialogue on issues relating to the health sector. For example a number of newspaper and magazine articles on key health issues directly relating to the Unit s work 6 ANNUAL REPORT 2011

9 6. Increased Supervision and monitoring at the local government and central level. Increased local community involvement in the health facility management. 7. Human Resources for Health Encouraged administrative procedures to be followed where necessary especially in disciplining errant health workers. Engaging local leaders and other stakeholders to own findings from health centres and propose local solutions. Engaged MOH top management on our findings on issues of accountability, value for money procurement, questioned expenditures and policies to map the best way forward in service delivery. Following MHSDMU s in-depth work on the HRH issue, a national health workers inventory is being created(in partnership with the ministry and the different districts) and many ghosts have been deleted while investigations into the matter are still on-going Protective gears for health workers including uniforms are being procured by MOH MOH has procured hep B vaccine for health workers as a mechanism to protect them Advocated for posting of more health workers in the various under staffed health facilities and districts Health workers concerns are being sought and addressed, e.g. The Unit has helped health workers not on payroll to access their salaries 8. Improved Inventory of health centers by working with NMS, JMS and MOH towards eliminating ghost facilities. 9. Improved interaction, integration and partnership among stakeholders in the health sector Ghost health centers were removed from the government list and investigations into the circumstances are on-going and being handled by the CID Department. MOH, NMS, JMS, NDA, Parliament, development partners(who,dfid and others) police, DPP, Auditor General, IGG, Solicitor General, NPA, CSOs s, professional bodies, etc have been involved in the Unit s work and reports availed to them. ANNUAL REPORT

10 10. Policy review and advocacy for change 11. Improved stewardship of health facilities by both the workers and the communities. The Monitoring Unit has, over the past two years, looked into policy issues as they impact on service delivery. By doing so we have highlighted the gaps in policy/guidelines/the law and contributed to the national debate to improve policy. We have also highlighted a number of implementation challenges and are working with relevant stakeholders to address these challenges. Some of the health related policies/guidelines or proposals reviewed include; National Drug Authority Act (1996), The Pharmacy and Drug Act (1970); Bonding of health workers; Private Wings management in Public Health Facilities; Private-Not-for-Profit (PNFP) Facilities; National Health Insurance Scheme (NHIS), Licensing of Nursing Training Schools, etc The Unit has witnessed remarkable improvement in the general management of health facilities since its operations especially due to increased community participation in the running of these facilities. 8 ANNUAL REPORT 2011

11 FINDINGS Despite concerted effort by government, development partners and other stakeholders, findings from the monitoring visits still present serious implementation gaps in service delivery for the health sector. Notable deficiencies were found in drugs and funds accountability, human resource and health services management and regulation. As a result, large sums of money have been lost and continue to be lost due to this negligence, intentional or otherwise. Part 1: Human ResourceS FOR HEALTH: THE NATIONAL PICTURE It is widely agreed that the human resource is the greatest input for any system in the world, and Uganda is no exception. Human Resources for Health (HRH) are at the forefront of delivering quality healthcare and a number of best practices of commitment, selflessness, and professionalism exist among Uganda s health workers. Out of the many health centers visited by the Unit there were many that had been functioning very well like Kamion HC II(district) was especially outstanding in the area of human resource, drugs and accounts management and the In-charge MrChillah Mathew is given credit for this. The commonest and recurrent findings affecting service delivery included; absenteeism, understaffing and pseudo understaffing, accumulated unpaid arrears for staffs, un-bonded staff members on study leave and total lack of evidence of the appraisal system. Other findings include greatly demotivated staff, lack of recruitment plans in local government facilities, lack of training of in-charges in managerial and financial management skills to mention but a few. Health workers absenteeism Overall absenteeism at the health centers visited was at 52% as shown in the figure below. 10% of over 250 health units visited were found closed on spot a problem that cuts across the entire nation. In some health centers in districts like Mukono,Wakiso and Kamuli it was as high as 80%.This vice has been going on over a long time and reported in every report of monitoring groups yet no apparent solution seem to work to stop the practice.. It is also accepted practice that lower health facilities do not work on weekends leave alone public holidays. It is not clear whether this is a formal and standard practice accepted by the Ministry of Health. ANNUAL REPORT

12 Pie chart showing absenteeism of health workers at the health centers visited Absenteeism of In-charges In charges absenteeism was at 52%and it is worth noting that, in most cases, Health facility In-Charges are the ones with the highest level of skills; therefore their absence deprives the local population served by their facilities of services they would offer. The major causes of absenteeism were among others found to be: in-charges attending to their clinics/drug shops and workshops/ trainings organized by NGOs. It was also noted that the DHOs had failed to regulate these various workshops and trainings since invitations were being sent directly to in-charges not through DHOs. We observed a decrease in both males and females 5+ years in OPD monthly attendance when the incharge was reported absent. This implies that there is a correlation between the absence of in-charges and patients attendance at the health centers. Unqualified staff Due to high absenteeism, some health facilities are left to be run by unqualified staff. E.g in Burere HCIII in Buhweju district, the facility had been left in the hands of an Askari to do clinical work. At Nankandulo HCIV in Kamuli,Bagezza HCIII in Mubende District drug dispensing was done by porters, and Askaris, There were no proper drug management records in place and no close supervision was ever done by the In-charge. It has also been established that nearly all graduates of illegal training have been employed in government facilities and this has contributed to the poor quality of health care. Poor / low motivation of health workers Majority of health workers across the country confessed to being de-motivated a factor that inevitablyhas had a negative effect on the way they work.under payment has been the major demotivator.theotherreasons for low motivation ranged from lack uniforms, not being protected from exposures like hepatitis B, non promotion, low pay, delayed confirmation, missing salaries and arrears. For example in (must confirm Amuria or Atiak HCIV ) a midwife who had worked for 30years had never been put on payroll while in 10 ANNUAL REPORT 2011

13 Mulago Hospital over 80 staff members had worked for over 5 years without confirmation which led some to leave. Through our intervention many of the health workers have been confirmed. Recruitment of unqualified staff Due the existence of many illegal nursing schools, many people who had qualified from illegal schools had been absorbed and were working in government facilities. In Lango sub region, many nursing Assistants employed in government health facilities qualified from quack schools operating in the district. Whilst in Kamuli, one nursing assistant employed by the district at Nabirima HCII could not even express herself in English when h interviewed, she said her training had only been on how to inject and confessed that she qualified from NILE CROUDLE KAMULI SCHOOL. Consultations with the district leadership revealed that this school was unlicencedand yet the district had employed an alumnus from this school The in-charge of Kitwe has never studied medicine despite him having gone through district recruitment process. He was found with forged document. He is undergoing prosecution. Understaffing/ pseudo ( add Hope s examples on Kole) understaffing So many health workers had left for studies without informing the districts, yet they continued receiving salaries. The bonding policy in public service that requires health workers to return to their post after studies has not been effectively implemented. This has created a shortage of staff yet government continues to pay these ghost workers. The liberalization of the labor force in the health sector means that doctors and other health workers upon completion of their training are free to venture into the private sector at the expense of the public sector. Some also travel abroad to seek better pay or opportunitieshaving benefited throughout their studies from taxpayers. The table below illustrates the number of medical students that have been produced by the four universities in the past ten years with more than half of these having been on government sponsorship. (COMPLETE TABLE WITH Dr. C AYUME) Total GULU KIU MUK # # 100 # MUST TOTAL 1,744 # Data not available by access Graduation ceremony not yet held by access time The above figures when compared to the number of health facilities that do not have the required caliber and number of personnel present an alarming picture. There are few or hardly any medical doctors in the upcountry health facilities meaning that the health care system in the rural health centers are mainly run by lower cadre staff and the repercussions are evident like poor diagnosis and prognosis, accountability, maintenance and planning issues. ANNUAL REPORT

14 Districts like Oyam, Mayuge,andBundibujyo had only the DHOs as the medical doctorsat the time of monitoring. In Kole, Buyende, Zombo and Aleptong there was no doctor in the entire districts. This clearly shows the level of healthcare output that would be expected from such districts whose planning and monitoring is left to junior staff. There are currently 114 districts, with some still in their infancy. Due to the decentralization policy, the recruitment of health workers in the districts including doctors has been left to the district service commission. Some districts have very poor infrastructure, lack equipment, vehicles and basic housing; while others are hard to reach and lack the basic social amenities. This means that some districts are unable to attract doctors while others have a considerable advantage. There was also a problem of attracting, recruiting and retaining motivated health workers in a number of districts for example Buhweju, Kanungu and West Nile. ( To be cut away and placed in a better place) Delayed health workers recruitment by the district service commission for instance in Sembabule, Ntungamo,Kisoro and Kole districts. Bonding has worked in some PNFP health facilities in Uganda where medical doctors are sponsored for further studies but have the obligation to come back and work for the institution on completion of their study for a set period.ironicallybonding,has not been implemented by government on health workers yet the policy exists and this is where it is needed most. The bonding strategy has been effectively implemented in Thailand when it is emplemented with other incentive strategies 1.Note that the success of the bonding strategy will depend on the implementation of other factors like the financial and non financial incentives. Other sectors like the road sector, electricity and other social amenities will also have to be developed in the near future to make the rural areas more habitable Un-professional conduct by Health workerssomehealthworkers were found to be engaging in unprofessional practices and so bringing disrepute to the health profession. The practices include corruption, negligence of duty and making dangerous decisions that directly affect the health of the population.. Note: Mbale& Dental Rapist Many district stores were disorganised with poor storage conditions; and many equipment s were lying idle in the stores instead of distributing them to facilities that needed them. 1 Charles Hongoro; Lancet 2004; 364: ANNUAL REPORT 2011

15 Expired syringes supplied to Nakawuka&Bussi HC IIIs in Wakiso in February 2011 with full knowledge of the DHO and DDI. The images below are the DHO s stores in Wakiso District. ANNUAL REPORT

16 Extortion by health workers from patients. Despite the existence of the No User Fees policy in government hospitals, a number of facilities were found to be charging patients even for basic services under the cover of private service. Of the total respondents interviewed in HCs visited, 80% have paid for services in lower government facilities responses. It is no surprise that extortion at government facilities and sell of government labeled drugs continues unabated because very few average citizens can identify them. In the course of our field work we found that many of the locals when asked if they could identify government medicines told us that they could not. 14 ANNUAL REPORT 2011

17 Lack of support staff The other major finding was non recruitment of support staff in the districts of Mayuge, Buyende and Kamuli. Busoga region does not recruit porters and Akaris and this was a big challenge to health centers in regard to safety and cleanliness of the facilities. This had led to unkemptness and loss of property in almost all health centers. For example, the lack of Askaris in Kamuli and Buyende must have been a major contributing factor to the reported theft of solar panels in all HCs. The facilities were thusindarkness. It is a requirement to recruit porters of qualifications of senior four by Public Service.Iit was noted that the majority of porters recruited do not do their work because they aremore qualified that nursing assistants that manage lower health centers and therefore see them as people who are incapable of supervising them.they also shun cleaning as dirty job to do with their qualifications.they end up despising the very jobs for which they were recruited. This leaves most health facilities with these highly educated porters and Askaris very filthy and/or unguarded. Withholding PHC funds by district officials for unclear reasons During the monitoring visits, the team established that the district officials had intentionally delayed disbursement of funds to health centers for long periods. e.gwakiso district officials had intentionally delayed disbursement of funds to all the facilities for 5 months.mbarara had also intentionally not disbursed PHC funds for 5 monthswhilepallisa withheld it for all facilities for 2 quarters. What is puzzling is the fact that in nearly all these scenarios the said monies lay idle on the district accounts without clear motive. Lack of staff uniforms and tags The monitoring team also found out that so many staff lacked uniforms and tags in almost all health units visited. It was impossible to differentiate health workers from the patients. Some in-charges were instead instructed by some districts to use PHC funds to buy staff uniforms because they did not budget for this at the district. Efforts by MOH to supply these uniforms are underway. Despite the communications sent out by the ministry so send out the list of the staff and their measurements, some districts have failed to respond making the planned procurement impossible. ANNUAL REPORT

18 Accommodation Out of the 250 facilities visited, 48 HCs had no staff houses at all making it difficult for the affected communities to access emergency health services. Though a continuing challenge, the Government is applauded for the efforts that have been taken to ensure that accommodation is provided for health workers. It was found that 80% of the centers visited had accommodation. There were a number of health facilities that had accommodation but abandoned. Most Mulago accommodation had been rented out to non staff only to benefit a few individuals. Another gap identified in the management of health facilities was attributed to lack of appropriate forums for the community to participate meaningfully in the running of their facilities. 16 ANNUAL REPORT 2011

19 PART 2: UN-REGISTERED CLINICS AND illegal NURSING SCHOOLS While the critical shortage of health professionals in the country and thus the urgent need for training institutions for the same cannot be over emphasized, the continued operation of sub-standard health training facilities should not be tolerated. Whilst the country could do with all manner of help to fill the Human resource gap in the health sector, a balance must be struck between urgent interventions and maintenance of high quality in the sector. In the course of investigations, the team discovered very many illegal clinics and drug shops (over 900 across the country) within Kamuli district alone, 412 drug shops/ clinics had operated for over 8 years. When the monitoring team arrested some of the owners of these facilities, they confessed to the team that the reason as to why they were operating normally without documents was because the DDIs offices were accepting bribes whenever they came for inspection. The existence of illegal Nursing Training schools across the country is a cancer to the health sector that needs to be addressed immediately. In the areas investigated, MHSDMU has unearthed many Illegal schools in Uganda. Beyond operating illegally, a number of other concerns arise with illegal training schools such as the fact that these schools are offering courses which are not relevant for our health system and also the appalling conditions in which they operate. MHSDMU found that nearly all the schools operating illegally lacked adequate clinical experience for training students. The schools were being run by people who had no qualifications at all. e.gpancrassokojoiin Mayuge was a former porter in St Francis Buluba Hospital who forged a certificate as a Nursing Assistant and then proceeded to start up a Cancer Clinic and Nurses Training School! He was convicted and fined 500, oooug shillings which is not comparable to the damage inflicted to the community. Forged certificate for the owner of Pancreas school Forged certificate of co-owner ANNUAL REPORT

20 Students mattresses on the floor in their dormitory Students classroom Dormitory of pancreas school Mayuge Kitchen of pancreas school Majority of the students enrolled to these schools were below the age of 18 years and some had just completed primary seven. This is against the entry age for all nursing school students who must be eighteen years and above and should have completed senior four with a background in science subjects especially biology, physics, chemistry and math and must have passed with at least principal passes.(see a specimen of notes) 18 ANNUAL REPORT 2011

21 Sample of the notes from one of the exercise books MEDICINES AND HEALTH SERVICES DELIVERY MONITORING UNIT Below is one of the illegal schools where the students were charged exorbitantly in falsified Teaching Hospital which was found to be a hostel. ANNUAL REPORT

22 Main building of Musinga school in Ntungamo Main entrance of Musinga hospital. Some training schools are managed by single persons Contrary to what regulations on setting up schools spell out, most of the illegal schools were found to be totally run by single persons without support staff like secretaries, accounts clerks or even kitchen staff. They would teach and also do the other works of support staff with the help of students. It is worth noting that majority of these proprietors do not even have the knowledge and experience to teach students. An example is Musinga Teaching Hospital in Ntungamo, the only Tutor doubled as the principal and lecturer while one of the students acted as bursar and collected fees from her colleagues while the rest took turns to do maintenance work for the school! Exorbitant school fees The investigating teams also found out that the fees charged were too high for the courses offered and this money could have supported these students in registered / recognized schools. The range of school fees was: Ntungamo, Musinga 1. 2,000,000/= for Nursing per Annum 2. 1,000,000/= for Nursing assistants per Annum Kamuli, Were school ,000/= for Nursing assistants per Annum Kamuli, CTI school 1. 1,600,000/= for Lab technologists per Annum Mayuge, Pacraas School 20 ANNUAL REPORT 2011

23 1. 1,000,000/= for Nursing assistants per Annum Involvement of senior district officials in these illegal schools MEDICINES AND HEALTH SERVICES DELIVERY MONITORING UNIT The team also established that these schools were operating in many cases under the knowledge of senior health officials in the districts. For example the Community training institute for Lab technologists in Kamuli was run by a health worker in Kamuli hospital whereas in NtungamoMusinga Christian School teaching hospital had the DHO Ntungamo on its board of directors despite its overwhelming anomalies and lack of proper registration Structure of CTI lab school in Kamuli students hostel CTI lab school Existence of Quack tutors Investigations also found out that some of the tutors working in these schools were quacks. For example in Kamuli district the head of dental department at Were Clinic nursing school Mr. Bazanya Simon claimed he was a public health dental officer. Further investigations revealed that he was not and he confessed that he had no academic documents. Verification with UNEB revealed that the O-level certificate he had submitted to the team belonged to a lady. Schools using students to do clinical work during the day It was also established that the nursing students that were being trained in these schools, would work as nurses during the day (without remuneration) and then go for nursing training classes in the evening. A good example was Were Clinic/ nursing school where students were working as nursing Assistants during the day and later have to study at night. According to in-depth interviews with the students, the intention of the school proprietors was not for students to gain clinical experience but rather they were being used as cheap and free labour. In addition the conditions under which they worked were not suitable for them to acquire new skills. ANNUAL REPORT

24 Use of stolen Government/Health Partners equipment Some of the illegal schools were found with stolen equipment from government and /or health partnerswhich they were using to train their students. For example Community Training Institute for Laboratory technologists in Kamuli had laboratory equipment (microscopes and printers) embossed with CDC that had been stolen from Bishop Hannington Health Centre (a PNFP) under Busoga dioceses that was being funded by AMREF to train microscopists. Recovered microscope at CTI Kamuli Nurses qualified from illegal schools already in government Facilities Due the existence of many illegal nursing schools, many people who qualified from these illegal schools had made their way into government facilities. In Kamuli, the district service commission had recruited a staff trained from the illegal nursing schools in Kamuli to work in a government health centre. E.g Nursing Assistant Kayima Sarah at Nabirima HCII who could not even express herself in English. When talked to she said she only knew how to inject and confessed that she qualified from NILE CROUDLE KAMULI. Teaching obsolete courses The official position and guidance from the Ministry of Health is that the position of Nursing Assistant has been phased out and there is no more absorption of Nursing Assistants in the health sector. However nearly all these schools were found offering this course. Over 70% of the students enrolled these illegal schools were doing a Nursing Assistant course. The impact of this on students and their families should not be underestimated; a parent struggles to look for money to educate a child who then goes on to study a course that can neither adequately train her nor guarantee a job in the mainstream health sector. Issuing forged certificates and stealing exams from other institutions Perhaps as a means keep up the farce of authenticity and to attract new recruits, many of the illegal schools have turned to issuing not only forged certificates but also stealing exams from the recognized institutions and offering them to their students a case in point was Pancrass School of Nursing. Samples of the certificates and exams issued by Pancrass School of Nursing 22 ANNUAL REPORT 2011

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26 From the few nursing schools visited and investigated the table below estimates the number of Alumni that have been released onto the unsuspecting public as health workers; 24 ANNUAL REPORT 2011

27 The table below lists the few schools that have so far been investigated by the Unit and estimates the number of alumni that have been released onto the unsuspecting public as health workers ; it is however not representative of the entire country. DISTRICT SCHOOL AVERAGE YEAR YEARS IN OPERA- TION TOTAL ESTIMATED ALUMNI Ntungamo Musinga Teaching Hospital 70 students 2years 140 students Lira KN Forward Medical services 7 students 1year 7 students Lira Lira laboratory Technical School 120 students 10years 1,200 students Lira Ronam Nursing School 30 students 5years 150 students Mayuge Pancrass school of Nusing 40 students 10years 400 students Kamuli Were Clinic 30 students 7years 210 students Kamuli CTI Laboratory Technicians School 30 students 5years 150 students Old Kampala M& S General Clinic 10 students 2years 20 students GRAND ESTIMATED TOTAL 2307 STUDENTS The impact of these practices on the quality healthcare provided cannot be overemphasized and these are illustrated more below; ANNUAL REPORT

28 The existence of these quack schools cannot however negate the applaudable schools that have weathered storms to provide high quality health training. Aside from the Ministry run or faith based health professional training schools, one such school is DAF College of Professional Health in Lira. The school has sought licensing from the Ministries of Education and Health and this has been denied unreasonably despite compliance with all necessary requirements whilst many of the substandard schools visited had licenses to teach even with the glaring anomalies existent. Illegal clinics and drug shops In the course of investigations, the team discovered over 900 illegal clinics and drug shops across the country. In Kamuli district alone, 412 drug shops/ clinics had operated for over 8 years without a lincence. When the monitoring team arrested some of the owners of these facilities, they confessed to the team that the reason as to why they were operating normally without documents was because the DDIs offices were accepting bribes whenever they came for inspection. 26 ANNUAL REPORT 2011

29 Part 3: Health services DELIVERY MEDICINES AND HEALTH SERVICES DELIVERY MONITORING UNIT The Monitoring Unit has found a number of success stories across the country in the way health services are delivered to the people. Special credit goes to Alebtong district health team for prioritizing maternal health and ensuring that almost all their health centers have placenta pits. This was especially noted because not many districts in the country showed such effort and commitment to service delivery. Kisoro district is also credited for ensuring that most health centre IIIs are admitting; this is not the case in most districts. The country however has witnessed poor service delivery in the health sector. This has been primarily as a result of weak supervision and implementation of planned programs. The Unit has come across many health centers IIIs which are not admitting as they are supposed to. This has a big negative impact on local populations who have to travel long distances for basic services thus increasing treatment time and mortality rates. In Kaabong district hospital, the private wing is being used mostly as a lodge for hire while two staff houses were taken up by the CAO and CFO. At the time of visit in Kamuli district, Nabirumba HCIII had given their wards to social work students from Nsamizi for accommodation. Meanwhile, Bayitembogwe HC III in Mayuge district had converted the OPD into a Music Dance and Drama school. Apuce HCII in Lira district had been completely abandoned to road contractors for a period of six months. No services were being offered. Many of the wards for instance did not have proper records to indicate what they received and how it was dispensed to the final user. Many of the stock cards at the departments though present and in use, were incomplete, unsigned and in certain instances did not tally with the requisition vouchers to these units. The graphs indicate that 59.8% of the facilities the monitoring team visited had no maternity drug dispensing books and 60.1% of the facilities had no wards patients register. THE CHART BELOW IS ON REGISTER S USE IN THE LABAROTORY AND WARDS IN THE FACILITIES VISITED Shoddy construction/ renovations and stalled works The team established that in many health facilities, there were shoddy constructions/renovations.in West- ANNUAL REPORT

30 ern Uganda for example, many contracts had been awarded to Multiplex but many of the constructions had stalled or were sub-standard. Stalled Multiplex structures and Endinzi HCIII as per 3/04/2011 Stalled Multiplex structure of Kakoba HC III 28 ANNUAL REPORT 2011

31 Poor waste management Waste management, hygiene and sanitation at health centres was alarming and in need of serious address as patients were at great risk of acquiring more disease whenever they came for treatment. For example at Kasangati HCIV in Wakiso, the placenta pit was not being used and instead placentas were being thrown in rubbish pits. InNankandulo HCIV in Kamuli, the placenta pit was covered by bushes. The placentas were instead thrown in the corridors of latrines and picked and littered by dogs in the compound. Poor infrastructure management Very old and dilapidated structures that are poorly maintained continue to exist like Entebbe hospital in Wakiso, Kinawampere HCII and Namasagali HCIII in Kamuli. In Kamuli district, Namasagalihospital (the former referral hospital for Kamuli district) is in a sorry state and renovation has only been done on two blocks. In Nagwere HC III in Pallisa, the facility originally had two structures that were demolished for renovation in January 2010 (the work was slated for one month in addition to the construction of a maternity ward). This work was abandoned in May 2010 for non- payment and the facility was found operating in a single room with no ventilators, ceiling or latrine for patients! The one room serves as the office, ward (patients were admitted on one table and floor), store and laboratory. It is however on the verge of collapse. ANNUAL REPORT

32 External supervision In most health facilities visited there were no records of supervision done by the responsible parties which largely accounts for the various anomalies found in these facilities. This is despite the fact that most of the vouchers looked at in the DHO s and HSD offices went towards monies for support supervision.while the majority of health facilities are not supervised, feedback was lacking for those facilities where some supervision had taken place and in other facilities we found. The graph below details the frequency of external supervision at these facilities which we found to contribute directly to poor performance. Under-utilization of HC facilities/non functional theatres National health system configurations clearly outline the types of services expected to be delivered at different health facility levels but this has not been followed A case in point was in Mbarara district were all healthcentre IIIs and IVs visited in the municipality offered no admission,claiming that the health centers lacked patients to admit. Interactions with the community and local leaders in this area revealed that patients are chased away so that health workers can rest (this was particularly true for Biharwe HCIII). Whilst in Matete HC III in Sembabule district the In-charge alleged that HC IIIs are not supposed to admit patients. In the facilities visited we found that 26.7% of HC IVs were not offering admissions, 50% of HCIIIs were not admitting, 84.6% of HCIVs were not doing major surgeries and 69% of HCIVs had no anesthetists which inevitably puts a very high work load on the district hospitals and referral hospitals in the area. Despite the non-admittance in these facilities they continue to receive the same funding with the facilities that admit. 30 ANNUAL REPORT 2011

33 HCIVs doing major surgeries HCIVs with anesthetists Non functional theatres Most HCIVs visited, had theatres that were equipped but were doing only minor surgeries. In some cases, there was no medical doctor to carry out operations while in others, the reasons given were unsatisfactory. The main reasons given are listed below; (i) (ii) (iii) (iv) (v) (vi) Failure to recruit and retain doctors by the districts. Inadequate power supply to sustain major operation procedures. Poor planning and assessment of the national medical human resource. Inadequate remuneration of health workers in terms of (accommodation, transport). Poor construction of the theatres. Shortage of medical supplies for example theater linen ANNUAL REPORT

34 The fully functional theatre in Wakiso HCIV that is not working due to lack of linen. Mugula HC IV Theater in Adjumani that has been non-functional since construction for lack of an anesthetic officer An analysis of health centers inventory in the country was done by comparing lists of facilities from different stakeholders such as CAO s, the MOH Inventory, NMS Inventory for Government owned health centers 32 ANNUAL REPORT 2011

35 and the JMS inventory for NGO owned health centers. Findings from this analysis are represented in the table below. 66 health centers were found to be wrongly classified with the various sectors while 303 health centers were known only to NMS and JMS and not MOH. NMS JMS MOH Appearing on MOH, Fin and NMS or JMS respectively. 2, ,041 Appearing only NMS/JMS Those health centers with Classification issues(i.e. said to be HC II yet is a HC III or vice versa) Appear in NMS List as well as JMS List Only MOH(under construction, yet to be opened) 630 Kampala Private HC s 1,332 Total 2, ,073 Non functional Ambulances The team established that most of the facilities in districts had lack of referral means as a major problem. In the cases where a referral mode of transport existed for example an ambulance, patients were often asked to pay for the fuel. Most of the ambulances were grounded in garages and/or in the facilities. Their maintenance costs had become high because of continuous break down. The DHO of Lira echoed what most DHOs gave as an explanation for the frequent breakdown of the motor vehicles citing that the budget assigned to the facilities does not take into account the routine servicing and maintenance required for the vehicles. A common unfortunate scenario in districts that had functional ambulances is that these ambulances were doing more of the administrative work at DHO s offices instead of referral services. An example of some of the broken down Ambulances at Kasanda HCIV, Mubende District The overall picture on transportation for the centers visited is represented below in a graph that shows the different modes of transportation and their functionality; ANNUAL REPORT

36 Ambulance Cars Motorcycles Bicycles Functional Non-functional Total There was lack of a good inventory management system for equipment in most districts. Inventory books are either unavailable in health centers or when available are not regularly reviewed. There is also in most facilities visited no plan in place for equipments maintenance and repair. Findings from the field are reflected in the graph below. Inventory book Inventory book review Maintenance plan Available Not available Missing HC data Total ANNUAL REPORT 2011

37 The lack of inventory management could be directly attributed to the fact that, in many institutions there were no clear maintenance plans. Assignment of maintenance and repair person for the infrastructure Non engraving of equipments The other finding by the monitoring team was that many districts do not engrave equipment. In thefacilities visited, very few equipment were engraved and thus any loss or theft was hard to resolve.this problem occurs even in larger facilities like hospitals. The Unit has recovered various equipment from the private sector that are labeled and thus easy to trace ownership but in some cases even when circumstances are suspicious, we have been forced to leave equipment with suspects because they were not engraved. The unit has advised the district health leaders to ensure that all equipment is engraved before distribution to the respective health facility. Ministry of Health Infrastructure department needs to follow up and ensure mandatory engraving of government property. VANDILIZATION OF VEHICLES MOH Case Report Early this year, the Medicines and Health Service Delivery Monitoring Unit (MHSDMU) received information concerning the unabated vandalization of government property and theft of government motor vehicles in the Health Infrastructure Department (HID) headed by Eng. Wanda the Assistant Commissioner Engineering department in Wabigalo. MoH started an exercise of boarding off vehicles that were not in use. In 2008, the Inspector General of ANNUAL REPORT

38 Government (IGG) halted the process citing breach of procedures. By then, some of the vehicles had been boarded off by the MOH and auctioned through Kamugisha Agencies. This Agency by the time MHSDMU started investigations owed MoH an an outstanding balance of 20,449,139M that had not been remitted for a period of three (3) years. MHSDMU first action point was recovery of this money and this has been done. As a result of the IGG s halt on the exercise, the MoH transport department then headed by HadijaWegosesa decided to tow the vehicles to HID in Wabigalofor safe custody. It was in Wabigalo and a number of other garages (where vehicles were taken for maintainence or repair) that vandalization and theft of these vehicles took place). The vandalisation was alleged to have taken place during December The matter came to the attention of the Police and a file (CRB/01/2010) had been opened in Kisugu police station but this case had stalled for unclear reasons. There were allegations that many other MoH vehicles were lying in different garages awaiting repair. In addition, MoH had failed to make payments for majority of the repaired vehicles had not been made. As a result these vehicles had been vandalized or sold off in the garages. Findings: Faulty handover process: The handover process raises a lot of concern. It was noted that there were no handover documents (formal/official communication) from MoH to HID stores for safe custody of the vehicles. Poor Security: The HID store in Wabigalo should ideally be guarded round the clock by two police guards on every shift, but this has not been the case. In most cases the place is abandoned hence exposing it. On several visits to the place we found the door open with no police guard on site. Furthermore, HID stores have no records, e.g. gate passes where guards would note down visitors and workers. As a result, vehicles or any other items entering or leaving the premises are not recorded. It is therefore not surprising that there was rampant theft of spare parts from the vandalized cars had occured and none of these stolen spare parts had been recovered. It would seem that MoH s Transport Department and HID leadership have either failed to execute their duties diligently or the concerned officials have merely chosen to be negligent. In addition to cars being vandalised at various garages, some cars have actually been vandalised within MoH premises. 36 ANNUAL REPORT 2011

39 Some of the vandalized cars with no engines Non-existent/ non-functional transport department: a case in point is the fact that the current transport officer is an administrator instead of being a technical person. It was also found that the engineering department does not evaluate cars that need repair. The ministry merely depends on the good will of the mechanics in the garages where the cars are taken to estimate what repairs are necessary. The ministry of health pays hundreds of millions per year in forgery or nonexistent repairs because some officers have been conniving with the mechanics to inflate the repair costs. This fact was confirmed by Ministry officials who sought anonymity. They said that they suspect that some garages belong to some officers in the ministry. Poor record keeping and stewardship: The records from the transport officer and the facts obtained from the visited garages were not tallying at all this exposes another big weakness. At the commencement of investigation the transport officer recalled all vehicles that were in garages, in-fact most of the vehicles had been brought back in a worse state than when they were taken and dumped behind the park-yard of MoH. It became clear that there was no knowledge of the whereabouts of most cars (details on the said vehicles in appendix 1). Another anomaly was with the former transport officer (HadijaWegosasa) who dumped the vehicles at HID stores Wabigalo and did not follow up on them. Financial loss: The cost implication of the vandalized cars found by the Unit was determined to be UGX 112,290,000; a full cost estimation is attached. Many of the permanently employed drivers are not used, instead the officers prefer casual drivers ANNUAL REPORT

40 whom they can use for any errands personal or otherwise. These casual drivers said that their per diem is cut by their bosses and they cannot complain since they are being helped with temporary jobs. Some of the drivers contracts had ended but had not been renewed yet they have continued to work (a full list of these drivers is in appendix 1). Breach of procedure: Although there is some semblance of PPDA procedures being followed, it became very clear that this was actually contravened at the initial stages and done retrospectively. The procedure for cars getting to the garages for major and minor repairs is being breached most of the time. In all garages visited, we found no vehicle that went through the right procedures before getting to the garage. Most of the vehicles that get involved in accidents are stealthily smuggled into garages with no assessment or police report. In the meantime the prequalified garages are deliberately and consistently sidelined when it comes to actual awarding of the work regardless of the fact that they have better technical capacity and equipment. Some have never been awarded work since prequalification while others have not got work in the last 5 years! TheGarages that have never received any work despite being prequalified to carry out repairs for MOH vehicles include; Kyeyunga motor garage Mak hill motors ltd Ephraim motors interprises Ltd Kita general works Ltd Owen Engineering Ltd Viena auto garage Ltd Kire engineering Ltd Burns engineering and general supply The pre-qualified garages which have not had work in the last five years include; Walusimbi auto garage. Toyota Uganda. Kampala Nissan Ltd. Fontana auto parts. Mitshibishi Auto Garage. Wamco Auto Garage. 38 ANNUAL REPORT 2011

41 Kyeyunga Enterprises U ltd. Singh Motor Garage. Our discussions with people from some of these garages disclosed that the reason they were denied work by MoH is because they refused to compromise on quality of work and/or inflate prices! The garages wherestealing and vandalizing MoH cars has occurred include; Good way auto garage, New Kabusu, Delo, Owen engineering, Stamina etc. Also, it was found that garages which commit to the work and complete repairs in time are not promptly paid and many times opt to retain the cars. The following garages have repaired cars but have not been paid: GARAGE AMOUNT UNPAID DURATION OF DEBT 1. Wamco Motors Uganda Limited 122,261,669 UGX 3 YEARS 2. New Kabuusu Auto Mobile Services 4,046,220 UGX 6 YEARS 3. Central Auto Centre Garage Limited 71,296,840 UGX 6 YEARS 4. Grace Lubega Motors 14,091,560 UGX 6 YEARS 5. United Engineering Services limited 14,595,000 UGX 5 YEARS 6. Maka Motors Works Ltd 6,700,000 UGX 4 YEARS 7. Delo Motors 19,388,000 UGX 2 YEARS 8. Global Auto Engineers 30,000,000 UGX 5 YEARS TOTAL 282,379,289/= This money had accumulated over a period of five to eight years and at the time of investigation no efforts were being made to settle the outstanding debts. For the vehicles that are forgotten due to poor follow up and or long bureaucratic procedures in processing payments; the garages slowly own the vehicles or exorbitantly charge the ministry for nonpayment and space occupied. When MoH fails to pay, as it has on a number of occasions, the vehicles are end up being retained, stolen, vandalized or sold off. ANNUAL REPORT

42 Vehicle in a sham garage The same car vandalized in sham garage Personalization of cars:according to the transport officer, many officers had more than two cars assigned to them. The reason they put in effort forward is that they were the ones who convinced the donors/sponsors of specific projects to buy these cars for their departments therefore they have the rights to own them! The Transport Department was found to be very inconsistent with its records of the officers owning or overseeing the different cars. Other cars have been personalized or owned by drivers who use them to carry out personal and unofficial tasks yet the cost of fuelling and maintaining these cars is met by MoH. It was alleged that most drivers are ignorant of the modern technology of the new vehicles. As a result the vehicles are not serviced on time and are poorly maintained resulting into breakdown. 40 ANNUAL REPORT 2011

43 One of the cars owned by a driver found parked at CDC offices. Unwarranted Purchase of New Vehicles; When vehicles have a mechanical problem (even those requiring minor repairs), officers have been known to dump them in garages and request for new ones. As mentioned before, many officers have more than one vehicle. When one breaks down, it s dumped and ignored because they have an alternative. This shows a laxity on the part of the transport office as far as stock-taking, supervision and management is concerned. An example is a car registration UG 0320 M (a vaccine truck) found in Grace Lubega Motors 2000 Ltd (Plot 205 Makerere Hill Road). This car has spent 6 years (since May 2005) in the garage following repair but MoH has failed to pay 14,000,000 UGX to pick it up despite still being in a good working condition. Another example is the Vehicle used by Eng. Wanda which, although its engine is still good, has been abandoned in a garage for 2 years with outstanding charges currently adding up to 19,000,000 UGX. ANNUAL REPORT

44 Eng. Wanda s (MOH head of engineering department) car in Delo garage for 2 years pending payment of UGX 19,000,000 The vandalized inside of Eng. Wanda s car pay Functional vaccine truck in garage for 6 yrs pending 14M 42 ANNUAL REPORT 2011

45 The IGG s (2009) report on boarding off of vehicles was released to the former Permanent Secretary Ms. Nnanono. However, to date no concrete deterrent action plan has been decided on. This is partly because the report did not give clear recommendation on what to do with the vehicles following the halted exercise. The MoH could have consulted the IGG who is a phone call away. The lack of decisiveness has contributed to increased vandalization. Lack of Coordination: The transport, procuring and personnel departments are not coordinated, they are very disorganized, fragmented and exhibit non-commitment to ensuring that government resources and assets are protected and put to good use as far as MoH transport issues are concerned. The concept of Value for money is not practiced in the transport sector of the Ministry. ANNUAL REPORT

46 Part 5: Drugs utilization and management Drugs are an essential part of achieving health outcomes. Almost 90% of public dissatisfaction with the health care system stems from the absence of drugs at health facilities; not so much the absence of health workers or their conduct. In the FY 2009/10, MHSDMU directed most of its interventions towards prevention of drug pilferage by clamping down on illegal points of sale as well as breaking up rackets that deal in the sale of government drugs. The unit has noted a significant reduction in the practice of illegal sale of government drugs over the past two years. In F/Y 11/12, there was significant increase in the budgetary allocation to the purchase of drugs realized. However, the problem of lack of drugs at health facilities persists. The Unit has establishedthis to be mainly due to poor medicines management at health facilities as well as a poor needs assessment by planners. This chapter will focus on the poor management and subsequent chapters shall address with the lack of proper planning. NMS has in the last year made decent efforts to supply drug management record forms like stock cards nationwide. Requisition and Issue books have however only been supplied albeit minimally to large hospitals and health centers have been left out. Some facilities have been able topurchase counterbooks which are used as drug requisition and issue books. Even in facilities with record documents,these documents remain unused or entries forged at best. Findings from the facilities visited indicated that 11.3% of the HCs lacked out-patients registers, 42.5% lacked out-patients drug dispensing books, 44.4% lacked lab patient s registers and 34.1% of the facilities visited lacked maternity patients registers. THE CHART BELOW IS ON DRUG UTILIZATION AND MANAGEMENT IN THE FACILITIES VISITED Push system and last mile delivery The other challenge found was the push system which applies to HC IIIs and IIs. In Busoga region the most prevalent diseases are Malaria, Respiratory tract infections (RTI s), Eye disease, Skin diseases and Candida, yet most of the medicines required to treat these prevalent disease are never delivered by NMS, rather certain drugs which are not very necessary are delivered in excesses. According to the graph below, 76.1% of the HC visited depend on this push system are continuously receiving drugs without any consultations from the end users. Credit must be given to NMS for improving on its schedules for drug delivery. 44 ANNUAL REPORT 2011

47 Who initiates the order for drugs(n=243) Many of the concerns raised about the push system as experienced in our field visits included; (i) (ii) (iii) (iv) That the kit is understudied and no consultations were made in respective regions to study disease prevalence. It represents very poor epidemiological findings that do not suit demand of the people and the health systems. In certain regions that we visited like the eastern the kit is not equipped with medicines that can treat the most prevalent diseases in the region i.e. ophthalmology complications. In Kisoro anti-malaria drugs are just kept in stores due to the very low prevalence of malaria. In some instances the deliveries made do not suit the functionality of the health centers. Medicines like Benzyl penicillin that are given six hourly are delivered to HCII yet the facility does not offer admission services. Aminophyllin (injectable) has also been found delivered in large quantities yet there are very few asthmatic emergencies in these regions. In other cases we found Quinine injectables being delivered in high quantities to HCIV s that did not have admitting facilities The quantity of pharmaceutical products delivered is insufficient for the most required items and always in excesses of the rarely used ones e.g large quantities of condoms and contraceptives are delivered nationwide and yet very fewantibioticsandsurgical gloves ever reach the health centers. What seemed like a logical solution to the excess drugs in some centers to be given to those in need raised accountability issues like; how would the finances in NMS reconciled? For every pharmaceutical product delivered, the financial status of a given facility is affected. So if a facility wereto give away the delivered product that was brought by the push system how does their account get reconciled for them to be able to retain their funds ANNUAL REPORT

48 All these concerns pointed to the fact that the kit needs constant revision to suit the requirements of health centers at different levels and disease prevalence in respective regions. In as far as drugs usage; (i) (ii) The government through National Medical Stores has embossed most of the pharmaceutical products delivered to public health facilities. Despite the effort made, the product still leaks to the private sector. The bigger challenge however lies in the pharmaceutical products that are freely given by government through Joint Medical Stores to PNFP s. These facilities have opted for economic benefits to sell these products which are supposed to be given for free After consultation with the MoH and all relevant players on the legality of private wings in many public health facilities. We discovered that there is no guiding policy on private wings in this nation. The existing guidelines were rushed after our intervention and are too shallow in meaning, content and offer very little guidance as far as responsibilities and activities of the PNFP s. Government medicines have been leaked freely to private wings and even though embossed the public has been made to pay for the government drugs. This drains the public sector and affects the government in its planning. It depicts a bad image and contradicts the government manifesto of providing free health care in all public health facilities. In addition Pharmaco-vigilance and Supervision is very poor. Pseudo classification of HC s. Many health centers have been elevated by classification due to political excitement and pledges but do not offer the intended services of a specified level like admission, theatre and lab services. This has led to NMS delivering medicines and other pharmaceutical products suited for a given level yet the drugs are not needed or even used at all. Kawempe HCIV for instance has no wards and the theatre is non-functional though fully equipped which means no admissions or operations can be done but the medicines delivered are of a HCIV yet it s only the Lab and OPD that is functional. These medicines end up stolen or expiring in these health facilities. No one seems to be in agreement to redistribute to the needy just because the medicines were withdrawn from his account and the financial status affected. Expired pharmaceutical products. The absence of a national formulary, the use of a kit to HCIII/II that is not extensively studied, inconsistencies in delivered amounts and lack of data on ground to assess pharmaceutical needs of respective regions has led to many drugs expiring and government losing a lot of money. The handling of the expired products is also questioned both in private and public health facilities. Due to the costs attached most people in the private opt for endangering the environment by disposing of these products wrongly. Pharmaceutical stores; Excellent desired results in therapy can only be acquired when the prescriber has the best pharmaceutical product for his patients. Today most of the stores in almost all health facilities visited are not up to date 46 ANNUAL REPORT 2011

49 to store the delicate product. That means that by the time these medicines are given to patients most of them have lost potency. This leads to infection resistances and poisoning patients. There is need to revamp all medical stores in this nation to ensure that they suit the required standards of storing pharmaceutical products. Pest control The other major finding was poor or non-existent pest control mechanism in Health centres. Almost all health facilities visited had been infested by bats and pests. In all the health facilities that had been taken over by bats, it was impossible to carry out any clinical work due to the strong stench that welcomed you at the entrance of these facilities. Most of the ceilings were also at a verge of collapsing. Pictures of the ceiling of the drug store at Bussi HC III in Wakiso ANNUAL REPORT

50 48 ANNUAL REPORT 2011

51 Part 6: Finances utilization and accountability The lack of transparency in planning and use of PHC funds has bred mistrust and resentment among In- Charges their workers and district officials. Most health centers Lacked proper accountability for funds (there were many forgeries, no receipts, no activity reports etc)and in many HCs visited it was found that the districts had not involved the in-charges and staff in budgeting and planning the facilities. The graphbelow also clearly shows that many of the in-charges and workers were not aware of the PHC amount their facilities were entitled to. Whereas PHC is public funds and the community is supposed to know how it will be used by displaying its workplan on the notice boards, our findings indicate that most HCs did not display these funds and the community and local leaders didn t know when and how it was being used Communication/Feedback on Acknowledged Accountability by District/Sub-county ANNUAL REPORT

52 Inadequate financial management skills Almost all health centre In-Charges could not fully account for the PHC funds given, and majority complained to the monitoring team that the districts had not equipped them with financial management skills and were therefore being creative to ensure that they give proper accountability, many of the HCs lacked financial records in place and had not been instructed and guided on how to account for these funds and besides the districts were not asking for accountabilities. Findings from the monitoring team indicate that most of the health centres were not accounting for PHC and the districts were not even bothering to ask for this accountability. Knowledge by the in-charges of accounting procedures (N=243 An accounted for funds The health departments in the districts visited had huge outstanding amounts of money that needed to be recovered which they could not account for. This amount is from outstanding personal advances and administration advances and excess expenditure on salaries. Details of the recoveries and pending cases are well detailed in part 6 of the report ( Legal section). Loss of PHC funds The district health department in Kamuli lost 72 million shillings meant for lower health centres to URA over non-payment of pay as you earn (PAYE) leaving lower health centres un-sure of how and whether they will run their PHC activities as planned in this FY 2010/11. Theft of funds meant for Yellow fever by M.O.H Officials This is a matter still under investigation of UGX 604,000,000/=. Officials in MoH s Public Health section 50 ANNUAL REPORT 2011

53 requested for six hundred and four million to do sensitisation on yellow fever from the ministry s account. The money was paid in March However, the same activity had previously been sponsored by ICRC (International Committee for Red Cross) and WHO (World Health Organisation) and the requisition and payment of this money was a duplication. The money was shared between officials and no single activity was done. When the Monitoring Unit started investigating, the concerned officials started forging accountability and disbursed monies to some districts in order to obtain signatures. Due to pressure from the Monitoring Unit, UGX 410,000,000 has so far been refunded by implicated officials. In addition, the Unit s investigating officers recovered UGX 2,572,000 from various districts in West Nile, Lango and Acholi sub-regions. No value for Health partners and Government money The United Nations Population Fund UNFPA and Government of Uganda contributed towards purchase of medical equipment and supplies to government health facilities. The costs of these equipments were inflated and worse still poor quality supplies were delivered to health centers and others have never received. One of the mattresses that had just been delivered at Ruhama HCIII Ntungamo ANNUAL REPORT

54 Part 7: legal framework in the health sector The Unit operates under the following mandate; to monitor and evaluate the performance of health facilities that provide medical care and those that engage training of health workers in the country Report and carry out investigations in respect of any criminal matters arising in the health sector. Carry out forensic financial audits in government health facilities and departments where it is suspected that fraud or misappropriation has been committed Work hand in hand with DPP courts of judicature to ensure that criminal offenders are brought to book. Advise medical workers on the rights and work with other departments of government to ensure that the welfare and concerns of health workers are expeditious handled by working hand in hand with existing government structures like the local government administration and public service. Advise and guide medical workers on the effective management of medicine in terms of storage, requisition and issuance of medicine to the units. Liaise with drug inspectors through NDA to ascertain whether drug shops and clinics adhere to the acceptable standard medical practices and laid down procedures In operationalizing it s mandate to improve the health sector,the Unit s experience and interactioncan best be appreciated in two interesting cases handled by this Unit and there outcomes; The first is the case of Uganda V Nassiwa Christine CRB 984/2010and Criminal case No. CR-CO-290 of 2010 (whose education level and background was suspicious but remained elusive throughout this trial) who was charged with Theft C/S 254(1),Unlawful Possession of government stores, Receiving stolen property &Possession of classified drugs (the drugs found in her possession were estimated at about UGX 4,000,000) after a long trial for nearly 2 years, were a trial within a trial was held and prosecution called 7witnesse who all had to travel back and forth between Kampala-Masaka and Rakai-Masaka to attend hearings and bear with numerous adjournments, the Chief Magistrate( Her Worship Mponye K. Sarah) convicted her to community service( to work at the health center II near her home for 1 hour each week day) for 3 weeks! A penalty that we considered ridiculous, given the time and effort put into investigations and prosecution and the countless lives that had been put at risk in this woman s dealings. In addition as if to encourage this sort of behavior the magistrate despite finding in her judgment that the accused was convicted on all countsordered that the drugs be returned to the accused except the drugs that had expired!!! The second case study is that of Uganda V Pancreas in Mayuge a former porter in St Francis Buluba Hospital. He forged a certificate as a Nursing Assistant and then with this proceeded to start up a general clinic, a cancer treatment center and nurses training school! At the time of his arrest, he had operated for 10 years with an average of students graduated each year, he had therefore accumulated minimum alumni of over 400 quack nurses from this sham school. In addition we found that he had been charging each student over UGX 1,000,000 per annum making his school one of the largest taxpayers in the district. The Unit proceeded to present him before a Chief magistrate for trial where he pleaded guilty on the counts of forgery, personation, obtaining money by false pretenses, running a training school illegally and running a clinic without a license and illegally. He was sentenced on all counts and fined a total paltry sum of UGX 500,000!Afterwhich he was released back into society. The test of victory for yet another fruitful year in operation is dulled when we list done case studies such as the above, even though it does not erase the impressive 43 convictions and over 160 cases in the court process in just 2 years. 52 ANNUAL REPORT 2011

55 The question topmost for the Unit when faced with scenarios like the above is not who is responsible for this frustration but how and when can we do away with such. PART 8: CHALLENGES FACED IN THE HEALTH SERVICES SECTOR The major challenge faced in the provision of proper health services is in the fact that the health sector relies on many other sectors to perform well. The National Drug Policy and authority act section 6 (4) provides for the committee on National formulary.traditionally, a formulary contained a collection of formulas for the compounding and testing of medication (a resource closer to what would be referred to as a pharmacopoeia today). However today national formulary is a medical and pharmaceutical reference book that contains a wide spectrum of information and advice on prescribing and pharmacology, along with specific facts and details about all medicines available on the essential medicines list(eml), including indication(s), contraindications, side effects, doses, legal classification, names and prices of available proprietary and generic formulations, it nevertheless also includes entries for some medicines which are not available under the (EML) and must be prescribed and/or bought. This is lacking and one wonders why the committee is not functional. Additionally it s practically impossible to control pharmaceutical product prices and also be able to trace for the manufacturers of the products on market. This not only gives chance to the counterfeiters to exploit these gaps and infiltrate the market with their products but also exposes the public to substandard products. NDA s guidelines on requirements to engage in pharmaceutical business restricts anyone convicted of an offence in the practice to apply. We have registered several convictions on individuals in the practice of managing pharmaceutical products and health services but because the judgments are not formally written down in time and court instructions not given to the National Drug Authority, it s impossible to effect the law. In many instance the punishment given by the courts and as stipulated in the Act are not deterrent enough, the convicts go ahead and engage in the same practice. Government institutions are supposed to work as a single entity to be able to accomplish set government targets. There seems to be a gap in communication and working relations between Institutions like; the health professional councils, Judiciary, the registrar of companies and NDA who are otherwise supposed to work together to track down the culprits and prevent them from engaging in a similar business again. ANNUAL REPORT

56 The National Drug Policy and Authority Act is outdated and requires amendments. The punishments outlined are not deterrent enough and some modern medical legal crime is not covered at all. NDA has directed much vigor in pursuing economic ends rather than concentrating on the product s safety and efficacy. Today it s not mandatory to do assay and qualitative test of the medicines and so the public is exposed and chances of having counterfeit drugs are high with very low potency and hence heightening the chances of infections becoming resistant to the available products on the market. NDA labs are located internally within the country. When a pharmaceutical product fails the standards tests, it s impossible for the product to be exported back to its origin. In most cases the product is offloaded along the way and circulated to compete with other genuine products on the market. We need to have Laboratories at boarder entry points where samples of every product are picked and tested. Once tests are failed the product has no chance of entry into the country. The policy and practice of recalling pharmaceutical products is not in existence and because no mandatory tests are done except for a few, we are risking and exposing the public to products whose potency and effectiveness we are not sure of. The NDPA mandates the Authority to gazette guidelines and bylaws for better executing of its duties. Today most of the bylaws and guidelines developed have never been gazette and this has led the authority to lose cases and funds. These impacts on the confidence and mandate to execute its duties concerning new medical crime cases. Despite increase in the number of pharmacist in the country the public sector is still failing to attract numbers even at hospital levels. The pharmacist role is still underestimated and doctors have the tendency to assume that they can handle pharmaceutical products on their own. Even within NDA we have identified misunderstandings in the recruitment process where medical doctors are taken on to do the technical work of a pharmacist. Looking at the newly presented salary increments of health workers, the pharmacist were not catered for yet they are the backbone on matters concerning medicines. To date many hospitals have not yet realized the positions of pharmacists in their functional structures; a matter that needs urgent attention to a point where referral hospitals have a minimum of 30 pharmacists to ensure therapeutic excellence. Delay in handling cases due to heavy case backlog. This works in favor of the accused persons as it gives the accused persons an opportunity to temper with investigations and harass witnesses. Even when the Unit registers some mode of success by way of convictions or interdictions the Ministry and District leadership response has been to merely transfer the said culprits to cause chaos in other parts of the country. 54 ANNUAL REPORT 2011

57 Many of the potential witness are required to give testimony against their fellow workers. When they testify, they are usually harassed at the work place or in the communities where they live. There is widespread ignorance and at times abuse of the procurement procedures which has caused financial loss and facilitated embezzlement of government funds by government officials. District health officers and district drug inspectors are not doing enough supervision at the district level to ensure proper service delivery. Understaffing is a critical challenge in the operation of the unit there is need to recruit more technical people such as auditors, lawyers, doctors, IT personnel, Procurement officers, construction engineers. Interference from the local leaders who interfere with the course of investigation and prosecution e.g. in Mukono and Kamuli in particular the stores assistant was found to be claiming per diems irregularly to transport drugs to health centers within the district but when questioned and asked to make a police statement verifying the same the RDC, Ag CAO and Ag DHO then defended him and said he was a relative to highly placed officials! There are many unqualified workers operating illegal training schools in the country and others have unfortunately been absorbed even in the mainstream public sector Lack of sufficient space for storing medical exhibits in all police stations. Issuing of very light sentences to offenders simply encourage offenders to commit offences. Shortage of transport at the unit to do routine monitoring in the field. Poor coordination amongst the existing health regulatory bodies, hence a failure to identify and restrain criminal elements. ANNUAL REPORT

58 Part 9: recommendations matrix The recommendations matrix below is drawn from the Unit s field findings. We hope that this report will serve as a catalyst for meaningful, sustainable change throughout the country s health sector. PROBLEM EXPLANATORY FACTORS PROPOSED SOLUTION RESPONSIBLE PERSON/ BODY TIME FRAME 1. SERVICE DELIVERY Human resources for health. 1. Pseudostaffing 2.Demotivated workforce 3.Poor Cadre mix 4.Ghost health workers 5. Understaffing 6.Large number of workforce on paid study leave with no bonding Poor human resource mgt at district level (Confirmation after probation, Placing on pay-roll, Salary errors) Sectarianism and tribalism Negligence & intentional Abuse of office Lack of vigilance and initiative at DHO s office Pseudo understaffing -Dual/Multiple employment -Focal persons for NGO projects -Long Leave of duty not reflected on inventory Un-coordinated Workshops Low recruitment and retention at district level Poor record keeping/ Inventory National Service Policy Re-centralization of senior health workers Bonding of undergraduate government students studying health related courses Enforce existing bonding arrangements for health workers on leave Recruitment to fill gaps created by workers on study leave Human resource departments should be held accountable for unreasonable delays or failure to address staff issues Improved supervision by MOH; Give MOH mandate to oversee DHOs since they are technical Workshops should be synchronized & evaluated for relevance. 1.MOH and PUBLIC SERVICE should re-visit or ensure that the policy on bonding health workers is followed, this will in just 1 year address the problem of understaffing 2. DHO S and CAO s should personally be held liable for existence of ghosts or unclean registers in their districts to stop the financial hemorrhage this causes the country MOH PUBLIC SERVICE CAOs District Service Commissions DHOs Both Short term & Long term 56 ANNUAL REPORT 2011

59 Poor work ethics manifested in practices like Poor training or lack of qualifications Dual employment Lack of supervision Low pay and motivation Focal responsibility duty and workshops Improved supervision by DHOs & MOH Partial Recentralization Punitive action against culprits caught with poor work ethics Enforce strict observance of working hours Performancebased payment & promotions : Integrated services to be found at health facilities as opposed to focal people All districts and government workers should be familiarized with national laws governing their behavior like the Anti- Corruption Act to act as a deterrent for some of this behavior DHOs In-Charges Health Subdistricts In-Charges health facilities MOH Short term Poor Health facilities Inventory Ghost health Centers & Wrong classification of HCs Weak administration Poor supervision Poor inventory management & annual review Political interference Negligence & Abuse of office Creating a central revised health facility inventory with Key stakeholders(moh, NMS, JMS, MHSDMU, Finance) Creating a proper communication chain on facility information & feedback Review with all primary stakeholders MOH NMS JMS Finance MHSDMU CAOs DHOs ANNUAL REPORT

60 Weak Supervision and Monitoring Poor Work culture and tolerance for mediocrity Non-decisive exercises &/or non-punitive measures taken Poor planning and prioritization Lack of enough resources Mandatory, rigorous and periodic supervision by at all levels with clear performance indicators Feedback should be an integral part of supervision and monitoring (to districts, facilities and health workers) Slippages should be noted and action plans drawn Capacity building for monitoring teams, review tools so that they are thorough and measure whatever they purport to. Avail adequate resources for the monitoring function Where the district heads or supervisors fail to do their work and thus contribute to the poor health care, they should be prosecuted for neglect of duty or in the very least demoted from those posts not merely transferred to other districts MOH DHOs In-Charges of health subdistricts and facilities National and district focal persons 58 ANNUAL REPORT 2011

61 Unlicensed drug shops and clinics NURSES; 1.Illegal nursing and paramedical schools. 2.Multiple Curricula Slow action from NDA on registering or closing down illegal drug shops and clinics Ignorance of the public Desperation following poor or no healthcare at government health facilities Multiple partners with no clear central organ managing Nurses Multiple Curriculum resulting in non-uniform Nursing cadres Courses approved don ttally with public service staffing norm e.g. Comprehensive Nursing Strict observance of NDA Act, to register all drug shops/ clinics Vigilance of drug inspectors esp. in district Sensitize public on dangers of seeking treatment from unlicensed facilities observance of closing and opening times e.g. all HCIIIs should treat severe malaria and provide admissions Come up with clear approved courses Review curriculum & develop central single curriculum Centralize registration, licensing & supervision of training Nurses Training of Nurses should revertback to MOH or at least MOH s mandate in this increased. -NDA should be vigilant and urgently clamp down these fake/ illegal drug shops -DHO s should ensure that their Drug Inspectors are supervising and not merely extorting money from drug shop owners as has sometimes been the case. -Districts that have many illegal drug shops should hold the DHO and DDI personally accountable -Publicizing list of licensed drug shops -Sensitization of the public on danger of unlicensed drug shops MOH, Ministry of Education & Sports, BTVET & other stakeholders should sit together & agree on courses, curriculalicensing of schools, Awarding of Certificates & supervision. NDA District Drug Inspectors MOH BTVET Ministry of Education & Sports, Allied healthprof. council Short term & ANNUAL REPORT

62 Proper auditing (value-for money and paper audits) Train all HC in-charges in accountability & make it part of orientation package Poor Corruption and greed Poor management practices & capacity building Weak auditing at all levels Weak or no supervision Unskilled people in critical positions e.g. In charges required to account with no such skills Poor record keeping Enforce strict accountability procedures Punitive action against people who flout accountability guidelines Public display of funding allocations at district and health facility notice boards Thorough activitybased monitoring for example checking whether supervision is really done in places for which allowances are claimed/ doublecheck claims made for monies e.g. cost prices of items, distances for fuel allocations, etc Involvement of all stakeholders (e.g. parish chiefs, health management committees) at all levels in budget planning & monitoring All districts and health facilities without proper accountability if found should have the heads and accounting officers personally held liable to serve as a deterrent to all other government workers MOFPED CAOs DHOs In-Charges Health Facility Accountants/ Finance -Health workers whose remit involves handling monies Short term Local councils & HMCs should furnished with 60 ANNUAL REPORT 2011

63 Prioritize infrastructure maintenance in budgeting Poor infrastructure and Equipment Inventory Management & Maintenance Unnecessary and/or Un-used equipment at HCs Unskilled personnel Work overload Rigid MOH tools e.g. HMIS inventory management for some items or infrastructure undertaken annually and does not provide for periodic updates of smaller items No integration in planning and funding priorities No coordination of donations resulting in dumping of equipment or purchase of unnecessary equipment for health facility level or staff cadres Regular update of inventory Donate unused equipment or resources to where they are required Stocktaking, cleaning up & organizing stores Mandatory engraving of all government equipment which should also be routine Spot checks on different departments and staff houses for facility equipment Periodic stock taking and record keeping/ acquisition and depreciation registers needed Repair of broken down infrastructure MOH should take the lead on this start by dedicating a bigger budget towards this -MOH should also create a better system & human resource with stringent measures for inventory management. -Motivation practices e.g. have the worst and best performing districts highlighted. -Strict donation procedures MOH DHOs In-Charges HSD In-Charges at health facilities Donors Short term Training of use and maintenance of infrastructure/ equipment ANNUAL REPORT

64 Rigorous and comprehensive supervision/ monitoring Underutilization and/or misuse of facilities and resources Anomalies in health facility grading and supplies allocation Negligence Disregard of policies e.g. Admissions not done by many HC IIIs as required, Closure of HCs on weekends Internal policy e.g. no admissions Weak management and supervision Poor work ethic Enforce proper stewardship and usage of infrastructure, equipment and medicines at health facility level Ensure compliance with national guidelines on service provisions for different health centre levels e.g. all HC IIIs should provide admissions, and health workers take up staff houses where available Remove wrong people (e.g. police officers, relatives ) and animals (cows, goats, poultry, etc) from health facility houses) Supplies to health facilities should be according to need for example more for lower level facilities serving larger catchment areas Responsible officials for inventory management need to be brought to book MOH DHOs In-Charges HSD In-Charges at health facilities Donors 62 ANNUAL REPORT 2011

65 Streamline contracts awarding procedure, make it more transparent. Poor Construction, unreliable contractors, Poor supervision of construction work Corruption, abuse of office & Low transparency on contract awarding Poor quality assurance Weak supervision by district, local councils and health facility staff esp. for centrally awarded contracts Unqualified contractors/ No performancerelated contract awarding Inaccurate BOQs Supervision of planning and implementation by qualified district personnel e.g. thoroughly prequalify BOQs, costing etc& monitor on-going work progress Local councils & HMCs should furnished with project information e.g. constructions & empowered to monitor work progress Enforce no payment until proper work is done Strict timelines for construction start and end Contractors should be pay for any losses, shoddy work or delays -There is need to deregister all construction companies or firms that have breached their contracts with government to construct health facilities. -In addition they should be compelled to refund all the monies they received. This will discourage the doing of shoddy work and breaching contracts with impunity. -There is need to educate government workers & sensitize the public about the procurement laws and enforce punishment against officers who breach it. MOFPED MOH PPDA CAOs District Engineers CFOs DHOs Contractors with poor performance records should not be awarded contracts ANNUAL REPORT

66 Medico-legal issues [Very many cases from the public of a medico-legal nature e.g. Negligence by Medics but almost no cases won in court] No policy framework Medico-legal issues not prioritized Low public awareness Fragmented and weak service delivery Greed & Corruption i.e. Monetary gains take priority over patients welfare & life Streamline medicolegal services as an integral part of the legal and policy framework Train investigators & prosecutors in handling medicolegal cases Raise the profile of medico-legal issues by sensitization & prioritization Commensurate punishment that reflects severity of crimes Give urgency to some medico-legal cases e.g. rape, Criminal Negligence etc in court Legislate and provide for very deterrent punishments for offenders who commit offences in health & medico-legal related field. Chief Justice Judiciary Directorate of Public Prosecutions Policy makers National Planning Authority Health workers Short term & Long term 64 ANNUAL REPORT 2011

67 PNFPs Non eligible facilities with PNFP status Poor Security e.g. Recurrent theft in Mulago NRH Flaunting the accreditation criteria Sectarianism, nepotism, Corruption and bribery Lack of awareness on eligibility criteria by public & officials Lack of awareness on provisions within the PNFP arrangements - No CCTV - Poor security system - Corruption &Negligence of duty by guards Compliance to PNFP eligibility criteria Disciplinary measure for officials involved in sectarianism or corruption Regulate PNFP charges on patients Enforce accountability and reports from PNFP facilities Initiate policy on embossment of all medicines supplied to JMS for PNFPs Put CCTVs in all Major hospitals Supervision of guards Strict employment criteria of guards with performance contacts instead of Permanent for quick disciplinary action -Urgently review current list of PNFPs -Investigate noneligible facilities in previous list -Regular rigorous Performance reviews should be undertaken for all PNFPs on the list by government -Embossment of medicines Planning department MOH should take lead in developing a policy and budget for this starting with Mulago Policy makers MOH Local government DHOs JMS Mulago MOH Hospitals Short term and Intermediate ANNUAL REPORT

68 Address implementation gaps Review weak policies Policy and Legal Framework (NDA Act, Anti- Corruption Act and other laws) Weak enforcement of existing policy & nondeterrent judgments Unclear guidelines in some frameworks e.g. donations, Classification of some medicines, Licensing, traditional practitioners and advertising. Clear policy and/ or guidelines for all issues Punitive action for culprits There is need to establish special court to try offenders in some exceptional cases that involve huge sums of funds or medicines. There is need for government to recruit and provide specialized training for prosecutors, judicial officer in handling medicallegal issues. Need to expand and provide space for storing medical related exhibits at police stations. This should be coupled with training the police stores personnel in handling the exhibits. -The law should be amended to make provision for very deterrent sentences for all criminal offenders in health related issues. -There is need to empower the monitoring unit by legislating on the power of the monitors to give express penalties in some cases as in traffic offences. -MP S should play a more active role in supervising and monitoring the health facilities in their jurisdiction. All Policy makers MPs The Law Reform Commission Judiciary Intermediate & Long term No Land Titles for government facilities thus takeovers & scrambles Many Government Health facilities built on land which was not surveyed & thus have no tittles, some of these were donated by the community years ago & in the recent scramble for land, this is being contested. Survey all health facilities land Process land titles. Planning department MOH should work together with Lands Registry to develop guidelines for this & speed up the current process MOH Ministry of Lands Ministry of Finance & Planning Long term 2. DRUGS UTILIZATION AND 66 ANNUAL REPORT 2011

69 Stock-outs of medicines at health facilities Theft of medical supplies Lack of Record & accountability Inadequate funding for national budget for medicines Last Mile delivery challenges e.g. some contactors failing Lengthy procurement procedures affecting emergency supplies PUSH system challenges e.g. delivery of unnecessary supplies & Less quantities of those needed Poor medicines management and accountability at health centers Theft/ pilferage/ diversion of medicines Poor ordering Lack of qualified & skilled staff in Increased funding Prompt NMS deliveries Review regularly essential medicines in health registry Streamline procurement procedures Prompt deliveries from districts to lower levels Health centers should feedback upwards to improve push system; which should be reflected in procurement and distribution Proper medicines management and accountability Ensure strict accountability including consistent and proper use of medicine documentations like stock cards, delivery notes, issue and requisition vouchers Sensitize the public on identification of government medicines & delivery schedules Proper supervision by local leaders & -National budget increment -Districts send in timely orders to NMS & NMS in turn makes timely scheduled deliveries. -Contracted companies, DHO and CAOs be held accountable for unexplained delays -Health centers In-charges to be held personally liable for thefts or lack of drug accountability. -All CAO s and DHO s should access copy of Anti-corruption Act and avail to workers to make them aware of criminal liability for their actions Long & Short term *MOH can take ANNUAL REPORT

70 Regular review of HCIII & II Kit by MOH & NMS Expired Medicines Push system sending un-required medicines in some places Poor inventory management Unskilled staff handling store No policy in handling expired drugs Long procedure for destruction of expired medicines Streamline planning and procurement for medicines, based on demand and demographics Proper drugs stores mgt at all levels Recruit pharmacists and dispensers to facilities as appropriate Urgent controlled expired medicine collection and destruction and punitive action against negligence. Develop a system of Coordination and redistribution of unwanted medicines which addresses the financial loss to Unit giving away the drugs -NMS and MOH need to have an agreed formula of medicines distribution based on disease prevalence in each district and/ or region not a general list of drugs across the board -MOH-DHO s need to have a clear guideline with all centers regarding exchange or borrowing of drugs across HC s to balance out the accounts of the receiving and donating HC. NMS MOH DHOs In-Charges Midterm Donors policy to be developed to prevent donation of medicines close to expiry or not aligned to local health needs 68 ANNUAL REPORT 2011

71 Lack of Space for storage Poor storage Poor store management practices including storing medicines with other incompatible items Bad hygiene and sanitary conditions in facilities Bats, pest and vermin in stores No temperature control system Capacity building in medicines store mgt Develop Standard operating procedures for stores mgt& circulate them Pest and vector control Train & Recruit store managers Thorough supervision from district at health facility stores -DHO s should ensure that all In-charges are taught on medicines handling. -DHO and CAO for should plan for proper stores in all facilities DHOs + district store personnel In-charges + health facility stores personnel and other staff Short term Bats, Vectors, Vermin infestation of HCs countrywide This has resulted into poor sanitation, decay of facilities etc Unqualified staff Negligence Lack of funding dedicated to this function Lack of central policy to address this Weak supervision Dedicate a budget to address this problem Supervision by MOH vector department to be stepped up Vector officers in districts should be diligent in their work All Vector control officers in the districts need to be made accountable for failure to supervise and advice the HC s on vector control. Failure to so, this would then shift the DHOs & CAOs MOH DHO CAOs MHSDMU Short term & ANNUAL REPORT

72 Appendices APPENDIx 1: vandalization of moh cars. The following vehicles were reported by the transport officer to be in these garages as per MOH inventory but were not found on physical check exercise: LOCATION (AS PER MoH NO INVENTORY) 1 Kyeyune Motors Ltd VEHICLE NO MAKE STATUS UG 2254 M Toyota Prado Previously removed & Packed at MoH backyard UG 0685 M Toyota Land Cruiser Previously removed & Packed at MoH backyard 2 New Kabuusu Auto Services. UG 1605 M Mitsubishi L200 D/pickup Previously removed & Packed at MoH backyard UG 3425 M Jeep Cherokee Missing UG 1681 M Land Rover Missing 3 Stamina Motor Garage Ltd UG 1050 M Toyota Land Cruiser Hard Top Missing UG 2209 M Isuzu KB D/Pickup Missing 4 Central Auto Centre Garage UG 1883 M Nissan Hard Body Missing UG 1147 M Mitsubishi L200 pick up Missing UG 0325 M Nissan Caravan Missing 5 Global Auto Engineers UG 1544 M Toyota Prado Missing UG 2348 M Nissan Hard Body Missing UG 1391M Toyota Hiace Missing UG 3528 M Toyota Land Cruiser Missing 6 Wamco Motors (U) Ltd. UG 2073 M Mitsubishi L200 Missing UG 1859 M Toyota Land Cruiser Missing The following vehicles whose whereabouts were not known were later brought and grounded during investigations. Vehicles returned after start of MHSDMU Investigations 70 ANNUAL REPORT 2011

73 NO VEHICLE NO MAKE STATUS 1. UG 1547 M PICK UP TOYOTA HILUX RETURNED &GROUNDED 2. UG 0418 M ST WAGON MITSUBISHI PAJERO RETURNED & GROUNDED 3. UG 1617 M ST WAGON TOYOTA L CRUISER RETURNED & GROUNDED 4. UG 1680 M PICK UP TOYOTA HILUX RETURNED & GROUNDED 5. UG 2117 M PICK UP NISSAN HARD BODY RETURNED & GROUNDED 6. UG 1056 M PICK UP FORD RANGER RETURNED &GROUNDED 7. UG 1605 M PICK UP MITSUBISH RETURNED & GROUNDED 8. UG 2132 M ST WAGON LAND ROVER RETURNED & GROUNDED 9. UG 1101 M ESTATE TOYOTA COROLLA RETURNED & GROUNDED 10. UG 2370 M STATE WAGON TOYOTA L CRUISER RETURNED & GROUNDED 11. UG 0109 M PICK UP MITSUBISH RETURNED & GROUNDED 12. UG 0685 M ST WAGON TOYOTA L CRUISER RETURNED &GROUNDED 13. UG 2254 M ST WAGON TOYOTA L CRUISER RETURNED & GROUNDED 14. UG 2149 M ST WAGON TOYOTA L CRUISER RETURNED & GROUNDED 15. UG 2364 M ST WAGON TOYOTA L CRUISER RETURNED & GROUNDED 16. UG 0667 M ST WAGON TOYOTA L CRUISER RETURNED & GROUNDED 17. UG 0292 M PICK UP TOYOTA HILUX RETURNED &GROUNDED 18. UG 1727 M ST WAGON LAND ROVER RETURNED & GROUNDED Cars that were found grounded at MoH park yard NO VEHICLE NO MAKE STATUS 1. UG 0678 M ST WAGON SUZUKI SUMURAI GROUNDED AT MoH OFFICE 2. UG 0383 M SALOON TOYOTA COROLLA RETURNED & GROUNDED 3. UG 0672 M ST WAGON SUZUKI SUMURAI GROUNDED AT MoH OFFICE Cars parked at MoH pending boarding off exercise No. Reg No. Details No. Reg. No. Details 1. UG 0678M St. Wagon Suzuki Samurai 11. UG 1101M Estate Toyota Corolla 2. UG 0383M Saloon Toyota Corolla 12. UG 2370M St. Wagon Toyota L/Cruiser 3. UG 0672M St. Wagon Suzuki Samurai 13. UG 0109M Pick-up Mitbushi 4. UG 1547M Pick-up Toyota Hilux 14. UG 0688M St. Wagon Toyota 5. UG 0418M St. Wagon MitbushiPjero 15. UG 2254M St. Wagon Toyota L/Cruiser 6. UG 1617M St. Wagon Toyota L/Cruiser 16. UG 2149M St. Wagon Toyota L/Cruiser 7. UG 1680M Pick-up Toyota Hilux 17. UG 2364M St. Wagon Toyota L/A 8. UG 2117M Pick up Nissan Body 18. UG 0292M Pick-up Toyota Hilux 9. UG 1056M Pick-up Ford Range 19. UG 1727M St. Wagon Landrover 10. UG 2132M St. Wagon Land Rover 20. UG 0667M St Wagon L/C ANNUAL REPORT

74 List of casual drivers not employed by MoH but driving ministry vehicles Names Vehicle number 1. Kwihangana Edison UG 2125 M 2. MuswujaKiwanuka UG 1731 M 3. Kawesa Mark UG 2368 M 4. Martin Okello UG 1705 M 5. Masiko UG 1958 M 6. Sunday UG 3526 M 7. RuhigwaRobence UG 2362 M 8. Serubiri UG 2164 M 9. Rone UG 1660 M 10. Muhangi UG 2325 M 11. Bob UG 3754 M 12. UG 2361 M 13. UG 2299 M The following vehicles, found in various garages, had not followed the right procedure: (i)good way Auto Garage; (Mulago Church Road). UG 1840 M-Nissan Hard Body D/pickup UG 2358 M Pick up Mitisubishi Rodeo UG 3425 M (on the windows)/uaa 526 X(on the body)-jeep Cherokee UAA 642 N UG 2136 M Pick up Mitsubishi L200 UG 0050 C Pick up Mitsubishi UG 1544 M-Toyota Prado UAA 594 N (ii) Delo Garage &Stamina Garage. (Plot 1 Bombo Rd, Sir Apollo Kagwa Rd). UG 1628 M ST. Wagon MitisubishuPajero UG 1702 M ST. Wagon L/Crusier. (iii) New Kabuusu Auto Mobile. (Kabuusu Road) UG 0668 M Ambulance Land Rover defender 110 (iv) Global Auto Engineer Ltd.8 th Street plot 31 4 th close UG 1608 M ST.Wagon. L/Cruiser 72 ANNUAL REPORT 2011

75 APPENDIX 2; CONCLUDED COURT CASES BY THE UNIT NO CASE FILE NO SUSPECT(S) OFFENCE(S) DISTRICT FINE/AMOUNT RECOVERED 1 CRB 877/11 NdyesigaProssy Operating a drug shop without a licence 2 CRB 106/10 Grace AnemoKok Abuse of office& Unlawful possession of government stores Convicted and fined UGX 200,000 Convicted and fined UGX 1,000,000 3 CRB 348/09 Major Stephen(alias) Theft (stole a microscope) Convicted to 3year jail term 4 CRB 1409/10 Kyomugezi Monica 5 CRB 1410/10 Ndungwa Armstrong 6 CRB 1420/10 Idro Basil& Another 7 CRB 856/10 Nafula Beatrice& 5Others 8 CRB 855/10 Anyango Beatrice& Another 9 CRB 1832 BakaliTenywa& Another Illegal possession of classified drugs& smuggling of drugs Being in possession of stolen property from outside the country (c/s 317 PCA) Illegal possession of classified drugs& Unlawful possession of government stores (c/s 316 PCA) Being in possession of stolen property from outside the country (c/s 317 PCA)& Unlawful possession of government stores (c/s 316 PCA) Unlawful possession of classified drugs& possession of drugs stolen outside the country Being in possession of stolen property from outside the country (c/s 317 PCA) 10 CRB 1835/10 Birungi Josephine Illegal possession of classified drugs&unlawful possession of government stores (c/s 316 PCA) 11 CRB 1834/10 MudoolaKarim& Another Operating a clinic without a certificate of suitability of premises& Unlawful possession of government stores (c/s 316 PCA) BUSIA Fined UGX 2,000,000 BUSIA Fined UGX 1,000,000 BUSIA Fined UGX 1,000,000 on each count, thus total amount is UGX 4,000,000 BUSIA Fined UGX 1,000,000 BUSIA IGANGA Cautioned with warning not to commit the same within 2year period or else face a 2year prison term Fined UGX 2,000,000 each, thus total amount is UGX 4,000,000. IGANGA Fined UGX 150,000 IGANGA Fined UGX 300,000 each, thus total amount is 600,000 ANNUAL REPORT

76 12 CRB 1009/09 Dr. Isanga Joseph Abuse of office,embezzlement and Causing Financial loss(anti-corruption Act) KABONG Sentenced to 5years on all counts to run concurently 13 E/400/2009 DrBalekeKamba embezzlement KAMPALA Fined UGX 38,000, GEF 02/10 Grace Otekat Abuse of office& Neglect KAMPALA acquitted of duty 15 CRB 195/2010 Tushabe Milton Abuse of office&theft of KASESE Fined UGX 200,000 HIV test kits 16 CRB 16/2010 Masereka Michael Unlawful possession of KASESE Fined UGX 300,000 government stores (c/s 316 PCA) 17 CRB 29/2011 BalukuDidas extortion KASESE Fined UGX 100,000 or 6months jail term in default 18 CRB 1401/09 Tumwine Fred and 5Others. Unlawful possession of government stores (c/s KIRUHURA Fined UGX 800,000 each, thus total amount UGX 4,800, PCA) 19 CRB 2505/10 Akello Mary Grace Operating a pharmacy without a certificate of suitability of premises& Unlawful possession of government stores (c/s 316 PCA) LIRA Fined UGX 500, MasikaSalima Unlawful possession of government stores 21 CRB 526/09 Wanzar Base Unlawful possession of government stores(c/s 316 PCA) 22 GEF 424/10 Nambalirwa Unlawful possession of government stores 23 CRB 78/2011 KengaziKellen Unlawful possession of government stores 24 CRB 001/2010 Nabagala Betty & Another LYAN- TONDE MANAFWA MASAKA MUKONO Convicted to 2year jail term Fined UGX 200,000 or 1year jail term in default acquitted Convicted and fined UGX 200,000 or three months imprisonment Extortion MULAGO Fined UGX 4,000,000 each, thus total amount is UGX 8,000, CRB 81/10 KaweesaEnock Personating a public MULAGO Convicted to 3year jail term officer 26 CRB 049/10 TibifumiraGoretti Abuse of office MULAGO Discharged and recommended for displinary action 27 CRB 233/10 NantaleMpungu Mariam Illegal possession of classified drugs& operating a clinic without a certificate of suitability of premises. NSANGI Fined UGX 300, CRB 210/10 Ssengero Ali personation RAKAI Convicted to community service 74 ANNUAL REPORT 2011

77 29 CRB 984/10 Nassiwa Christine Unlawful possession of government stores 30 CRB 424/10 Kawanguzi Emma& 2 Others 31 E/075/2010 DrNdyomugenyi& 2 Others 32 CRB 1419/2010 Jane Masaki Unlawful possession of government stores (c/s 316 PCA) Corruption & Neglect of duty Unlawful possession of government stores (c/s 316 PCA) RAKAI WANDE- GAYA MINISTY OF HEALTH HEADQUA- TERS BUSIA Convicted to community service Fined UGX 100,000 each, thus total amount is UGX 300,000 Acquited Convicted and fined UGX 3,000, GEF 1213 DrMubiru Embezzlement KCC Refunded UGX 8,460, NabakozaSpecioza Unlawful possession of classified drugs&operating business of a Pharmacy without a license MUBENDE Convicted and fined UGX 100,000 or in default. TOTAL AMOUNT RECOVERED IN COURT FINES. UGX 79,210,000 ANNUAL REPORT

78 APPENDIX 3: PHOTO GALLERY COMMUNITY EDUCATION AND MOBILISATION HEALTH WORKERS CONCERNS A sample list of health workers concerns from Itijo Hospital. 76 ANNUAL REPORT 2011

79 ANNUAL REPORT

80 A sample analysis of health worker concerns from Lira, Wakiso, Alebtong and Kisoro districts. 78 ANNUAL REPORT 2011

81 HEALTH SERVICES MANAGEMENT; EQUIPMENT AND INFRASTRCTURE MANAGE- MENT. Abandoned generator of BudadiriHciv The above is the compound of a Health center in Wakiso which the workers have turned into a washing bay. ANNUAL REPORT

82 A unisex two holed one roomed latrine constructed in Rwamabondo HC II in Ntungamo!!! Equipment bought by Mulago hospital (at $ 480,000) in 2000 to analyse data. The said machine has never worked and on investigations from the internet it was found to cost just over $ ANNUAL REPORT 2011

83 Theatre equipmentsabandoned inalebtong HC IV. An abandoned dental surgical bed in Alebtong HCIV. ANNUAL REPORT

84 The shoddy work of theatre in Atiak HC IV that was turned into a dormitory/hostel for students in a nearby illegal nursing school. One of the patients Beds in Adwir HCII The leaking roof combined with the bats wastes are causing the ceiling in Abia HCIII to fall in.

85 DRUGS UTILIZATION AND STORAGE The above images are the DHO s stores in Wakiso and Lira Districts. This were the living quatres of a Nursing Assistant in Buikwe where stolen drugs worth about UGX 600,000 were recovered. ANNUAL REPORT

86 The wards where patients sleep in Oteno HCII. A case of shoddy construction works; Awei HCII after the wind blew off the roof. 84 ANNUAL REPORT 2011

87 NURSES TRAINING SCHOOLS and ILLEGAL CLINICS/DRUG SHOPS An example of good practice was at DAF College of Professional Health in Lira. Nursing students classroom demonstration treatment room The admission area of an illegal clinic in Lira ANNUAL REPORT

88 Introduction letter written in December 2010 for Nursing Assistant student The laboratory of the illegal Lira Health Care clinic in Lira District. 86 ANNUAL REPORT 2011

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90 Certificates awarded for registration and operation of clinics that are believed to have been forged. 88 ANNUAL REPORT 2011

91 ANNUAL REPORT

92 HEALTH SERVICES MANAGEMENT One of the abandoned health facilities in Amuru. abandoned staff houses in Akali HC III due to witchcraft in the area 90 ANNUAL REPORT 2011

93 FINANCES UTILIZATION AND ACCOUNTABILITY Unpresentedcheques that were found kept in the drawers of the Accounts Assistant Wakiso for 1year while health centers went without basic items ANNUAL REPORT