Annual Health Sector Performance Report

Transcription

1 THE REPUBLIC OF UGANDA Annual Health Sector Performance Report Financial Year 2006/2007 October 2007

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3 Foreword The health sector in FY 2006/07 implemented the 2 nd Year of the Health Sector Strategic Plan II (HSSP II). The focus has been on scaling up interventions and consolidating reforms initiated during the HSSP I and in the 1 st Year of the HSSP II in order to achieve the Poverty Eradication Action Plan (PEAP) objectives and Millennium Development Goals (MDGs). The Uganda Demographic and Health Survey 2006 shows that there have been improvements in Infant Mortality Rate, Under5 Mortality Rate and Total Fertility Rate. The data is not conclusive on Maternal Mortality Ratio. These improvements in health outcomes indicate that it is indeed possible to make a difference in the life of Ugandans. The improvements in health outcomes were contributed to by different sectors; however the contribution of the health sector in terms of stewardship and advocacy, and improved coverage with good quality services for preventive, promotive and curative has been key. The AHSPR 2006/07 documents sector performance against agreed HSSP II indicators and Year II targets. The AHSPR 2006/07 indicates fairly good performance as shown by the performance against the 8 PEAP and HSSP II indicators. The sector performance for FY 2006/07 was on or above target for 3 indicators namely: Couple Years of Protection (CYP) a measure of family planning uptake; Proportion of children below 1 year that have received pentavalent vaccine 3 rd dose; and New OPD attendance per capita. Sector performance was below target for 3 indicators namely: Proportion of deliveries taking place in government and PNFP health facilities; Proportion of health facilities with tracer medicines all the time (i.e. without stock outs of tracer medicines); and Sanitation measured by household latrine coverage. It was not possible to determine sector performance against 2 indicators namely: Proportion of approved posts filled by trained health workers; and HIV Sero-prevalence. The sector s performance over FY 2006/07 had many challenges including: low and stagnant levels of funding from the government budget; and increasing but rather unpredictable and earmarked funds from Donor Projects and Global Health Initiatives. Given this scenario it is important that we continue improving our coordination mechanisms within the sector to ensure increased efficiency and maximum benefit from all resources available to the sector. All stakeholders in the sector including central and local government leaders (politicians, administrators and technical staff), development partners, civil society representatives, and private providers of health services, need to contribute to improved sector performance. The National Health Assembly and Joint Review Mission present an opportunity for sharing of ideas among stakeholders. At the end of December 2007 we will have been through two and a half (2 1 / 2) years of the HSSP II. As stakeholders in the sector it is important that we review our Mid- Term performance and see whether we are in line with the HSSP II and MDGs. If the current strategies are unlikely to take us where we would like to go, we should be frank and say so, and come up with more relevant and appropriate strategies. Dr. Stephen Malinga, MP MINISTER OF HEALTH iii

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6 Pictures from NHA, JRM 2007 and TRM

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8 Table of Contents Foreword Acronyms Illustrations Executive Summary Chapter 1 Introduction Chapter 2 Overview of Health Sector Performance FY 2005/06 Chapter 3 Package Delivery of the Uganda National Minimum Health Care Chapter 4 Integrated Health Sector Support Systems Chapter 5 Implementation of Health Sector Strategic Plan II Annexes Annex 2.1: Annex 3.1: Annex 4.1: Annex 5.1: 8

9 Acronyms ABC AFP AHSPR AIM ANC ARV BCC BEmOC CB-DOTS CDC CDD CEmOC CME CYP DDHS DOTS DPs ENT EPI ESD FP GFATM GoU GTZ HC HDP HMIS HPAC HRD HSSP HUMC IDSR IEC IMCI IPT IRS IST ITN JRM KABP KDS KPI LLIN LSS LTPM MAAIF MCP Abstinence, Be faithful, Condom use Acute Flaccid Paralysis Annual Health Sector Performance Report AIDS Integrated Management Ante Natal Care Antiretroviral Behaviour Change Communication Basic Emergency Obstetric Care Community based Directly Observed Treatment Centre for Disease Control Community based Drug Distributors Comprehensive Emergency Obstetric Care Continuing Medical Education Couple Years of Protection District Director of Health Services Directly Observed Treatment Development Partners Ear, Nose and Throat Expanded Programme for Immunisation Epidemiology and Surveillance Division Family Planning Global Fund for AIDS, TB and Malaria Government of Uganda German Technical Cooperation Health Centre Health Development Partners Health Management Information System Health Policy Advisory Committee Human Resource Division Health Sector Strategic Plan Health Unit Management Committee Integrated Disease Surveillance and Response Information, Education and Communication Integrated Management of Childhood Illnesses Intermittent Presumptive Treatment Indoor Residual Spraying In-service Training Strategy Insecticide Treated Nets Joint Review Mission Knowledge, Attitude, Behaviour change, Practice Kampala Declaration on Sanitation Kampala Pharmaceutical Industries Long Lasting Insecticide Nets Life Saving Skills Long Term Permanent Methods Ministry of Agriculture, Animal Industries and Fisheries Malaria Control Programme 9

10 MDGs MIP MNT MoES MoH MoU MRC MTR NCD NCRL NGO NHA NHP NIDs NMS NVS OPD OPV PC PEAP PEPFAR PET PHC PHC-CG PHP PMTCT PNFP PPPH PSI QA RIDs SHI SHSSP SOP SRH SWAp TASO TBL TCMP TOT TT UBTS UDHS UNBS UNHCO UNHRO UNMHCP UPHOLD UVRI VACS Millennium Development Goals Malaria in Pregnancy Maternal and Neonatal Tetanus Ministry of Education and Sports Ministry of Health Memorandum of Understanding Medical Research Council Mid-Term Review Non Communicable Diseases Natural Chemotherapeutics Research Laboratory Non Government Organisation National Health Assembly National Health Policy National Immunisation Days National Medical Stores National Voucher Scheme Outpatient Department Oral Polio Virus Palliative Care Poverty Eradication Action Plan President s (Bush) Emergency Plan for AIDS Relief Post Exposure Treatment Primary Health Care Primary Health Care Conditional Grant Private Health Practitioners Prevention of Mother to Child Transmission Private Not-For Profit Public Private Partnership for Health Population Services I Quality Assurance Rabies Immunisation Days Social Health Insurance Support to the Health Sector Strategic Plan Standard Operating Procedures Sexual and Reproductive Health and Rights Sector Wide Approach The AIDS Support Organisation TB and Leprosy Traditional and Complementary Medicine Practitioners Training of Trainers Tetanus Toxoid Uganda Blood Transfusion Services Uganda Demographic and Health Survey Uganda National Bureau of Standards Uganda National Health Consumers Organisation Uganda National Health Research Organisation Uganda National Minimum Health Care Package Uganda Programme for Human and Holistic Development Uganda Virus Research Institute Vitamin A Capsule Supplementation 10

11 VCT VPH WHO WP Voluntary Counselling and Testing Veterinary Public Health World Health Organization Wettable Powder Formulation 11

12 Illustrations Figures 12

13 Tables 13

14 Boxes 14

15 Executive Summary: 15

16 Chapter 1 Introduction Background The framework for achieving sector goals & objectives The Annual Health Sector Performance Report FY 2006/ Sources of Information Outline of the Report Figure 1.1: Framework for the Sector Programme in the HSSP II

17 Chapter 1 Introduction 1.1 Background The FY 2006/07 was the second year of implementation of the Health Sector Strategic Plan II (HSSP II 2005/06 to 2009/10). As per the Memorandum of Understanding (MoU) for the implementation of the HSSP II through the Sector Wide Approach (SWAp), the preparation and discussion of an Annual Health Sector Performance Report (AHSPR) is a key milestone. 1.2 The framework for achieving sector goals & objectives In the HSSP II the framework for the sector programme has been adjusted to reflect the central nature of the delivery of the Uganda National Minimum Health Care Package (UNMHCP) and the important and supportive role the programme objectives have. Similarly the organisation of sector plans and reports like the AHSPR reflect this restructuring, with the focus in the document on the performance against the UNMHCP and the supporting Health System (Figure 1.1). 1.3 The Annual Health Sector Performance Report FY 2006/07 The AHSPR 2006/07 objectives are: o To review the performance of the sector for the FY 2006/07 identifying achievements and constraints; o To assess progress towards HSSP II targets in particular review against HSSP II Year II targets. The HSSP II includes a set of indicators and targets against which sector performance is reviewed. The indicators were chosen through a thorough consultative process to reflect: o Sector policy priorities, based on international and national commitments like the Millennium Development Goals (MDGs) and Poverty Eradication Action Plan (PEAP), and major sectoral issues; o available and projected sector resources (financial, human, infrastructural and logistical); o the different levels of responsibility national, sectoral, programme and local government. The PEAP Uganda s comprehensive national development framework is linked to a monitoring and evaluation framework the PEAP Matrix which includes health and health-related indicators. These include some of the indicators in the HSSP II indicators that were considered the most appropriate to monitor sector progress at the national level, and in addition includes health and health-related outcome indicators. The performance against the health outcome indicators is contributed to by more than one sector, with the health sector having a key role in stewardship and advocacy. The AHSPR 2006/07 provides information on 17

18 some of the health outcome indicators as reported by the Uganda Demographic and Health Survey The process of compiling this report has greatly benefited from the experience of preparing Annual Health Sector Performance Reports (AHSPRs) over the HSSP I and Year I of HSSP II implementation. Within this framework, efforts have been made to: 18

19 Figure 1.1: Framework for the Sector Programme in the HSSP II Development Goal Expanded Economic Growth Increased Social Development Poverty Eradication Programme Goal Reduced Morbidity and Mortality from the major causes of ill health and premature death and reduced disparity therein Health Service Strategy Effective delivery of an integrated Uganda National Minimum Health Care Package Programme Objective 1 Programme Objective 2 Programme Objective 3 Programme Objective 4 A Health Care Delivery System that is effective, equitable and responsive To strengthen the Integrated support systems To reform and enforce the Legal and Regulatory Framework An Evidence-based Policy, Programme, Planning and Development in place Components Components Components Components 1. Central level organization and management 2. Decentralized heath care delivery system 3. Public/Private Partnerships in Health 4. Intersectoral action for health 1. Human Resources for Health 2. Health Financing 3. Health Infrastructure 4. Essential Medicines and health supplies 5. Diagnostic and Blood transfusion services 1. Health Acts 2. Professional Councils and Associations 3. Private Sector Regulation 4. Traditional and Complementary Medicine Practitioners Regulation 1. Health Policy and Planning 2. Health Management Information System 3. Integrated Disease Surveillance 4. Quality Assurance 5. Support and Supervision 5. Effective Community Participation 6. Research and Development 19

20 Assess sector performance against the HSSP II 25 indicators; o Present highlights of performance against the UNMHCP with the application of national, central and district level indicators; o Present highlights on the Integrated Health Sector Support Systems for the provision of the UNMHCP with the application of national, central and district level indicators; o Maintain the focus on performance at the district level and making comparisons among the districts by use of a League Table o Highlight the individual and collective contribution of the National and Regional Referral and General Hospitals as well as the PNFP hospitals at similar levels; o Provide a Health Sector Financial Report for the period under review, including a donor expenditure analysis; and o Review the progress made towards the 4 th National Health Assembly Resolutions and 12 th Joint Review Mission Undertakings. 1.4 Sources of Information As with the previous reports, the compilation of this report relied heavily on the traditional sources of information enshrined in the Monitoring and Evaluation Framework of the HSSP and in particular the Health Management Information System (HMIS). Other sources of information include: Reports of Undertakings sanctioned by the November 2006 GoU/DP Joint Review Mission and the 4 th National Health Assembly Resolutions. Surveys and studies undertaken by various stakeholder institutions like the Uganda Demographic Health Survey; and specific studies carried out for purposes of the AHSPR 2006/07 which include: analysis of Functionality of HC IVs; and assessment of sector response to the challenges in Northern Uganda; Specific information requested from districts in areas of inputs management human resources; financing; medicines; MoH programmes and other central level institutions reports were mainly obtained from quarterly and annual reports; Supervision Reports including Area Team, and Yellow Star Reports. 20

21 1.5 Outline of the Report The Report is divided into five chapters. Chapter 1 is an Introduction and Chapter 2 covers an Overview of the Sector Performance for FY 2006/07 and includes the overall performance of the sector against HSSP indicators; comparison of district performance using the District League Table; comparison of hospital performance using the Hospital League table; and a summary of the financial report. Chapter 3 is a detailed presentation of the delivery of the Uganda National Minimum Health Care Package and Chapter 4 outlines the performance of the Integrated Health Sector Support Systems. Chapter 5 details the Monitoring of the Implementation of the HSSP II focusing on three areas of particular interest namely: HC IV functionality; status of health services in Northern Uganda; monitoring of SWAp implementation, and a review of the Supervision, Monitoring and Mentoring framework. 21

22 Chapter 2 Overview of Health Sector Performance FY 2006/ Performance Against PEAP Health-related Outcome Indicators Performance Against HSSP II Indicators Summary Financial Report FY 2006/ Comparing Local Government Performance Factors Influencing Local Government Performance Hospital Performance Assessment Comments on Statistics for the AHSPR for FY 2006/ Figures Figure 2.1: Variation of New OPD Attendance by District FY 2006/07 29 Figure 2.2: Variation of Pentavalent Vaccine Coverage by district FY 2006/07... Figure 2.3: Variation in proportion of expectant mothers delivering in health units FY 2006/ Figure 2.4: Variation in Medicines spending by districts at NMS & JMS against the Indicative Budgets for the FY 2006/ Figure 2.5: Variation of Household Latrine coverage by district in FY 2006/ Figure 2.6: League Table Top and Bottom Performers for the FY 2006/07 42 Tables Table 2.1: UDHS Health-related Outcomes 1995, 2001 and Table 2.2: Performance against 8 PEAP indicators for the FY 2006/07 27 Table 2.3: Total Number of Deliveries in Government and PNFP Units 32 Table 2.4: Public Expenditure on Health FY 2005/06, 2006/ Table 2.5: District League Table Trends FY 2005/06 and 2006/

23 Chapter 2 Overview of Health Sector Performance FY 2006/ Performance Against PEAP Health-related Outcome Indicators The health sector, together with other sectors and institutions both public and private, contribute to the national performance against health-related outcomes. The PEAP matrix includes the following healthrelated outcome indicators: o infant mortality rate; o under-5 mortality rate; o maternal mortality rate; o total fertility rate; and o chronic malnutrition as measured by stunting. Data on health-related outcomes is only available from large surveys like the Uganda Demographic and Health Surveys (UDHS) or the census. The UDHS has provided current information on these indicators for this report. This information is presented in comparison to UDHS results of 1995 and 2001 in Table 2.1 and in the context of the PEAP Matrix in Annex 2.1. Table 2.1: UDHS Health-related Outcomes 1995, 2001 and 2006 Indicator Infant Mortality Rate (/1000 live births) Under 5 Mortality Rate (/1000 live births) Maternal Mortality Ratio (/100,000 live births) Total Fertility Rate Contraceptive Rate % Stunting (low height for age)% 3 38 The UDHS 2006 reported improvement in health outcome indicators compared to the previous surveys of 1995 and 2001 as shown in Table 2.1, for Infant Mortality Rate (IMR), Under-five Mortality Rate (UMR), Total Fertility Rate (TFR), and Contraceptive Prevalence Rate (CPR). The figure for Maternal Mortality Ratio (MMR) reported by the UDHS 2006 for the 10-year period before the survey is 435 statistically though the actual value lies in the wide range of 345 to 524, given the methodology 1 The UDHS 2006 Report is available in hard copy and on the UBOS website 2 Infant Mortality Rate 75(76) & Total Fertility Rate 6.5 (6.7) indicated in the table differ from UDHS 2006 published figures (shown here in brackets), because of adjustments to use only data from comparable survey areas 3 Changed methodology to new WHO Standards does not allow comparison with previous UDHS results 23

24 and the fact that Maternal Mortality is a relatively rare event. Therefore it is not certain that there has been improvement in this indicator, as the range indicated includes the MMR value from the UDHS The indicator for nutrition status (stunting) for UDHS 2006 was derived with a new methodology as per WHO recommendation and therefore is not comparable to previous figures. Given the contribution of several sectors and institutions to improvements in health status, it is difficult to tease out the specific contribution to these improvements by the health sector. It is however reasonable to conclude that the many reforms in the sector over the period of the late 90s and the HSSP I period, that led to improvements in management, health services inputs and marked increases in health services output contributed to improvements in health outcomes over the 10-year period prior to the UDHS In particular increased access (geographical and financial) to basic health services coupled with improved services quality (increased medicines availability and more and better skilled health workers) led to marked increases in the utilization of preventive, promotive and curative services. This has been documented elsewhere but is also illustrated by the UDHS 2006 output level data. For example the following improvements were noted between the 2001 and 2006 surveys: Fully Immunized Children (FIC) by 12 months increased from 37% to 46%, whereas those who had received none of the basic vaccines declined from 13 to 7%; children s access to treatment/professional advice following an episode of Diarrhea improved from 45% to 70%; and use of preventive services/goods like mosquito nets 4 13% to 34%; women attending ANC at least once remained at the high level of 94% whereas those having at least 4 visits as recommended by WHO increased from 42 to 47%; women delivering under skilled supervision increased from 39 to 42% while those delivering in a health facility increased from 37 to 41% 5. Preliminary analysis of the UDHS 2006 data indicates that a number of demographic and socioeconomic factors can be associated with variation in health outcomes as has been the case in the past. These include: place of residence urban/rural; UDHS region 6 ; level of education of woman (or mother); and household income. These indeed indicate the importance of contributions by other sectors. A woman s level of education is particularly seen to be associated with not only increased utilization of available services, but also higher quality of service accessed. This together with improved hygiene and child care leads to much lower morbidity and mortality especially for children born to these mothers IMR of children born to women with secondary education was 66 per 1000 live births compared to 104 per 1000 live births for women with no education; similarly U5MR was 102 per 1000 live births 4 All nets whether treated with insecticide or not 5 These comparisons have not been adjusted for districts that were not surveyed in These are: Kampala; Central 1&2; East Central, Eastern, North, West Nile, Western & South West; the Internally Displaced Persons (IDPs) and Karamoja within the North were specifically highlighted. 24

25 compared to 169 per 1000 live births. The differences are however not as marked for only primary education this therefore has implications for other sectors policy priorities like Universal Primary Education (UPE) and Universal Secondary Education (USE). In Chapter 5 Section 5.1 the performance of the Northern Region is compared to the rest of the country. Plans are underway for health sector stakeholders working with Uganda Bureau of Statistics (UBOS) to carry out more in-depth analysis of the UDHS data to look at: linkages between poverty and health and specific ways the health sector can tackle inequities in access to services and health outcomes; further tease out the association between improvements in health status with current sector policies and interventions; more thorough analysis of the sexual and reproductive health data including looking at: unmet need for family planning, malaria in pregnancy and linkages between Reproductive Health and HIV/AIDS; typing of anaemia; and producing a detailed gender report. In future efforts will also be made to relate health outcomes with the local government administrative levels. 2.2 Performance Against HSSP II Indicators The performance of the health sector over the FY 2006/07, judged against the HSSP II indicators is considered good. This opinion is based on judging the performance of indicators in FY 2006/07 against performance of the FY 2005/06 and against targets set in the HSSP II for the second year of implementation as shown in Annex 2.2. The following provides a brief analysis: The HSSP II indicators showing improvement between the FY 2005/06 and FY 2006/07 are: 1. The proportion of children under one year who have received 3 doses of the pentavalent vaccine as per schedule improved from 89% in FY 2005/06 to 90% in FY 2006/07; the year s HSSP II target was 87%. 2. Proportion of expected deliveries in public and PNFP health facilities increased from 29% to 32% just short of the year s target of 35%. 3. Proportion of women receiving a complete dose of Intermittent Presumptive Treatment (IPT 2) for malaria increased from 37% to 42%; the year s target was 50%. 4. The proportion of health facilities without stock-outs (i.e. health units with tracer medicines and supplies all the time) improved from 27% in FY 2005/06 to 35% in FY 2006/07; 5. Couple Years of Protection (CYP), a measure of contraceptive uptake has improved from 309,757 in FY 2005/06 to 357,021 in FY 2006/07, which is above the annual target of 325, Household coverage of Insecticide Treated Nets in 2006 was reported at 34%. This information is from the UDHS 2006 when compared with data from the UDHS 2000/01 value of 13%, this indicates a 25

26 marked improvement. However note should be made that this is over a five year period and the HSSP II target for 2009/10 is 70%. 7. TB cure rate improved from 70.5% in FY 2005/06, to 73% in FY 2006/07 against the HSSP II annual target of 80%. 8. Proportion of children under five years who receive malaria treatment within 24 hours from a Community Drug Distributor (CDD) has improved from 60% in FY 2005/06 to 71% in FY 2006/07 against the HSSP II annual target of 65%. The indicators that have stagnated include: 1. New Outpatient Department (OPD) attendance, a measure of utilization remained at 0.9 attendances per capita since the beginning of the HSSP II. The FY 2006/07 target was set at 0.9; 2. The proportion of households with latrines as proxy measure for Sanitation Coverage has stagnated - 58% in the FY 2005/06 and 58.5% in FY 2006/ TB notification rate was 50% in FY 2005/06, and again in FY 2006/07. The target for FY 2006/07 was 60%; 4. Proportion of districts submitting quarterly reports have remained at 20% since beginning of the HSSP II. The HSSP II indicator showing decline is: 1. Proportion of districts submitting HMIS monthly returns to the MoH on time has declined from 75% to 68% against a FY 2006/07 target of 95%. For a number of indicators it is difficult to determine whether there has been improvement in performance or not because of various reasons. 1. Proportion of approved posts that are filled by health professionals at 38.4% this figure computed for this report has been based on information in 65 district annual reports, and is not comparable to the previous figure from the Human Resources for Health Inventory (HRHI) of FY 2003/04 and 2004/05. Data on the following indicators may be available: - to change this as appropriate 2. The percentage of the government of Uganda budget that is allocated to the health sector 3. total public financial allocation to the sector; 4. proportion of the Primary Health Care Conditional Grant (PHC CG) released on time to the sector; 5. proportion of disbursed PHC CG that is expended; For a number of indicators, data is not available for the AHSPR 2006/07. These indicators were also not reported on in the AHSPR 2005/06. These indicators include: 1. Caesarean Section Rate per expected pregnancies; 2. Percentage of population residing within 5 kms of a health facility; 3. Percentage of health units by level providing all components of the UNMHCP; 26

27 4. Percentage of health units providing Emergency Obstetric Care (EmOC); 5. Proportion of surveyed population expressing satisfaction with health services; 6. Percentage of fever or uncomplicated malaria cases correctly managed at health facilities; 7. HIV sero-prevalence, the HSSP II baseline data was derived from the HIV Sero-Behavioural Survey and annual data is expected from the ANC sentinel surveillance sites. However this has not been available for the last 2 years. These indicators were considered crucial during the HSSP II development process however it was recognized that data on some of these indicators would not be readily available on annual basis. It is important that during the Mid-term Review (MTR) of the HSSP II efforts are mad to get values for these indicators or these indicators are dropped. Some of these indicators like client satisfaction were inherited form the HSSP I and for the last 7 years have never been reported on. HSSP II and PEAP Health Indicators The 8 indicators common to the HSSP II and the PEAP matrix (PEAP 2004/05 to 2007/08) are: New OPD attendance; DPT/Pentavalent 3 rd dose coverage; Proportion of women delivering in public and PNFP health facilities; Proportion of approved posts filled by trained health workers; HIV sero-prevalence; Proportion of health facilities without stock-out of 6 tracer medicines/supplies; Sanitation coverage/latrine coverage as proxy; and Family Planning uptake measured by Couple Years of Protection (CYP). Performance against these indicators for the FY 2006/07 as compared to the target for Year II of the HSSP II, and the performance in the FY 2005/06 is presented in Table 2.2, and the PEAP health-related matrix and the HSSP II Indicator Table in Annex 2.1 and 2.2 respectively. A presentation and discussion on district performance on each of these indicators is provided here below. Table 2.2: Performance against 8 PEAP indicators for the FY 2006/07 Indicator Baseline FY 2004/05 FY 2005/06 achieved FY 2006/07 target FY 2006/07 achieved OPD Utilisation in govt. & PNFP units DPT 3 / Pentavalent vaccine coverage 89% 89% 87% 90% Percentage of deliveries taking place in Health Facilities ( Govt. & PNFP ) 25% 29% 35% 32% 27

28 Proportion of Approved Posts filled by 68% No new data 85% 38.4% 7 Trained Health Workers National Average HIV Sero prevalence at 6.1% 8 No new data 4.4%* No new data ANC Surveillance sites Proportion of Health facilities without 35% 27% 55% 35% stock-out of 5 tracer medicines & supplies 9 Household Latrine coverage 57% 58.% 72* 58.5% Couple Years of Protection (CYP) 234, , , ,021 *target is for end of HSSP II in 2009/10; there was no specific 2006/07 target New Outpatient Attendance in Government and PNFP health units New Outpatient Attendance in government and PNFP units is a measure of utilisation of health services, and is used as a proxy measure for both the quality and quantity of services (supply side) and the health seeking behaviour of the population (demand side). Per capita attendance has stagnated at 0.9 per capita for the FY 2006/07 as was for FY 2005/06 and FY 2004/05. This is a marked difference from the trend of the HSSP I. During the HSSP I, the initial increase in new OPD attendance per capita was attributed to the abolition of user fees in public facilities (and the decrease and flattening of fees in the PNFP facilities) the sustained rise over the HSSP I was interpreted to be because of the other reforms especially increased geographical coverage of health services, and increased funding for primary health care inputs (staff, medicines and supplies) leading to improved quality of services, which attracted the population to use the services. The stagnation of this indicator since the FY 2004/05 seems to be related to the stagnation in inputs like financing for primary health care services especially for medicines and supplies; stagnant funding to the PNFP sub-sector; and the continuing high level of medicines stock-outs recorded at the health facilities. The performance against this indicator ranges from 0.1 in Kiboga district to 2.1 per capita attendance in Abim district. The variation in district performance is shown in Figure 2.1 and Annex 2.3. Districts that have new OPD attendance of above 1.2 per capita include: Abim, Rukungiri, Gulu, Lyantonde, Kabale, Kisoro, Kapchorwa, Tororo, Adjumani, Mityana, Amuru, Bududa and Rakai. Some districts previously noted to be good performers on this indicator like Adjumani, Gulu, Kabale, Kisoro, Rukungiri, and Tororo have maintained these positions. One common factor amongst these districts is that they all share borders with the neighbouring countries, and could be providing services to some of their people. It is more challenging to explain the very high performance of Abim and Lyantonde - as new districts this may be because of differences between the documented and actual population figures, 7 This is not comparable to previous data as different methodology was used 8 This is data from the sero-survey; ANC surveillance data for 2005/06 is still to be analysed 9 The tracer medicines and supplies are: (1 st -line antimalarials /Fansidar, Depo Provera (injectable contraceptive), ORS, measles vaccine, cotrimoxazole) 28

29 leading to artificially low denominators; on the other hand it could be because the new district makes service provision in the catchments easier. Figure 2.1: Variation of New OPD Attendance by District FY 2006/07 Districts that have performance of less than 0.60 new OPD per capita attendances include: Kiboga, Oyam, Bugiri, Koboko, Kaabong and Mubende. Of the poor performers on this indicator (below 0.6 per capita) Oyam, Koboko and Kaabong are districts that have been created in the recent past that may have a number of challenges; Kibaale, Kiboga and to a less extent Mubende have consistently performed poorly on this indicator. Districts that showed particular changes in performance on this indicator between the FY 2005/06 and 2006/07 are: Mityana marked improvement; Mpigi marked decline. It is interesting to note that poor performance on this indicator is associated with poor performance 29

30 in Medicines Management as measured by proportion of EMHS budget spent at NMS and JMS more on this in Sections and DPT 3 / Pentavalent Vaccine Coverage Coverage of all infants with the third dose of the Pentavalent Vaccine (previously the vaccine against diphtheria, pertussis and tetanus referred to as DPT 3) is used as a proxy for overall immunisation performance. The national performance for FY 2006/07 against the pentavalent vaccine 3 rd dose coverage in infants is 90%. This is a small improvement compared with the performance of the FY 2005/06 of 89%, and indicates that the sector has achieved the HSSP II target for FY 2006/07 of 87%. The high level of coverage that has been maintained for the FY 2006/07 is rather surprising given that there have been challenges in availing districts with immunisation logistics especially for the maintenance of the cold chain. Supervision visits have noted that some health units were not carrying out immunisation at the static and outreach points due to lack of gas and viable vaccines. Figure 2.2: Variation of Pentavalent Vaccine Coverage by district FY 2006/07 30

31 Variation in district performance is pictorially represented in Figure 2.2 and Annex 2.4. Districts with performance of at least 100% include: Bududa, Manafwa, Gulu, Kumi, Bukedea, Amuru, Kampala, Jinja, Dokolo, Mbale, Kotido, Kabarole, Wakiso, Nebbi, Kalangala, Butaleja, Isingiro, Abim, and Sironko. Of the top performers, Kumi, Mbale, Kotido, Kabarole, Wakiso, and Sironko were similarly good performers in the FY 2005/06. The district pairs of Bududa, and Manafwa; and Kumi and Bukedea; previously composing one district each pair are good performers on this indicator the old district of Bududa though was a poor performer on this indicator in the FY 2005/06. Districts with performance of less than 70% include: Moyo, Oyam, Nakapiripirit, Kiruhura, Hoima, Namutumba, Apac, Kaabong, Kibaale, Kapchorwa, and Nakaseke. Moyo, Kiruhura, Hoima, Kapchorwa and Nakaseke were among the poor performers on this indicator in the FY 2005/06. There is a more detailed discussion about Immunisation under 31

32 Section 3.2 of the Report, including relating the HMIS, EPI Survey and UDHS data Sexual and Reproductive Health and Rights Sexual and Reproductive Health and Rights continues to be a high priority in the HSSP II. The sector performance at frequent intervals (PEAP indicators are monitored quarterly) can be measured by progress on the 2 indicators: proportion of expected deliveries taking place in public and PNFP facilities and Couple Years of Protection from unwanted pregnancy. Deliveries in Health Facilities Table 2.3: Financial Year Total Number of deliveries in GoU & PNFP health facilities Proportion of all expectant women delivering in GOU & PNFP units Total Number of Deliveries in Government and PNFP Units Baseline FY 2005/06 FY 2006/07 % FY 2004/05 Values Values increase 340, , ,836 15% 25% 29% 29% 10% The national average for proportion of all expectant mothers delivering in health facilities (public & PNFP) is 32%, which is an improvement on FY 2005/06 at 29% - an improvement of 10%. The improvement is seen to be bigger when absolute numbers are considered 15% increase. The performance for the FY 2006/07 of 32% is less than the annual HSSP II target of 35%. The national average covers a wide range of individual district performance, ranging from 4% in Kaabong and Nakapiripirit to 73% in Kampala. District specific information is provided in Figure 2.3 and Annex 2.5. The best performing districts are Kampala, Kumi, Gulu, Jinja, Nebbi, Nakaseke, Bukedea, Kisoro, Kitgum, Soroti, Rukungiri, Kabarole, Butaleja, Pallisa and Mukono with more than 40% of expecting women in their respective populations delivering in the public and PNFP health facilities. This is an improvement from the FY 2005/06 where only 8 districts had more than 40% of their expectant women delivering in public and PNFP health facilities. It is worth noting that all these districts have at least one hospital and in most cases as in Gulu, Jinja, Kampala, Kisoro, Mukono, Nebbi and Rukungiri have more than one hospital each and in the case of Mukono and Nebbi functional HC IVs too. Gulu district is of particular interest the proportion of women delivering in health facilities has almost doubled - increased from 33% in FY 2005/06 to 61% in FY 2006/07. More on this is in Box 3.3 in Section 3.2. The slow but steady 32

33 improvement on this indicator across the country in the medium term seems to reflect the improved physical access to maternity services and efforts to improve the quality of services with recruitment of midwives and availability of supplies e.g. mamma kits. Figure 2.3: Variation in proportion of expectant mothers delivering in health units FY 2006/07 Eighteen districts have reported less than 20% of expected women delivering in their health facilities in the FY 2006/07, and these are: Kaabong, Nakapiripirit, Isingiro, Kotido, Kalangala, Kamwenge, Bukwo, Oyam, Moroto, Dokolo, Amolatar, Mubende, Manafwa, Sembabule, Kapchorwa, Bugiri, Koboko, Buliisa and Kibaale districts. Kaabong, Nakapiripirit, Kotido and Moroto are in the Karamoja region, which has been noted in the past to have very poor performance against this indicator because of cultural beliefs. The districts of Isingiro, Kalangala, Kamwenge, Bukwo, Manafwa, Sembabule, Koboko and Buliisa do not have hospitals and do not have functional HC IVs. The districts of Amolatar, Bugiri, Kibaale, Mubende and Oyam have hospitals, yet they are falling in this group. 33

34 Family Planning Uptake Couple Year s of Protection (CYP) as a measure of family planning uptake is one of the recently introduced PEAP indicators reflecting the importance the government and the sector stakeholders place on maternal and child health, and the role unwanted pregnancies may play in this. CYP is an absolute number which is computed using routine data in the HMIS, considering the uptake of the various methods of family planning. This considers utilization of contraception services from public and PNFP facilities but does not usually include services received in the private-for profit sub-sector. The total CYP for the country for the FY 2006/07 is 357,021 which is a marked improvement over the FY 2005/06 performance of 309,757 and above the year s target of 325,407. Annex 2.6 provides the information on CYP by district. The district specific data provides information however it is rather challenging to make comparisons between districts given that CYP is an absolute number and districts have different population figures. It is notable though that Kampala district has by far the highest CYPs contributing 33% to the national figure. 31 districts have less than 1000 CYPs each, and only Kampala, Kamwenge, Tororo and Bugiri had CYP figures higher than 10,000. Bugiri and Kamwenge are a surprise in this group as their performance on other Reproductive Health indicators like proportion of expecting mothers delivering in health facilities is very low. More of the issues on Sexual and Reproductive Health and Rights are discussed under Section 3.2 of this report Approved posts filled by trained health workers District Annual Reports for FY 2006/07 have been utilized to provide information on health workers in post. Complete information was available from 65 districts, for the levels of the District Health Office (DHO) and the Health Centres. It has not been possible to include Hospital (for all levels General, Regional Referral, National Referral), and all PNFP personnel. The staffing norms used are the new Local Government staff norms. The proportion of approved positions filled by trained health workers using this data is 38.4%, varying from 10.4% in Kaabong to 92.6% in Ntungamo. The variation in staff positions filled by trained health workers for the 65 districts that provided complete information is shown in Annex 2.7. This figure is not comparable to the previous figures in the AHSPR of 2003/04 and 2004/05, because in these reports, the indicator was computed using comprehensive data from all the districts in the country, with data from public and PNFP facilities and all the levels of care. In addition the HSSP I norms were used; the current estimates use the new LG norms which have increased staff positions. 34

35 2.2.5 HIV/AIDS Control There is no new data on the HIV prevalence indicator for the FY 2006/07. Data used for this indicator for FY 2004/05 was from the HIV/AIDS Sero-Behavioural Survey; expected figures from the ANC sentinel surveillance system were not available for FY 2005/06 and FY 2006/07. The Ministry of Health with the support of various stakeholders has in the HSSP II embarked on an ambitious programme of scaling up HIV/AIDS Control activities across the country. This especially includes: HIV Counseling and Testing (HCT), Prevention of Mother to Child HIV transmission (PMTCT) and Anti-retroviral Therapy (ART). The HSSP II targets the provision of HCT and PMTCT at all HC IIIs and higher levels, and ART at all HC IVs and higher levels. As in the FY 2005/06, an assessment of the progress against these targets has been made across the country, and a performance against these targets of: HCT 42%; PMTCT 45% and ART 57% has been achieved. The details by district and intervention are attached as Annex 2.8, and the composite indicator of HIV/AIDS Control service delivery is included in the District League Table. More on HIV/AIDS Control activities is available in Section Essential Medicines Availability The HSSP II indicator that measures medicines availability (as a proxy for quality of care) measures the percentage of health units without any stock-outs of HSSP indicator medicines 10 - i.e. a measure for zero tolerance for medicines stock-out. Information available in the routine HMIS has not been useful for this analysis, and for the last 4 years a survey has been done to collect data for this indicator. Figure 2.4: Variation in Medicines spending by districts at NMS & JMS against the Indicative Budgets for the FY 2006/07 For all 6 indicator medicines and supplies, there were only 35% of the health units surveyed that did not report a stock-out over the 6 months of the FY 2006/07 that were studied. This is an improvement on the figure of 27% of the FY 2005/06, but still falls short of the HSSP II Year II target of 55%. This indicates a major challenge to the health sector and is very closely related to the stagnation/minimal improvement in a number of output indicators as medicines availability is a very important signal of quality of services to the community. However these levels of medicines stock-outs are not surprising given the stagnant Essential Medicines and Health Supplies (EMHS) budgets, and the low expenditures on EMHS local government and hospital budgets. 10 First line antimalarial/fansidar, ORS, cotrimaxazole, Depo Provera and measles vaccine 35

36 There is no district specific information on medicines stock-outs as the data was from a survey. However there is district specific information about how medicines and supplies are being managed in the districts. Specifically there is information on how much of the district EMHS budgets are spent at National Medical Stores and Joint Medical Stores as per agreed guidelines. Figure 2.4 and Annex 4.??? illustrate the variation in spending on EMHS at NMS and JMS by the districts. A number of districts are doing very well with at least 100% of the EMHS budgets being used to procure medicines and supplies at NMS and JMS. These include: Bukedea, Kumi, Gulu, Ibanda, Amolatar, Katakwi, Mbarara, Kiruhura, Nebbi, Pader and Mityana this is a decline from FY 2005/06 where more than 10 districts spent above 120%. Most of these districts actually used more than 100% of the EMHS budget possibly from using some of the funds that were not ear-marked for EMHS, or by mobilizing from other sources of funds. This is commendable, as EMHS are a very key input in health services. 25 Districts have spent less than 40% of the EMHS budget at NMS and JMS; while 10 districts have spent less than 20% of their budgets namely: Terego-Maracha, Kaliro, Kamuli, Bukwo, Kanungu, Amuria, Kisoro, Moroto, Lyantonde and Abim. Terego-Maracha, Kaliro and Kamuli districts have spent 0% of the EMHS budgets at NMS or JMS. More information is available on Medicines Management in Section 4.4 in the section on medicines management and financing Sanitation coverage Figure 2.5: Variation of Household Latrine coverage by district in FY 2006/07 36

37 Access to appropriate sanitation facilities is one of the HSSP II and PEAP indicators given that a high proportion of the diseases in the country are associated with poor sanitation. Latrine coverage is used as a proxy measure for this indicator. Performance against this indicator has stagnated with household latrine coverage at 58% in FY 2006/07 and FY 2005/06. The current performance is still short of the HSSP II target of 72%, and way off target for 4 th National Health Assembly Resolution of 100%. The variation in performance against this indicator has not changed much ranging from 2% in Abim to 98% in Rukungiri, as dramatically highlighted in Figure 2.5. The best performing districts are Rukungiri, Kampala, Bushenyi, Kabale, Masaka, Mukono, Ntungamo and Kabarole all with coverage of at least 80%. All these districts are either in the South-west, Western or Central regions of the country. Districts with household latrine coverage of less than 40% include: Abim, Kotido, 37

38 Kaabong, Nakapiripirit, Moroto, Kitgum, Amuria, and Pader. The regional bias is again obvious with the worst performing districts on this indicator from the Karamoja region closely followed by districts in the neighbourhood. There is a strong cultural association with this indicator. More information about Sanitation is in Section 3.1. FY 2.3 Summary Financial Report FY 2006/ The FY 2006/07 Resource Envelope The total budgetary allocation for the health sector in FY 2006/07 was Ug. Shs?????? of which Ug. Shs bn was the GoU budgetary allocation including donor budget support, and Ug Shs. was?????. the actual expenditure over FY 2006/07 was Ug. Shs bn by GoU, and?????? by donor projects. Total Public Health Expenditure (TPHE) over FY 2006/07 is therefore Ug. Shs?????, which is equivalent to Ug. Shs????? per capita or US $???????. Table 2.4: Public Expenditure on Health FY 2005/06, 2006/07 GoU Funding Ug. Shs Bn. Donor Projects & GHIs Ug. Shs. Bn. Total Public Health Exp. Per Capita Exp. Ug. Shs. Per Capita Exp. US $ GoU Exp. On Health as % of total GoU Budget Brief Discussion on HSSP II Resource Envelope trends GoU (Health) Budget Performance Annual Budget Increase 2004/ % 5.7% HSSP II Baseline 2005/ , % 4.7% (507.26) 2006/ ( ) (737.14) (26,946) (15) , % 95.6% Budget Performance in the FY 2006/07 GoU health sector budget performance was 96.8% in FY 2006/07 up from 95.7% in FY 2005/06, as shown by grant and level of service delivery in Annex 2.9. This includes budget performance against the Wage grant of 97.7%, Non-wage recurrent grant of 97.3% and the Development grant of 92%. Performance against the Wage grant has particularly improved from 91.6% to 97.7%. This reflects new recruitment of health workers at the various levels. GoU Budget Expenditure on Health as a proportion of Total GoU Expenditure for the FY 2006/07 was????? which is down from 9% in FY 2005/06 and much lower than 9.7% at the beginning of the HSSP II. The governments in Africa previously agreed to 15% as the optimum level of funding of the health sector by countries in the region. 38

39 Donor Projects and Global Health Initiatives performance has been analysed considering: donor project funding that is included in the MTEF; donor project funding that is not in the MTEF; Global Health Initiatives; and Consolidated Appeal (CAP) funding. In total the Donor Projects and GHIs including CAP had a budget performance of 210% against budgets initially declared to MoH; with per capita spending of Ug. Shs. 19,121/= or US $ Local government funding for health services in FY 2006/07 was composed of GoU Primary Health Care Conditional Grant (PHC CG) at an average of 80%; Donor Project funding at 16% and local government contribution of 4% Improving Efficiency over the HSSP II Aligning Funding with HSSP II Priorities, maximizing Outputs from available Inputs Over the HSSP II there has been overall increase in sector funding compared to the HSSP I. However this does not seem to translate to a notable increase in sector outputs most of the key indicators are either marginally increasing or stagnant. This is related to the declining funding of basic services especially for District Primary Health Care Services and PNFP health services. This is because the increase in funding has been mainly for Donor Projects and Global Health Initiatives (GHIs) which have prioritized specific areas like: provision of ART; provision of ACTs; support for the Consolidated Appeal Process (CAP) for Northern Uganda; support to the private sector; technical assistance and project management. These are all useful inputs; however in some cases the focus of the projects and GHIs is not similar to HSSP II agreed priorities. Analysis of Donor Projects for alignment to HSSP II priorities for the FY 2006/07 indicates that up to 31% of project spending is on non-hssp II inputs including Technical Assistance and parallel project management. The Facility-Based Private not for Profit (FB PNFP) sub-sector is a key component of the health sector, whose outputs are included in the sector outputs and monitored by the HSSP II and PEAP indicators. The GoU budget has since 1997/98 provided subsidies for the FB PNFP sub-sector the proportion of the GoU funding to PNFP funding peaked at 36% in FY 2002/03 and has since declined to 22% in FY 2006/07. This has resurrected marked reliance by these institutions on user fees and donor funding which are inequitable and unpredictable. This is already being shown by declining productivity and efficiency in these units as shown by the PNFP Hospital outputs in Sections 2.6 and 3.4. This is contributing to the overall stagnating sector outputs Financial Management Monitoring The government procedures are followed for sector financial monitoring. The bulk of the funds used for service delivery in the public sector is 39

40 from the GoU budget and are released by the MoFPED directly to implementers. The Auditor General continues to provide annual reports, and the Auditor General s Report of FY2005/06 is to be presented to the Joint Review Mission together with this AHSPR. At the level of the health sector monitoring is carried out at the central, regional and local government levels. Monitoring of financial management at the local government levels is carried out by the integrated teams form the Ministry of Health, the Area Teams and in specific instances separately by the Accounts Section of the MoH. Some of the findings by the Teams in the FY 2006/07 include: The release of funds to the districts by the MoFPED continues to improve in timeliness and completeness. However there are still a number of challenges at the district level with marked delays in disbursements between the district collection account and sector account; and the release of funds to implementers. There is often poor information flow in the districts with a number of districts not publishing PHC CG releases at all levels district, heath sector, HSD and health facility. There is inadequate and often poor quality data passed on to MoH in the monthly HMIS and annual reports submitted. Figures on timeliness of releases and expenditure from Olle write up this space should be enough. 2.4 Comparing Local Government Performance During the HSSP I it was recognized that average national performance against HSSP II indicators masks marked variation between the local governments. It was also noted that studying the pattern of performance across a set of given priority indicators would provide information about possible associations between good performance and local government characteristics. This would enable the sector to learn lessons and best practice. Thus the District League Table (DLT) was developed in the AHSPR 2002/03, in the HSSP I, and maintained over the HSSP II, with some adjustments. To be relevant the DLT is likely to keep evolving with the possibility of including assessment of performance in the municipalities in future The Purpose of the District League Table The District League Table (DLT) was put in place to facilitate the following: Comparison of sector performance between districts to enable ranking of district performance; Provision of information to facilitate the analysis of circumstances behind good and poor performance at the district level, and thus enable appropriate corrective measures; 40

41 Design of appropriate corrective measures which may range from increasing the amount of resources (funds, infrastructure, equipment or staff) to the local government, to more frequent and regular support supervision as required; Increase Local Government ownership for achievements the AHSPR is discussed at the NHA where political, administrative and technical leadership of the districts are in attendance; Encourage good practices e.g. good management, innovations and timely reporting. The League Table is not meant to embarrass local government leaders of poorly performing districts, but rather to make them question why their district is performing poorly, and considering ways in which that performance can improve Composition of the League Table A number of HSSP II and other district health sector monitoring indicators have been used for the DLT as applied in the HSSP II. These are: Management Indicators (decisions/actions taken by the local government that influence health services delivery): o Management of the PHC-CG measured by proportion of received funds (quarterly) that has been spent which is influenced by timeliness of reporting and/or requests; o Expenditure on key inputs measured by proportion of indicative PHC CG budgets spent on medicines at NMS and JMS as by agreed guidelines; o Applying the flexibility provided by the Fiscal Decentralisation Strategy (FDS) in favour of the health sector as a measure of the local government s appreciation of health services as a o priority area; and Management of health data measured by timeliness of HMIS reporting; Service Delivery Output Indicators (a combination of the local governments capacity to deliver services, and the demand of the population for services) o o o o o o o DPT3/Pentavalent vaccine coverage; New OPD attendances per capita; Proportion of expectant mothers delivering in GoU and PNFP units; Proportion of expected TB cases that are notified; Proportion of pregnant women receiving IPT 2 [2nd dose of Sulphadoxy-pyrimethazine (SP commonly referred to as Fansidar) in Pregnancy]; and Pit Latrine coverage as a measure of sanitation coverage; and Availability of HIV/AIDS control activities by level. 41

42 2.4.3 The League Table Scores for FY 2006/07 The national average performance on the DLT for the FY 2006/07 is a score of 60.5, which is a slight improvement from the FY 2005/06 performance of There is wide variation in performance ranging from 77.2 for Gulu at the top to 38.2 for Bukwo at the bottom of the table. Given the marked increase in the number of districts over the recent past from 56 to 80, the districts highlighted in this report have been increased from 20 to 30 considering the top 15 and bottom 15 performers of the DLT. Pictorial presentation of the top and bottom 15 districts is shown in Figure 2.6, and the detailed District League Table including explanatory notes is in Annex The top 15 performers are: Gulu, Jinja, Mbarara, Kampala, Tororo, Katakwi, Mityana, Kumi, Pader, Bundibugyo, Kabarole, Masaka, Wakiso, Kabale and Rukungiri. The bottom 15 performers are Bukwo, Nakapiripirit, Kaabong, Terego-Maracha, Mubende, Budaka, Amuria, Kotido, Moroto, Kibaale, Kisoro, Yumbe, Kamuli, Oyam and Kiboga districts. Figure 2.6: League Table Top and Bottom Performers for the FY 2006/07 42

43 Table 2.5 presents an analysis of consistently very good performers over the HSSP II period and in the case of Jinja ever since the DLT was put in place in FY 2002/03. The consistently poor performers for the HSSP II period are also indicated. In addition to considering good and weak performance in relation to the top 15 and bottom 15 positions on the DLT, it is worthwhile to note the districts that have shown particular improvements and those that have markedly declined. Table 2.5: District League Table Trends FY 2005/06 and 2006/07 FY 2005/06 FY 2006/07 For 2 years Particular mention League Table Position Top 10/15 Jinja, Tororo, Kampala, Mbale, Nebbi, Mpigi, Kumi, Mbarara, Gulu & Ntungamo Bottom 10/15 Kaabong, Manafwa, Kaliro, Kiruhura, Amuria, Moroto, Iganga, Bukwo, Koboko, Kamuli Gulu, Jinja, Tororo, Kampala, Katakwi, Mityana, Kabarole, Bundibugyo, Masaka, Mbale, Pader, Mbarara, Wakiso, Nakasongola, Arua Nakapiripirit, Bukwo, Kaabong, Oyam, Kibaale, Budaka, Kotido, Amuria, Terego-Maracha, Yumbe, Mubende, Moroto, Kisoro, Kamuli, Kiboga Jinja, Gulu, Tororo, Kampala, Mbarara, & Mbale Kaabong, Bukwo, Amuria, Kamuli, Moroto, Districts recording particular improvements include: Mityana, Wakiso, and Masaka who have all moved from the bottom half of the DLT to the top 15. This may be explained by a number of factors including: more complete submission of information and improved management of EMHS budgets. Some districts have showed decline in performance, including Nebbi and Mpigi districts from top 10 positions to below average, which is largely explained by poor performance on the EMHS management indicator. Jinja is the only district that has been amongst the best (10 or 15) performers since the beginning of the DLT in FY 2002/03 3 of the 6 districts appearing in the least performing districts for both years of the HSSP II are all new districts (new created in the last 2 years); Moroto is from Karamoja; Kamuli is an exception 2.5 Factors Influencing Local Government Performance The purpose of the DLT as indicated above is not just to gauge performance of the districts but to also tease out possible reasons for good and poor performance. This would make it possible to identify factors that are facilitating good performers and those hindering poor performers which would make it possible for the different levels of government and other stakeholders to transfer/duplicate good lessons from the good performers and map out possible ways of solving the challenges facing poor performers. 43

44 Analysis of the performance against the DLT of FY 2006/07, just like with previous DLTs, shows that a number of factors are associated with the performance of the different districts. These include: Level of development of the district; Peculiar circumstances; The local government management capacity; Level of Development of the Local Government The weak performance of many of the new districts is glaring. Of the 15 bottom performers, 6 of them are among districts created in the recent past namely: Kaabong, Oyam, Budaka, Bukwo, Terego-Maracha and Amuria. Conversely there is no new district amongst the top 15 performers. The explanations for this are not all known, but include: New districts were previously marginalized parts of the more established districts. This argument is supported by the fact that some old districts performance has markedly improved on separation from the new districts e.g. Arua (Nyadri); Mbarara (Kiruhura, Ibanda, Isingiro); and Tororo (Butaleja). The marginalization often translates into gaps in health inputs like infrastructure and human resources. The management is the new district is still facing many challenges as many of the offices get manned, and systems are put in place. For example many new districts have District Health Officers (DHOs) in acting capacity and lack most members of the District Health Team (DHT), and infrastructure and logistics e.g. transport. This may be part of the explanation for the many gaps in information from these districts and poor performance on indicators like proportion of funds spent on medicines and supplies Local Government with peculiar circumstances It was previously noted that districts with particular circumstance were less likely to perform well on the DLT. Such circumstances were noted as local governments in conflict or post-conflict situations; and districts with peculiar cultures and norms. The DLT of 2005/06 and the current one of FY 2006/07 shows marked improvement in the performance of districts in mid-north with Gulu and Pader in the top 15, and many of the other districts performing fairly well (except new districts ). This is good news and can be attributed to: Improved security in the region, with improved service delivery; Specific interventions for the region by government and partners; However the challenges in Karamoja are still pertinent Nakapiripirit, Kaabong, Moroto and Kotido are still in the bottom 15 of the DLT, and critical examination of performance against specific indicators like household latrine coverage, and proportion of expected women delivering in health facilities shows particularly poor performance by the districts of Karamoja. More on the improvements and challenges in Northern Uganda is presented in Section

45 2.5.3 Local Government Management Capacity Close scrutiny of the DLT shows that top performers tend to be consistent in their performance across the range of management (including information management) and service delivery indicators. This as in previous AHSPRs seems to point to robust district management at the political, administrative and technical level. A few districts continue to provide information late and incomplete despite frequent reminders and the experience of the last 5 years. This is true especially of information on the PHC CG expenditure. Information management is a key tool in health services management, and needs to be applied more often for monitoring at all levels Responding to the District League Table Performances It is necessary for all stakeholders to use the information from the DLT to make the necessary decisions at the various levels. These actions should include but not necessarily be limited to: o Level of Development of Local Government the Ministry of Health and Development Partners need to prioritise new and otherwise disadvantaged districts. This should be translated into affirmative action in allocation of resources financial; human and infrastructure; and more support supervision, monitoring and mentoring. Specifically districts without Hospitals should be supported and supervised to make sure there HC IVs are functional. o Efforts should continue to relate to peculiar circumstances interventions need to be planned and implemented especially for the Karamoja region. o There is need for the MoH to compile and share best practices and experiences from good performers and encourage peer support. A study is planned under the Mid-term review to further explore some of the issues surrounding good performers on the DLT. 2.6 Hospital Performance Assessment The hospitals are a major component of the health system and utilize a big proportion of the health sector resources in the form of infrastructure; human resources and funds for medicines and supplies and other goods and services. The Annual Hospital Report has been part of the AHSPR for the last 5 years. This has been evolving initially specific information was only available for the National and Regional Referral Hospitals. However in the AHSPR of 2005/06 and in this report it has been possible to extend individual hospital analysis and comparison with similar hospitals to the level of the General Hospital. 45

46 A more in-depth discussion of the Annual Hospital Report is available in Section 3.4 and a stand alone report is available 11. The analysis has been done at the General Hospital; Regional Referral Hospital and National Referral Hospital levels General Hospitals The General Hospitals (GHs) reported an average income of Ug. Shs. 258,891,142. However this is recognized as an underestimate as in many public hospitals the wage component was not included in the submissions. More than 50% of the expenditure at the GHs is on employment costs, with 61% of recommended staffing positions filled, but only 49% for the medical staff 13. Pharmacy and dental units have the highest proportion of unfilled positions. Iganga hospital registered the highest outputs as measured by the Standard Unit of Outputs (SUO) 14, similar to FY 2005/06; while Kuluva Hospital emerged best on quality assessment. The final Hospital League Table (HLT) is produced using a composite indicator that considers the magnitude of outputs (measured by the SUO), efficiency and quality of services. For the HLT FY 2006/07 Iganga, Atutur, Bwera, Kawolo, and Adjumani are the top 5 performers, while Kaabong, Amudat, Moroto, Nyenga and Tororo Hopsitals emerge the bottom Regional Referral Hospitals The analysis of Regional Referral Hospitals (RRHs) includes 4 PNFP hospitals with high volume outputs and a high degree of specialization namely: Nsambya, Rubaga, Mengo and Lacor hospitals. The combined income of 12 RRHs was 43,073,293,517 of which 43% was from government grants, 30% from user fees (both private wings and PNFP fees) and 27% from donors. Employment costs used 51% of the funds, medicines and supplies 15% and 12% for capital expenditure. 75% of the established positions were filled, with 61% of medical staff positions filled. 6 hospitals reported stock-out of at least one time in a quarter. Some of the RRHs are not able to carry out major operations or diagnosis using X-ray machines. This is a major gap. Lacor Hospital had the highest number of outputs, and Kabale the least. On quality assessment, Nsambya hospital scored highest and Soroti the lowest. Masaka RRH scored highest on the overall RRH League Table and Fort Portal as the lowest. 11 the detailed Annual Hospital Report will be available at the JRM, and can also be accessed from the Department of Clinical Services; MoH Library/Resource Centre and Health Planning Department. 12 PNFP hospitals are assigned to one of the levels given the size, complexity and specialisation levels. 13 This excludes administrative staff; support staff and nursing assistants. 14 The computation of the SUO and the efficiency and quality parameters is explained under Section

47 2.6.3 National Referral Hospitals Butabika National Psychiatric Referral Hospital had a total income of Ugshs 13,240,522,792 of which Development was Ugshs 10,143,295, % of staff positions are filled; however the hospital had stock-outs of at least one indicator medicine in each quarter. The hospital continues to provide specialist psychiatric services and general outpatient services; and training of psychiatric nurses, clinical officers and specialists. Mbarara National Referral Hospital received Ugshs 3,167,179,979, which was evenly distributed between wage and non-wage recurrent spending. 80% of staff positions are filled; the hospital had a stock-out of one medicine in one quarter. The hospital provides a range of specialized and general inpatient and outpatient services plus training of health workers of the nursing, medical officer and postgraduate categories. Mulago National Referral Hospital did not provide an Annual Report PNFP Hospitals Over the HSSP I the PNFP hospitals recorded improvement in a number of parameters especially the volume of services and efficiency in production of services by maximizing outputs form available human and financial resources 15. Over the 2 years of the HSSP II however, there has been a worrying trend of reversal with overall declining outputs, including OPD, IP and Primary Health Care services like Antenatal Care and immunisation; increase in User Fees; and decreased staff productivity. This is attributed to 2 main factors: the decline government grants to the PNFP hospitals (in absolute and especially in proportional terms); increased cost of service delivery especially employment costs. This is an important phenomenon that should be noted for appropriate decision-making by sector stakeholders. 2.7 Comments on Statistics for the AHSPR for FY 2006/07 During the HSSP I work methods were established to get information from the different implementing levels and institutions. Data availability improved over the period of the HSSP I. However in the preparation of the AHSPR it has been quite challenging to get data from the different levels district, hospital, and central level institutions. This coupled with the increase in HSSP II indicators from 18 to 25 has resulted in gaps in the HSSP Indicator table and the PEAP Indicator table. More is discussed on this, and the Monitoring of the HSSP II in Section 5.4 of this report. Data Quality is another issue of concern given the maturing of sector monitoring, and the decline in performance of the Health Management 15 this is documented in previous AHSPRs 47

48 Information System (HMIS) indicators of timeliness and completeness. The later has led to dependence on local government and hospital annual reports rather than the accumulated monthly reports. In September 2006 the MoH (Resource Centre and Expanded Programme for Immunisation EPI), and WHO carried out a Data Quality Self Assessment (DQSA) on immunisation data covering 8 districts. The DQSA recorded an Accuracy Ratio AR 16 of 61% for pentavalent vaccine 3 rd dose and 75% for the measles vaccine. An AR of < 100% indicates over reporting, whereas >100% indicates under-reporting. The DQSA therefore noted a fairly high level of over-reporting from the lower levels. A validation exercise carried out for the AHSPR 2006/07 reported similar findings. It is recommended that more information be sought on health sector data quality under the MTR a more comprehensive Data Quality Assessment should be carried out preferably by an independent entity like Uganda Bureau of Statistics (UBOS) or institutions from Academia. This would provide the basis for more concrete recommendations. 16 Accuracy Ratio = (no. of vaccine doses e.g. measles counted at health facility level from tally sheets/no. of vaccine doses for measles reported in HMIS reports at HSD or district level for the same period)*100 48

49 Chapter 3 Delivery of the Uganda National Minimum Health Care Package Health Promotion, Disease Prevention and Community Health Initiatives Maternal and Child Health Prevention and Control of Communicable Diseases Prevention and Control of Non-communicable Diseases / Conditions Figures Figure 3.1: Trends in Infant and Under 5 Mortality Rate...64 Figure 3.2: U5MR-MDG4, Actual and Accelerated Performance...64 Figure 3.3: Reported NNT cases by year in Uganda, (Source HMIS)...69 Figure 3.4: Trends in uptake of PMTCT services 2004 June Figure 3.5: Trends in number of person on ART Figure 3.6: Number of TB cases notified...79 Figure 3.7: TB treatment outcome...79 Figure 3.8: Trends in Malaria morbidity Figure 3.9: Number of nets re-treated...85 Figure 3.10: Malaria-positive Blood Smears, Kihihi HC IV, Kanungu District Aug 06-June Figure 3.11: Income for General Hospitals FY 2006/ Figure 3.12: Overall Quality in General Hospitals FY 2006/ Figure 3.13: Expenditures from Regional Referral Hospitals FY 2006/ Figure 3.14: Volume of outputs (SUO) from Regional Referral and large PNFP Figure 3.15: Quality Score for Regional Referral Hospitals Figure 3.16: Outputs from PNFP Hospitals 1997/ / Tables Table 3.1: Health Promotion and Education key outputs - FY 2006/07 52 Table 3.2: Environmental Health key outputs - FY 2006/ Table 3.3: Control of Diarrhoeal Diseases key outputs - FY 2006/ Table 3.4: School Health key outputs - FY 2006/ Table 3.5: Occupational Health key outputs - FY 2006/ Table 3.6: Reproductive Health key outputs - FY 2006/ Table 3.7: Newborn Health key outputs - FY 2006/ Table 3.8: IMCI key outputs - FY 2006/ Table 3.9: Expanded Programme on Immunisation key outputs - FY 2006/ Table 3.10: Nutrition key outputs - FY 2006/ Table 3.11: HIV/AIDS key outputs - FY 2006/ Table 3.12: Health facilities providing PMTCT by level

50 Table 3.13: HCT Coverage by Health facility levels in 2006/ Table 3.14: Number of Health Facilities accredited for providing ART in 2006 and Table 3.15: Tuberculosis control key outputs - FY 2006/ Table 3.16: Malaria Prevention and Control key outputs - FY 2006/07 82 Table 3.17: HBMF performance in 4 selected districts (FY 2006/07)...83 Table 3.18: IRS performance in selected districts...86 Table 3.19: Veterinary Public Health key outputs FY 2006/ Table 3.20: Guinea Worm key outputs - FY 2006/ Table 3.21: Onchocerciasis Control key outputs - FY 2006/ Table 3.22: Non-Communicable Diseases key outputs - FY 2006/ Table 3.23: Disability, Injuries and Rehabilitative Health key outputs - FY 2006/ Table 3.24: Mental Health key outputs - FY 2006/ Table 3.25: Staff in general hospitals Table 3.26: Outputs from the General Hospitals FY 2006/ Table 3.27: Staff in Referral Hospitals Table 3.28: Ranking of Regional Referral and Large PNFP Hospitals Table 3.29: Outputs from Mbarara Hospital Table 3.30: Oral Health key outputs - Year 2006/ Boxes Box 3.1: Kaliro District: The move to increase household sanitation coverage to 100%...55 Box 3.2: A discussion on Reproductive Health Indicators trends in the Uganda Demographic and Health Surveys...62 Box 3.3: Innovations to increase supervised deliveries in Gulu District 63 Box 3.4: Comparison of data from various sources

51 Chapter 3 Delivery of the Uganda National Minimum Health Care Package The Uganda National Minimum Health Care Package continued to constitute the priority health care interventions for addressing the high disease burden in Uganda during year two of HSSP II. The interventions in the package continued to be implemented in clusters in order to enhance the integrated approach to service delivery and to encourage increased coordination in planning, budgeting and implementation of the interventions at all levels of care. This chapter discusses the achievements and progress that has been attained in the delivery of the UNMHCP and the challenges experienced during year two of HSSP II in each of the interventions of the following clusters: Cluster 1 Health Promotion, Disease Prevention and Community Health Initiatives Cluster 2 Maternal and Child Health Cluster 3 Prevention and Control of Communicable Diseases Cluster 4 Prevention and Control of Non Communicable Diseases 3.1 Health Promotion, Disease Prevention and Community Health Initiatives The burden of disease remains high in Uganda and continues to be caused by mainly preventable diseases. Appropriate and timely public health and preventive measures could therefore reduce the high disease burden in Uganda. Health promotion, disease prevention and community health initiatives offer effective interventions in increasing community awareness and health literacy on disease prevention and promotion of health lifestyle in order to have a health and productive population. The cluster on Health promotion, Disease Prevention and Community Initiatives includes the following interventions; Health Promotion and Education, Environmental Health, Control of Diarrhoeal Diseases, School Health and Epidemic Disease Prevention, Preparedness and Response Health Promotion and Education Health Promotion and Education is increasingly being appreciated and acknowledged to be effective in reducing the burden of disease and mitigating the social and economic impact resulting from ill health. Health Promotion and Education and disease prevention help in increasing health awareness, increase community participation and involvement in promoting health, increase demand and utilisation of available health services in addition to adoption of health promotive and 51

52 disease preventive lifestyle. Its major aim is to make health choices easy choices for the general public. Main achievements during FY 2006/07: Table 3.1: Health Promotion and Education key outputs - FY 2006/07 Indicator Baseline FY Target FY 2005/ /07 Achieved Comments Central level programme performance indicators Quarterly performance reports Technical programme meetings Proportion of media institutions participating in health promotion and education 20% 20% Materials were provided to media institutions for public education District level (Service delivery level) indicators Proportion of Village Health 25% 25% Supported 34 districts to Teams trained Proportion of health facilities and community institutions with health promotion materials Proportion of political and cultural institutions promoting health Proportion of population seeking health services according to national standards conduct training of VHTs. 20% 10% Produced & distributed leaflets & posters on cholera, booklets on Avian Influenza & posters on Injection safety. 58% Behaviour Change Communication Developed, translated and disseminated posters, leaflets, brochures, fliers to promote various interventions such as Child Days Plus, cholera, avian flu. Developed and disseminated radio messages on various health interventions. Developed and disseminated radio spots and programmes to promote Child Days Plus. Held talk shows for promoting family planning on 6 radio stations. Capacity Building Supported 12 district based Health Educators to pursue advanced training in Health Promotion and Education at Uganda Martyrs University, Nkozi. Supported thirty four districts to establish and conduct initial training of the Village Health Teams. Community mobilization 52

53 Held community film shows in all districts to raise awareness on reproductive health issues, avian flu, malaria, cholera, STD/AIDS and sanitation. Oriented District Health Educators from 10 districts on various family planning issues in order to mobilize their communities. Advocacy for the Health Sector Strategic Plan Organised press conferences to provide information on priority health issues highlighted in the press. Disseminated fortnight press releases on various health conditions. Held interactive meeting addressing Reproductive Health issues with representatives of media houses. Coordinated the publicity activities for the World Health Day, Africa Malaria Day, Safe Motherhood day, launching of RH communication strategy. World Health Day Invest in Health Build a Safer Future Kampala District 13 th April 2007 Major challenges Inadequate funding to support media educational programmes, Evidence Based Health Promotion, production of IEC materials and VHT roll out programmes. Inadequate human resources to coordinate various Health Promotion and Education Programmes. Low implementation of community based health promotion initiatives. Unable to utilize the printing unit because of lack of funds, inappropriate location and inadequate staffing. Lack of reliable transport for support supervision Environmental Health In Uganda, poor sanitation and hygiene has remained a major predisposing factor to the high burden of disease. It is estimated that 70-80% of Uganda s disease burden is preventable and is associated with 53

54 poor sanitation and hygiene and poor living conditions. A significant indicator has been the cholera and dysentery outbreaks in many districts of Uganda during the year. The mission of Environmental Health therefore is to contribute to a significant reduction of environmental health related morbidity, mortality and disability among the people of Uganda. It was planned that this would be achieved through increased access to sanitation and hygiene services and facilities. The Environmental Health programme therefore continued operating a policy of strengthening an integrated and multi sectoral approach to environmental health management. This encompasses the implementation of a comprehensive legal framework and related regulations for environmental health promotion at local government level. Achievements during FY 2006/07: Table 3.2: Environmental Health key outputs - FY 2006/07 Indicator HSSP II indicators Percentage of Households with pit latrines Baseline FY 2005/06 Target for FY 2006/07 Achieved Comments 58% 100%** 58.5% 2007 DHIs Annual Conference report Central level programme performance indicators Quarterly performance reports Technical programme meetings Proportion of districts implementing Water Quality Surveillance and promotion of safe water consumption Proportion of districts implementing EHMIS using HAB District level (Service delivery level) indicators Percentage of persons washing hands with soap ** Target set by the 2006 National Health Assembly 20% 22% 25% See districts covered in WQS above 10% 20% 30% Tools ready for dissemination in all districts of Uganda 0% 0% 14% Baseline Report on Hand washing by The Steadman Group. This is a new initiative Sanitation: Successfully held the Annual Sanitation Conference for District Health Inspectors and other Sanitation stakeholders. The conference reviewed the national latrine coverage and noted that it had stagnated at 58% for three consecutive years. It should be noted that the ambitious target of achieving 100% latrine coverage by all districts set by the 2006 National Health Assembly could not be achieved. Finalised and printed 5,000 copies of the Household Assessment Books (HABs). This is to facilitate district based Environmental Health Management Information System (EH-MIS). Finalised the 10 Years Improved Sanitation and Hygiene (ISH) Financing Strategy. 54

55 Food Safety and Hygiene: Finalised and officially launched the Food Safety Strategic Plan. The plan emphasizes the need to create consumer awareness about food safety and quality issues and to upgrade the skills of food control inspectors. Water Quality Surveillance: Conducted training of district staff on Water Quality Surveillance techniques for 90 health workers in the 9 districts of Pader, Kitgum, Gulu, Amuru, Nebbi, Adjumani, Yumbe, Moyo and Arua. Oriented 11 DHIs from the districts of Nebbi, Arua, Yumbe, Moyo, Adjumani, Lira, Apac, Kaberamaido, Soroti, Katakwi and Nakaprirpirit. The districts were also equipped with water testing kits, reagents and surveillance tools and manuals. Conducted technical support supervision to districts with emphasis on district planning for safe water chain including the water testing kits and reagents. Distributed Safe Water Chain promotional materials Hand Washing Campaign Initiated a national Hand Washing Campaign, through the public private partnership arrangement. The campaign aims at improving hand washing practices and targets caregivers of children below 5years, children between 6-14 years and the general public. Box 3.1: Kaliro District: The move to increase household sanitation coverage to 100% 55

56 Challenges/Constraints Inadequate resource allocation to hygiene promotion and sanitation at all levels which limits implementation of environmental health programmes. Existence of very high level of poverty in the country makes cofunding of environmental health projects with contribution from the community almost impossible. Inadequate information management especially at lower local governments makes it difficult to establish the actual environmental health situation on the ground leading to inadequacies in planning. Poor enforcement mechanisms for public health regulations. The growing population and economic activities are progressively degrading the environment, resulting in negative economic and health implications. Lack of log-term support to ensure sustained behavior change. Sanitation/hygiene involves behavior change, which takes time. Households do not consider sanitation to be a priority; yet household sanitation is considered an individual responsibility. This is a fallacy as an individual s irresponsibility or lack of means can have an adverse effect on an entire community. Although the provision of water is largely subsidized, there is no subsidy for household sanitation, apart from what goes into promotional messages. It is time government reviewed the pro-poor strategy and evaluated the provision of targeted sanitation subsidies to the very poor (terminally ill, child headed households, the elderly, women headed households, PWDs) Control of Diarrhoeal Diseases Diarrheal diseases and outbreaks (cholera and dysentery) remain among the five major causes of morbidity and mortality in the country. During last financial year, the health sector focused on promotion of interventions that prevent diarrhea in general and ensure proper case management for the sick. Achievements during FY 2006/07 Table 3.3: Control of Diarrhoeal Diseases key outputs - FY 2006/07 Indicator Baseline Target FY 2005/06 FY 2006/07 Achieved Comments Central level programme performance indicators Quarterly performance reports Technical programme meeting Incidence of annual cases of epidemic 3/1000 diarrhoeal diseases Cholera specific case fatality rate 2.4% % District level (Service delivery level) indicators Proportion of patients with epidemic diarrhoea receiving appropriate 56

57 treatment within 12 hours of onset of symptoms Initiated the process of reviewing the CDD policy and introduced new innovations into the management of diarrhoea i.e. o Zinc National Task Force was formed and is functional, o Zinc and Low osmolarity ORS were included in the 2006 Uganda Essential Medicines List (UEMEL), Provided timely technical, logistical, and financial support to 27 (out of the 80) districts which reported Cholera outbreak. The Cholera outbreaks were controlled. Built capacity to manage cholera cases. Standard guidelines for cholera outbreak prevention and control were printed and distributed to affected districts. Thus, cholera case fatality rate reduced significantly from 2.4% during FY 2005/06 to 2.0% in 2006/07. The same efforts used to control cholera also checked dysentery outbreaks in the country. Challenges/Constraints Complacency, hence loss of continued mobilization and good practices in the management of diarrhoea among both health workers and caretakers Poor sanitation and low safe water coverage especially in affected areas (Kampala and IDP camps i.e. coverages below 50% in some districts) Continuous migration across country borders (Sudan and Democratic Republic of Congo) Inadequate enforcement of bye-laws at local levels School Health School Health programme was introduced to create an enabling environment for delivering quality education, for inculcating healthy habits and practices in children in their formative years when they are most receptive. With the implementation of Universal Primary School Education (UPE) and Universal Secondary School Education (USE), a sizable population close to 40% is currently in the education sector. The goal of the School Health program is Healthy school children, staff and healthy school environment. Healthy school children and staff are likely to perform better in all curricular and non-curricular school programmes. Achievements during FY 2006/07: Table 3.4: School Health key outputs - FY 2006/07 Indicator Baseline FY 2005/06 Target for FY 2006/07 Achieved Central level programme performance indicators Quarterly performance reports Comment 57

58 Technical programme meeting Technical support supervision to districts District level (Service delivery level) indicators Proportion of primary and secondary schools implementing the main components of Health Promoting School initiative (HPSI) Proportion of primary and secondary schools having healthy physical environment with latrine and safe water facilities that meet the national guidelines: - pupil per latrine stance ratio 40:1 or better - hand washing facilities, - safe water within 0.5 km radius of institution Proportion of schools providing basic school health services 40% 100% 50% Something being in each component. 50% 20% 60% 56.8% 23% 60% Some progress in quantity but not in quality Finalized arrangements to start mass School Based Tetanus Toxoid Immunization for school girls aged years in upper primary, secondary and tertiary schools. The relevant guidelines and IEC materials were developed and printed. Implemented bi-annual de-worming programme for children aged 1-14 years. Besides getting the tablets, children were educated on personal and domestic hygiene. Developed First Aid booklets for primary schools, and developed IEC messages on school health. Started mass screening of school children in a number of districts such as Mpigi, Bushenyi and Kasese. Challenges/Constraints Delays in finalization of School Health Policy and Memorandum of Understanding between Ministries of Health and Education & Sports Epidemic and Disaster Prevention, Preparedness and Response Epidemic and Disaster Prevention, Preparedness and Response aims at improving emergency preparedness and response both at national and district levels in order to promote health, prevent disease and reduce death among the affected population. Emergencies were routinely handled through early surveillance and mounting a national response as discussed below. Achievements during FY 2006/07 Prevention and control of epidemics i. Cholera Controlled cholera epidemics in 15 border districts with Sudan and DR Congo. A cumulative total of 5,194 cases with 105 deaths were reported. The last districts to be affected were Kitgum, Pader Kampala and Source: MoES Survey report,

59 Ntungamo (specific details are on CDD section). The focus is now on addressing the main root causes such as poor sanitation, poor hygiene and inadequate safe water through inter-sectoral linkages and health education. ii. Meningitis outbreak Contained the meningitis epidemic in Kotido and districts of West Nile. A cumulative total of 3,324 cases and 73 deaths were reported giving a fairly low case fatality rate of 4%. The epidemic was controlled by active case search, vaccination of vulnerable population and effective treatment of cases. iii. Plague outbreak Instituted control measures in Arua, Nebbi and Masindi for plague outbreak. A cumulative total of 22 cases with 10 deaths were confirmed. iv. Alcohol Poisoning 49 people died of alcohol poisoning in the districts of Kampala, Mukono, and Mubende following poisoning by alcohol. This was later confirmed to be contaminated with methyl alcohol (methylated spirit). Steps were taken jointly with the Police, the Uganda National Bureau of Standards to apprehend culprits and ensure control measures Occupational Health The overall objective of Occupational Safety and Health Programme is to prevent occupational accidents, diseases and injuries in Health facilities and other workplaces, ensure maximum awareness of occupational safety and health issues among workers and employers. Achievements Developed and finalized policy and guidelines on Occupational Health services, Table 3.5: Occupational Health key outputs - FY 2006/07 Indicator Baseline FY 2005/06 Central level programme performance indicators Quarterly performance reports Technical programme meeting Technical support supervision to districts Target for FY 2006/07 Achieved Comments District level (Service delivery level) indicators Proportion health workers in the formal sector accessing Occupational health services 30% 50% Proportion health workers in the informal health sector accessing Occupational health services Proportion of workers made aware 30% 50% 59

60 and sensitized on OH&S. Proportion of workers accessing OH services Challenges/ Constraints Inadequate funds to roll out the programme Bureaucracy in the policy formulation procedures 3.2 Maternal and Child Health The Maternal and Child Health Cluster constitutes the priority health care interventions for addressing the disease burden especially in women and children. Perinatal, maternal and childhood conditions constitute the biggest proportion of the national disease burden. The priority health care interventions for addressing the maternal and childhood conditions which are planned and implemented together because of the interdependency and close linkage between mothers and children are Sexual Reproductive Health and Rights and Integrated Child Survival. The specific interventions within Integrated Child Survival include; Newborn Health and Survival, Management of Common Childhood Illness, Expanded Programme on Immunisation and Nutrition Sexual Reproductive Health and Rights The HSSP II prioritized Sexual Reproductive Health and Rights (SRH) programme and together with the Reproductive Health Strategy ( ) identified three priority areas to accelerate implementation of reproductive health strategies. These include (i) Increasing access to institutional deliveries and emergency obstetric care (EmOC) and (ii) Strengthening of Family Planning (FP) services. The 2006 Joint Review Mission also re-emphasized the importance of Reproductive Health and agreed on two Undertakings to be achieved by October 2007 namely; i) provision of CEmOC in 100% of hospitals and 50% of HC IVs and BEmOC in 50% of HC IIIs and ii) Zero tolerance for stock out for contraceptive supplies. Achievements during FY 2006/07 Table 3.6: Reproductive Health key outputs - FY 2006/07 Indicator HSSP II indicators Percentage of health units providing EmOC Baseline FY 2005/06 Target for FY 2006/07 Achieved Comments Couple of Years Protection 309, , ,021 Percentage deliveries taking place in a 29% 35% 32% health facility Caesarean Sections per expected pregnancies (hospital) 7% 30% 60

61 Proportion of pregnant women receiving a complete dose of IPT2 37% 50% 42% Central level programme performance indicators Quarterly performance reports Technical programme meetings Contraceptive Prevalence Rate (CPR) 23% 31% 23.6% Adolescent Pregnancies (Teenage 32% 26% 25% pregnancy) Total Fertility Rate (TFR) 6.5 Maternal Mortality Ratio (per 100,000 live births) Unmet EmOC needs 86% 68% 65% District level (Service delivery level) indicators Proportion of women attending 4 ANC visits 42% 46% 47% Scaling up of EmOC Procured and distributed 30 ambulances to Health Centres IVs and IIIs in 9 northern districts Procured and distributed EmOC equipment to 9 northern districts: RH kits consisting of Delivery kits, Caesarean section kits, MVA kits, FP kits, TBA kits. Assorted EmOC equipment (Vaginal specula, scissors, artery forceps, B.P. machines, Needle Holders, Mucus extractors etc.) Supplies and protective wear (gloves, gynaecological gloves, Gum boots, Aprons etc) Procured a total of 30,793 Safe Delivery Kits (Mama Kits) and distributed them to districts through NMS and JMS. Annex 3.1 provides the distribution lists of Mama Kits to the districts during FY 2006/07. As a result of the improved referral for maternity services and increased availability of logistics and supplies for safe delivery in health facilities, the proportion of expectant mothers delivering in health facilities increased from 29% in FY 2005/06 to 32% in FY 2006/07. The achievement nearly reached the year s target of 35%. Established an equipment credit line by which health facilities will obtain the obstetric equipment required at different levels for the provision of services. Carried out technical support supervision visits and on-job skills development for EmOC in all hospitals in order to scale up EmOC. Revitalisation of Family Planning Conducted training in basic Family Planning in 24 districts. A total of 200 service providers were trained and a total of 220 Community Reproductive Health workers were trained in the community based distribution of family planning methods mainly pills and condoms. Quantified national contraceptive requirements and procured sufficient amounts. Held monthly meetings with partners especially DELIVER, FPAU, UNFPA, USAID and National Medical Stores to streamline contraceptive procurement, storage and distribution. 61

62 There was improvement in Couple Year s Protection (CYP) a measure of family planning uptake, which increased from 309,757 in FY 2005/06 to 357,021 in FY 2006/07. The achievement surpassed the year s CYP target of 325,407. Recruited a Reproductive Health Commodity Security Coordinator and set up an effective monitoring system of the supply chain for RH commodities to reduce the stock outs at the service delivery points. Other achievements Costed and finalized the roadmap for reduction of maternal mortality and newborn. This was discussed and endorsed by Top Management Committee of Ministry of Health. Revised and updated the training curricula for Life Saving Skills and Family Planning. Established Obstetric Fistula training centres at the National Referral hospital Mulago and the Regional Referral hospitals of Soroti, Mbale, Arua, Gulu, Masaka, Kabale and Kitovu. Established Youth Friendly services in 5 Health Centres IVs supported by adolescent Peer Educators in the surrounding subcounties. 30 service providers have been trained in the provision of Youth Friendly Services; 15 in the northern region and 15 from the eastern, central, southwest, Karamoja and north west regions Safe Motherhood Day A Planned Pregnancy A Joyful Birth Soroti District 11 th October 2006 Box 3.2: A discussion on Reproductive Health Indicators trends in the Uganda Demographic and Health Surveys 62

63 Box 3.3: Innovations to increase supervised deliveries in Gulu District Challenges/Constraints Inadequate staffing especially midwives, medical officers, anaesthetists and laboratory technicians for Health Centers IVs Insufficient funds to scale up EmOC to Health Centers IVs and IIIs; and make repeat visits to hospitals. Training of FP providers, Life Saving Skills is expensive and the districts do not allocate funds to these activities. Consequently the trained ToTs are not active and may lose their skills. Ensuring contraceptive commodity security is a big challenge. The pull system through which districts are supposed to get these supplies needs to be strengthened through training and regular technical support supervision Integrated Child Survival The health status of children in Uganda continues to remain poor. There are however cost effective interventions which if well and widely applied can address the major causes of morbidity and mortality in children. HSSP II therefore aims at scaling up the proven and cost effective interventions for addressing the burden of disease among the children and ensuring their integrated delivery. The following are the priority child survival interventions: 63

64 Newborn Health and Survival Management of Common Childhood Illness Expanded Programme on Immunisation and Nutrition Although childhood mortality is still high, recent information from the 2006 Uganda Demographic and Health Survey (2006 UDHS) shows that there is a slight decline in both Under 5 and Infant Mortality Rates. Under 5 Mortality Rate has declined from 152 in 2000 to 137 deaths per 1,000 live births in 2006, while Infant Mortality Rate has declines from 88 in 2000 to 76 deaths per 1,000 live births in Figure 3.1 below shows the trends in Under 5 and Infant Mortality Rates over the last ten years. The national aim is to reduce these rates and achieve the Millennium Development Goals (MDGs) of reducing Under-five Mortality Rate to 51 per 1000 live births and IMR to 29 per 1000 live births by Figure 3.1: Trends in Infant and Under 5 Mortality Rate IMR 137 Under * 39 In order to achieve a sustained scaling up of known/new and cost effective child health care interventions, a comprehensive Child Survival Strategy is being developed to promote national wide and integrated delivery of child health interventions particularly the prevention of ill health and management of sick children. The strategy addresses the gaps within the current survival interventions such as Home Based Care for treatment of common childhood illnesses, immunization, and promotion of good nutrition. It is hoped that cost effective interventions will be implemented on a national scale to ensure that Uganda attains the Millennium Development Goal No. 4 of Reduced Child Mortality Rate. Figure 3.2 shows the anticipated progress towards the attainment of MDG 4 with the implementation of Child Survival Strategy. Figure 3.2: U5MR-MDG4, Actual and Accelerated Performance 64

65 Actual Projected Accelerated MDG Source: Child Survival Strategy for Uganda 2007 Uganda is implementing the Child Days Plus (CDP) strategy, one of the key interventions within the Child Survival Initiatives, for accelerating the implementation of child survival interventions particularly Vitamin A supplementation, de-worming children aged 1-14, immunization, and promotion of key family care practices. Two rounds of Child Days Plus (November 2006 and April 2007) were successfully implemented by all districts with very good coverages. a). Newborn Health and Survival About half of deaths in infants occur in the neonatal period (first 28 days after birth). Of these nearly 2/3 die in the first week of life, and 2/3 of those deaths occur within the first 24 hours after birth. HSSP II therefore prioritized newborn health interventions and are being integrated in the maternal and child health care. Achievements FY 2006/07 Table 3.7: Newborn Health key outputs - FY 2006/07 Indicator Baseline FY 2005/06 Target for FY 2006/07 Achiev ed Central level programme performance indicators Quarterly performance reports Technical programme meeting Technical support supervision to districts 1 4 District level (Service delivery level) indicators Percentage reduction of low birth weight 25% 10% 8% Percentage reduction of neonates seen in health facilities with septicaemia/severe disease 45% 20% 5% Comments Conducted a situation analysis for newborn health in preparation for development of a framework for implementation. 65

66 Developed guidelines for community based newborn care for Community Resource Persons trainers Trained a team of 6 national facilitators for newborn health and 24 district trainers in integrated community based newborn care in seven districts Established a national steering committee on newborn health b). Management of Common Childhood Illness The Integrated Management of Childhood Illness (IMCI) is a key strategy for delivery of integrated child health through improvement of health worker skills in regard to integrated assessment and management of malaria, acute respiratory infections, diarrhoea, and malnutrition, which contribute to over 70% of overall child mortality. During HSSP II the main focus of IMCI is to strengthen district capacity to roll out and sustain IMCI, mobilise resources for implementation and monitor outcomes of key activities at institutional, population level and community level in line with the delivery approaches agreed upon in the Uganda child survival strategy. Achievements during 2006/07 Table 3.8: IMCI key outputs - FY 2006/07 Indicator Baseline FY Target FY 2005/ /07 Achieved Comments Central level programme performance indicators Quarterly performance reports Technical programme meeting Technical support supervision to districts District level (Service delivery level) indicators Proportion of sick under-fives seen by a 45% 55% 60% health worker using IMCI guidelines. Proportion of under fives with fever, 30% 40% 54% diarrhoea and pneumonia seeking care within 24 hours Proportion of under-fives with acute 37% 45% 43% diarrhoea receiving ORT. Proportion of under-fives with pneumonia 30% 45% 47% receiving appropriate antibiotic treatment Percentage reduction of missed opportunities for immunization among sick under fives. 45% 75% 33% Initiated the process for reviewing and scaling policy for community pneumonia treatment Conducted a study towards improving presumptive diagnosis of childhood malaria and pneumonia in lower level health facilities Developed training guidelines for home based care of malaria, pneumonia, diarrhoea and newborns Trained 145 district trainers for home based care and community newborn care in seven districts 66

67 Trained 45 national and district trainers for early diagnosis and treatment of paediatric HIV using the IMCI complementary course guidelines Conducted a post UDHS verbal autopsy study to ascertain causes of child deaths in the country Conducted a national level stakeholder advocacy meeting for integrating newborn health into reproductive and child health Challenges/Constraints Inadequate human resources especially at implementation levels Lack of vehicles for field activities Severe shortage of funds to support the programme activities Limited capacity in the newly created districts c). Expanded Programme on Immunisation Immunization is a nationwide programme targeting mainly infants and women of childbearing age (15-49 years). The mission of UNEPI is to contribute to the reduction of morbidity and mortality due to childhood diseases to levels where they are no longer of public health importance. The programme goal and objective in HSSP II is to ensure that all children are fully immunized against the targeted vaccine preventable diseases before their first birthday and all babies are born protected against neonatal tetanus. Achievements during FY 2006/07 Table 3.9: Expanded Programme on Immunisation key outputs - FY 2006/07 Indicator HSSP II indicators Percentage of children <1 year receiving 3 doses of DPT/pentavalent vaccines Baseline FY 2005/06 Target for FY 2006/07 Achieved Comments 89% 87% 90% Central level programme performance indicators Quarterly performance reports Technical programme meetings Technical support supervision to districts District level (Service delivery level) indicators Fully immunized children 41% 64% * 46% Measles coverage 91% 87% 88% Reduction of DPT 1 3 drop out rate 16% 11% 11% * Results of UDHS 2006 The GoU continued to contribute 100% towards the procurement of the BCG, OPV, TT and measles routine immunization vaccines and their related injection safety materials. DPT-HepB + Hib vaccines are being provided by GAVI in-kind. Carried out monthly delivery of vaccines, injection safety materials, gas and other EPI logistics to the districts. The districts and HSDs 67

68 distribute the logistics to the health facilities that carry out immunization at static and outreach sessions. Box 3.4: Comparison of data from various sources Diseases targeted for eradication and elimination Polio eradication There has been no reported case of wild poliovirus infection since 1997 due to the concerted efforts of the GoU, Development Partners and NGOs. The African Regional Certification Commission (ARCC) declared Uganda polio-free in October The polio surveillance indicators have remained above the target with the Non-Polio AFP rate of Measles Control A decline in measles cases was realized following the successful implementation of the under-15 mass measles campaign in An upsurge in the number of confirmed measles cases was observed at the beginning of the financial year. Most of the affected children were below 5 years and were un-immunized. In response, a nationwide measles campaign targeting children 6 months to 5 years was implemented in August November 2006 and nationwide coverage of 99.5% was achieved. There has been a decline in the reported measles since the campaign. Maternal and Neonatal Tetanus Elimination The programme has been implementing the 5-year MNT elimination strategic plan since The strategy involves carrying out 3 rounds of 68

69 TT mass vaccination targeting WCBA (13 49 years) in high-risk districts with the target of 80% coverage in each round. The mass vaccination was carried out in 3 phases and was concluded with the implementation of the 3 rd round in the nine 3 rd phase districts in November A decline in neonatal tetanus cases has been observed since UNEPI started implementing the strategic plan as shown in Figure 3.3 below. Figure 3.3: Reported NNT cases by year in Uganda, st SIAs nd SIAs # of cases rd Phase year (Source HMIS) Major Challenges/Constraints Inadequate funding for UNEPI operational activities both at the national and district levels which has resulted in; Irregular delivery of vaccines and other logistics from the center to districts leading to vaccine shortages. Uneven distribution of vaccines and supplies from districts to lower level health facilities. Irregular functioning of outreaches. Lack of support supervision from center to districts and from districts to lower levels. Lack of regular cold chain maintenance at all levels leaving some fridges not functioning. This has further been compounded by the creation of new districts that need new infrastructure to be set up. d). Nutrition 69

70 Nutrition is a crucial, universally recognized component of the child s right to the enjoyment of the highest attainable standard of health as stated in the Convention on the Rights of the Child. These rights have however not yet been realized in many environments. Malnutrition has been responsible directly and indirectly for 34 percent of the 6.2 million deaths annually among children under five. The overall objective of Nutrition Programme therefore is to improve the nutritional status of the population with emphasis on the vulnerable groups of the children and mothers. Nutrition is a cross cutting programme and therefore collaboration and partnership with UN agencies, various relevant ministries and departments, NGOs, Industries, University Departments and other bodies in the implementation of activities is crucial. Achievements during FY 2006/07 Table 3.10: Nutrition key outputs - FY 2006/07 Indicator Baseline Target FY FY 2005/ /07 Achieved Comment Central level programme performance indicators Quarterly performance reports Technical programme meetings Technical support supervision to districts District level (Service delivery level) indicators Increase the prevalence of exclusive breastfeeding Reduce the prevalence of underweight among under fives Increase Vitamin A supplementation uptake for 6-59 months Attain and sustain 100% household consumption of iodized salt 62% 64% 23% 20% 61% (UDHS 2006) 16% (UDHS 2006) 37% 70% 60% 94.8% 100% Over 95% Infant and Young Child Feeding Efforts were made to streamline the implementation of Infant and Young Child Nutrition especially in co-ordination and integration of the various component activities with other programmes such as PMTCT and Reproductive Health. The programme has consequently made some progress especially in improving the skills of health workers in counseling women on feeding infants 0-6 months both under normal circumstances and when affected with HIV/AIDS. Reviewed the policy on feeding infants and young children in the context of HIV/AIDS to include all the aspects of Infant and Young Child Feeding. Revised guidelines on the management of severe malnutrition to include HIV/AIDS and Community Therapeutic Care (CTC). Researches in the African region including Uganda have shown that management of uncomplicated malnutrition (about 75%) is feasible in the communities through an innovative approach involving highly fortified, Ready to Use Therapeutic Feeds (RUTFs). A training manual 70

71 on managing malnutrition has been developed to accompany the guidelines. Regularly conducted Nutrition Surveys in northern, eastern and the Karamoja region. The levels of malnutrition have reduced considerably although the living conditions in the camps are still poor. The assessment results have been used to revise and recalculate food rations, as well as improve on the health and nutrition related interventions and for advocating for other non-food interventions. Successfully celebrated the 2006 World Breastfeeding Week whose theme was Regulate the Marketing of Infant Foods: Protect, promote and support breastfeeding. Several activities were carried out at both national and district levels to mark the event. The aim of WBW is to advocate for the implementation of interventions to promote appropriate infant and young child feeding practices at all levels. Prevention and Control of Micronutrients Deficiencies In collaboration with Uganda National Bureau of Standards (UNBS) and Uganda Revenue Authority (URA), the Ministry of Health has successfully sustained the programme of Universal Salt Iodation. This is evident from a number of border monitoring exercises of nine districts namely; Rakai, Kisoro, Kabale, Kasese, Masindi, Hoima, Tororo, Busia and Nebbi. The use of adequately iodized salt by households remains at 95%. The proposal submitted to Global Alliance for Improvement of Nutrition (GAIN) was successful and the grant has been awarded. Held the Iodine Deficiency Disorder (IDD) awareness activities at both the national and district levels. The climax of the activities was a national event in Tororo District. Other activities included Press Conference, media personnel sensitization meeting of 30 people, Film van shows Developed and distributed various IEC materials during Child Days Plus Challenges/Constraints Inadequate prioritization of nutrition activities in the district health plans resulting in inadequate funding for nutrition activities Inappropriate deployment of Nutritionists to Regional Referral Hospitals and not at the district. This limits their work to mainly clinical services and leaves a gap in public health nutrition interventions. 3.3 Prevention and Control of Communicable Diseases Uganda s disease burden is mainly due to communicable diseases. HSSP II therefore prioritized the prevention and control of communicable diseases in order to reduce the high national disease burden. The 71

72 priority health care interventions being implemented in HSSP II to prevent and control communicable diseases include; Prevention and Control of STI/HIV/AIDS, Prevention and Control of Malaria, Prevention and Control of Tuberculosis and elimination and/or eradication of some particular diseases such as Leprosy, Guinea Worm, Onchocerciasis, Trachoma, Lymphatic Filariasis, Trypanosomiasis and Scistosomiasis Prevention and Control of STI/HIV/AIDS HIV/AIDS continues to pose serious public health and development challenges in Uganda. The implementation of HIV/AIDS and STDs programme continued to be challenging because HIV/AIDS remains a complex disease and incurable, while STDs are becoming complicated by the herpes simplex virus type 2 (HSV-2) which has contributed to HIV infection. During FY 2006/07, there was an increase in new HIV infection of 120,000 individuals. The scale up of universal access to antiretroviral treatment had a noticeable improvement in reducing AIDS related morbidity and mortality. The stagnation of HIV prevalence continued. Achievements during FY 2006/07 Progress was made in implementation of the following interventions: Table 3.11: HIV/AIDS key outputs - FY 2006/07 Indicator HSSP II indicators Urban/rural specific HIV sero-prevalence rats Baseline FY 2005/06 6.4% Target FY 2006/07 Achieved Comment Central level programme performance indicators Quarterly performance reports Technical programme meetings Technical support supervision to districts Proportion of districts with at least one PMTCT site District level (Service delivery level) indicators Proportion of health facilities from HC III and above that are providing HCT Proportion of health facilities from HC IV and above that are providing ART Proportion of health facilities from HC III and above that are providing PMTCT. Proportion of new ANC clients tested for HIV Proportion of expected pregnant women tested for HIV during pregnancy Proportion of expected HIV positive pregnant women who received ARVs for PMTCT Proportion of HIV positive pregnant women given ARVs for PMTCT 100% 100% 100% 42% 57% 32% 40% 45% 58% 70% 79% 24% 35% 40% 19% 30% 36% 70% 70% 78% 72

73 Information, Education, Communication and Behaviour Change Promotion (IEC/BCC) Developed, printed and disseminated the HIV/AIDS handbook for life planning skills for health educators Developed and pre-tested IEC/BCC materials for ART advocacy (4 posters & 2 leaflets). This awaits printing and dissemination. Disseminated HIV prevention road map in South Eastern and Western regions to 50 district leaders Conducted film shows in 15 selected districts with fishing communities to sensitize them on HIV prevention messages. Printed and distributed 5,000 leaflets, 5,000 posters for TB/HIV collaborative activities to districts of Northern Uganda. Airing of TV spot, Talk show as well as Radio spots to inform the public about measures taken to ensure quality of all condoms in the country including the re identified Engabu. Production and dissemination of Video on Condom testing in Uganda. Production and distribution of 1,000 Support ABC for prevention bags for Community Condom distributors Carried out assessment of condom availability, distribution, storage status in 35 districts Trained 60 district condom focal persons in logistics management Trained 175 trainers for Community Condom distributors in 7 districts ie Nakapiripirit, Kabale, Kasese, Arua, Pader, Mayuge and Masaka. Training 840 community condom distributors in 6 districts i.e. Kabale, Kasese, Arua, Pader, Mayuge and Masaka. Printing of 500 copies of the National Condom distribution guidelines Distributed 85 million public sector condoms through National Medical Stores Prevention of Mother to Child Transmission of HIV (PMTCT) Continued scaling up and strengthening of PMTC programme with particular focus on strengthening postnatal care. Table 3.8 shows the proportion of health facilities by level providing PMTCT services. Table 3.12: Health facilities providing PMTCT by level. Health facility level Total Coverage (2006) Coverage by June 2007 Hospital (94%) 98(97%) HC IV (87%) 151(92%) HC III (20%) 258(29%) HC II The quality of PMTCT services has greatly improved across many districts. The number of health facilities providing routine HIV counselling and testing for pregnant women increased, raising HIV test uptake from 70% of all clients attending ANC at health facilities 73

74 providing PMTCT in 2005/06 to 80% in 2006/07. Figure 3.4 shows trends in uptake of PMTCT services. In addition missed opportunities in administration of antiretroviral drugs to HIV positive mothers has greatly reduced; 81% of all clients diagnosed HIV positive are given ARVs as opposed to 58% of clients tested HIV positive in the period Jan June 2006 Figure 3.4: Trends in uptake of PMTCT services 2004 June Percentage % New ANC counselled % of New ANC tested % HIV + given ARVs % Baby given ARVs Jan - Jun 06 Jul - Dec 06 Jan - Jun 07 Developed PMTCT policy and clinical guidelines based on the New WHO recommendations. Developed and launched the National Guidelines for Implementation of Family support groups in Prevention of Mother to Child HIV Transmission. Developed and printed Guidelines for Health workers for Early HIV Diagnosis and Care among Infants Launched guidelines for nutrition among people with HIV/AIDS ( improving the Quality of Life through Nutrition: A guide for Feeding People Living with HIV/AIDS). Finalised the PMTCT Training package i.e. The facilitator and participant manuals for Training Health Workers on Strategies for Prevention of Mother to Child HIV Transmission December 2006). Developed, printed and now disseminating data collection registers (integrated antenatal register, delivery register and postnatal register). This allows for integrating routine reproductive health data and HIV/AIDS services. 74

75 HIV Counselling and testing Successfully rolled out Routine Testing in the clinical settings (RCT) starting with the Regional Referral Hospitals. Table 3.13 shows HCT coverage by health facilities levels in FY 2006/07. Table 3.13: HCT Coverage by Health facility levels in 2006/07 Level of Health facility Total no. in the Country No. of HCT sites as of June 2006 % coverage in 2006 No. of HCT sites as of June 2007 % coverage in 2007 Hospitals HC HC Finalized the HCT Policy Implementation Guidelines Integrated HIV Counselling and Testing data into the HMIS Developed HCT training standards Control of Sexually Transmitted Diseases/Infections Trained 60 district STD trainers from 10 districts. Supported 10 condom outlet points for the most at risk populations (Commercial sex workers, Fishing communities and long distance truck drivers stop areas) Continued with the on-going community surveillance study on HSV2 in Kawempe division - Kampala District. Introduced and provided RCT (routine counseling and testing) to 6,000 clients at the national STD/Skin clinic. Infection Control (Universal Precautions) Carried out auditing of infection control and injection safety practices in 4 districts of Jinja, Kamuli, Kayunga and Kampala covering 24 health sub districts. Sensitised 60 members of the District Health Management Teams and District leaders in Kamuli on infection prevention and injection safety. Developed post exposure prophylaxis (PEP) policy and implementation guidelines. Drafts are available awaiting printing and dissemination. Trained 20 Home Based Care trainers in infection control, PEP and injection safety at Health units and community level. Comprehensive HIV/AIDS Care Sustained the increase in the number of persons receiving ART since the launching of universal access in The increase has been slow in children due to difficulties in administering peadiatrics formula, early identification of children with HIV (diagnosis) and capacity of health care providers to manage peadiatric HIV/AIDS. Figure 3.5 shows the trends in the number of persons on ART since

76 Figure 3.5: Trends in number of person on ART Trends of patients on ART (Children <14 yrs Vs. Total ) 120, ,000 No. on ART 80,000 60,000 40,000 20, Dec 2004 June 2004 Dec 2005 June 2005 Dec 2006 June 2006 Dec 2007 April Total on ART Children <14yrs The number of health facilities accredited for providing ART increased from 212 by June 2006 to 306 health facilities by end of June 2007 as shown in Table Sites offering ART include two National referral hospitals, 11 regional referral hospitals, 97 HC IVs, 29 HC IIIs, 54 clinics and 106 hospitals (including both NGO and government hospitals). Table 3.14: Number of Health Facilities accredited for providing ART in 2006 and 2007 Health facility level Total Coverage by June 2006 (%) Coverage by June 2007 (%) National referral 2 2 (100%) 2 (100%) Regional referral (100%) 11 (100%) Other hospitals (86%) 88 (100%) Health centre IV (40%) 97 (59%) Health Center III Quality of Care Quality Assurance Rolled out a countrywide Quality Improvement programme to ensure that health workers provide HIV care and treatment according to set standards. This has been done in collaboration with Quality Assurance Project (QAP). The programme activities which initially started in 57 health facilities have now been expanded to cover 87 facilities in all the districts in the country. A steering committee, a core team and regional coordinators have been appointed to facilitate the smooth running of these activities. 76

77 Ministry of Health formulated a set of Quality Improvement objectives and indicators for this programme. Quality Improvement Successfully piloted the Continuous Quality Improvement (CQI) approach in 20 health facilities through coaching and mentoring clinical teams to build their capacity in quality management to provide improved quality of care. This was initiated through a partnership between the Ministry of Health and CDC. Home Based Care Developed national HBC policy guidelines Support supervision of 2 districts to strengthen human capacity at district level to improve on quality of HBC services. Trained 60 HBC Trainers of trainers in HBC in 10 districts HIV/AIDS/STI Surveillance, Monitoring and Evaluation and Operations Research Updated the protocol for conducting ANC and STD clinic based HIV surveillance. Trained 47 sentinel surveillance site staff from the 25 sentinel sites in the updated protocol for conducting ANC and STD clinic based HIV surveillance. Conducted the 2006 ANC and STD clinic based HIV surveillance in the 25 sentinel sites. The process of testing blood samples, data analysis and report writing is on going. Continued to disseminate the National HIV Sero-Behavioral survey at regional levels. Conducted the integrated support supervision in 45 districts considering all the components of the national response to HIV/AIDS/STD. Provided on site support to strengthen district level M&E of health sector interventions in 16 districts. Trained 50 M&E focal persons from 30 districts in Monitoring and Evaluation of HIV/AIDS activities in districts with M&E gaps. Completed and disseminated the KABP survey report on STD/HIV/AIDS for fishing communities Wakiso district. Challenges/Constraints Weak district capacity in implementing the health sector response to HIV prevention, care and treatment leading to slow scale up of activities at all levels of service delivery: o Delay by Ministry of Public Service to establish counselors` cadre. o Inadequate number of staff at facilities compared to workload comprising the quality of services. High attrition rate of trained skilled health care providers especially 77

78 doctors in comprehensive HIV care activities including ARV. Weak supply chain management system leading to frequent stock outs of health commodities in health facilities particularly ARVs, Testing kits, laboratory consumables and Condoms. This has also led to expiry of some commodities at national and district level. Coordination of partners involved in HIV prevention, care and treatment is becoming difficult as more sites get accredited for ART. The National Coordination Committee has not been functional due to lack of funds and the District Health Officers have not been able to coordinate HIV activities among partners. Weak monitoring system for HIV activities resulting from poor documentation and reporting by facilities, lack of data from ANC surveillance sites and poor reporting to the ministry by partners (Both PPF and PNPF). Inadequacies in diagnostic equipment especially CD4 machines at hospitals many of which have broke down. Bad image of Engabu still lingers on after the quality issues of This necessitated the borrowing of Lifeguard name for one year. Rebranding process for a new public sector Condom is in progress. Procurement of condoms has not been timely which leads to limited stock and procurement of condoms through Emergency arrangements with development partners Tuberculosis Control The burden of Tuberculosis is still high. Globally, 1/3 of the World population is infected with TB with 9 million new cases and 2 million deaths annually. Nationally, a total of 80,000 new cases are expected annually. In 2006, a total of 41,927 cases were notified. The mission of the National Tuberculosis Control Programme therefore is to reach the Global targets of Case Finding and Treatment success by 2010 and Integrate Leprosy services at HC III level countrywide by The intervention strategies of TB control are tailored along the Global STOP TB Plan, the Expanded DOTS strategy, MDG Goals, Abuja Declaration, Maputo Declaration, and Leprosy elimination strategy. Achievements during F 2006/07 Table 3.15: Tuberculosis control key outputs - FY 2006/07 Indicator HSSP II indicators Proportion of Tuberculosis cases notified compared to expected (CDE) Proportion of Tuberculosis cases that are Baseline FY 2005/06 Target FY 2006/07 Achieved Comments 50.3% 65% 49.6% 70.4% 80% 73.2% cured (successfully treated). Central level programme performance indicators Quarterly performance reports Technical programme meetings Technical support supervision to districts

79 CB-DOTS coverage per district 100% 100% 100% District level (Service delivery level) indicators Proportion of TB patients offered 40% 60% 75% Counseling and testing per district Proportion of deaths among newly registered smear positives per quarter 6.2% 3.1% 6.6% Trends of Tuberculosis notification in Uganda: The number of Tb cases notified is still high but seems to have stabilized at around 42,000 cases as shown in Figure 3.6. This however is still a low detection rate of 49.6% in Figure 3.6: Number of TB cases notified 50 Thousands All cases AFB + AFB- EPTB Source: WHO update / Quarterly case finding reports, Uganda NTLP Achievements during FY 2006/ Expanded Community Based TB care with Directly Observed Treatment with Short Course (DOTS) drugs to all districts in the country. Treatment success rate increased from 70.4% in 2005/06 to 73.21% while Case detection stayed at 49.6%. Figure 3.7 shows the TB treatment outcome for the whole country of those registered in Figure 3.7: TB treatment outcome 79

80 5 Treatment Success Died Failed Defaulted Transferred Source: WHO update/quarterly treatment outcome reports, Uganda NTLP ( Kampala City included ) Procured and distributed 300 motor-cycles to strengthen community supervision of TB and Leprosy interventions in the districts. Procured and distributed ample fixed dose combination anti-tb medicines and laboratory reagents supplies countrywide. Developed and operationalized countrywide a new Distribution and Tracking systems for medicines, reagents and supplies. Produced a modular Training Manual and Job/Desk Aide to standardize training, practice and Care. Conducted various refresher training of in-service health care workers at national and district levels. Established a national Coordination Committee for TB/HIV activities, drew a TB/HIV Policy, Communication strategy and Implementation Guidelines. A separate TB Communication strategy was also drawn during the year. The Policy and Communication documents were launched in Implemented the Intensified Support and Action Countries (ISAC) Initiative by appointing 2 National Professional Officers (NPOs), 3 Assistant Professional Officers (ANPOs) in WHO-Country office to boost CB-DOTS implementation. This has resulted in 100% coverage of all districts. A Logistics/Administrative Officer was posted to the Central Unit of NTLP. Secured funding for physical rehabilitation and strengthening of External Quality Control (EQA) of the National Reference TB/Laboratory. All zones except Karamoja have been covered with improved performance of the laboratory network. Conducted operational research on Integrating TB and HIV care in VCT services in Nsambya hospital. This approach facilitates comprehensive screening for both TB and HIV for easy access to DOTS, Isoniazid Preventive Therapy (IPT) and ARVS. The IPT has now been expanded to AIC centres in Kampala, Mbarara, Mbale and Jinja. 80

81 World TB Day TB Anywhere is TB Everywhere Mpigi District 24 th March 2007 Challenges/constraints Understaffing at Central Unit and in health units especially shortage of laboratory personnel limits the diagnostic capacity for TB. The position of District TB and Leprosy Supervisors (DTLS) was removed during the Local Government restructuring exercise. The personnel working as DTLS are therefore not full time and this lowers the quality of support supervision to units. Districts do not budget and allocation enough funds for TB and Leprosy control activities. Flow of funds to and within districts is slow and this makes it hard for the DTLSs and Sub-County Health workers to complete their quarterly monitoring on time. Inability of the health system to capture information of patients who go to purely private units. Multiple Drug Resistance (MDR) Tuberculosis is on the increase. Data on culture and sensitivity testing from the National Reference Tuberculosis Laboratories over the period January September 2007 showed 15 cases of MDR out of 640 tested (2.3% among both new and re-treatment cases of tuberculosis) compared to 14 patients FY 2005/ Prevention and Control of Malaria Malaria remains one of the most dangerous diseases in Uganda with respect to morbidity and mortality burden, as well as economic losses. 81

82 Malaria contributes about 30 50% of outpatient burden and 35% of hospital admissions. The goal of Malaria Control Programme therefore is to control and prevent malaria morbidity and mortality, as well as to minimize social effects and economic losses attributable to malaria. In order to achieve this, the malaria control programme endeavours to go to national scale with a package of effective and appropriate interventions, attaining high coverages and promote positive behaviour change so as to prevent and treat malaria in the country. The mainstay of intervention strategies for malaria includes: Prompt and effective case management at facility, community and household levels; Use of insecticide treated mosquito nets; Indoor residual spraying with efficacious insecticides; Environment management where feasible; Intermittent preventive treatment in pregnant women; as well as Epidemic preparedness and response. Achievements during FY 2006/07 During FY 2006/07, key achievements were noted in IPT2 coverages, promptness in treatment of children with a fever, ITN coverages and IRS consolidation and expansion. Table 3.16 shows performance against key indicators of health sector performance. Table 3.16: Malaria Prevention and Control key outputs - FY 2006/07 Indicator HSSP II indicators Proportion of children under 5 years with fever who receive malarial treatment within 24 hrs from a community drug distributor % of fever/uncomplicated malaria cases (all ages) correctly managed at health facilities Proportion of pregnant women receiving a complete dose of IPT2 Baseline FY 2005/06 Target FY 2006/07 Achieved Comment 60% 80% 71% Data based on 4 surveyed districts (Rakai, Kumi, Hoima & Apac) 31% 60% 42% 37% 50% 35%* Incomplete data figure based on quarters 1,2&3. Percentage of house holds with at least one ITN Central level programme performance indicators Quarterly performance reports Technical programme meetings Technical support supervision to districts Number of districts in epidemic prone areas covered by IRS 1 District level (Service delivery level) indicators Proportion of children under 5 15% having slept under an ITN the previous night 82

83 Effective Case Management This strategy is mainly through health facility and community based channels. Community channel Consolidation of the Home Based Management of Fever strategy (HBMF) in districts through retention of Community Medicines Distributors (CMDs) and treatment or referral of patients by CMDs as shown in Table There was also piloting of ACTs at community level in 5 districts (Kitgum, Gulu, Pader, Amur and Kiboga). Table 3.17: HBMF performance in 4 selected districts (FY 2006/07) Indicator Apac Hoima Kumi Rakai Average % CMDs still active 75% 72% 75% 76% 75% % patients treated by CMD who received Homapak within 24 hrs % patients treated or referred by CMDs who recovered 70% 70% 76% 63% 70% 94% 91% 95% 96% 95% Health facility channel Rolled out use of ACTs in facility based malaria case management in the whole country through procurement, distribution, capacity building (84% training coverage), distribution of guidelines, as well as follow up support supervision. Trained private practitioners across the country. The programme has started registering a decline in malaria morbidity. Figure 3.8 shows the trend of outpatient malaria cases from 1999 to There is a 39.3% reduction in the total outpatient cases (9.9 million cases in 2006 compared to 16.3 million cases of the year 2005). The reduction could be due to roll out of new malaria treatment policy change to ACTs (Coartem), the introduction of IRS in Kabale dstrict and the slight increase in ITN coverage. Figure 3.8: Trends in Malaria morbidity

84 Uganda;Trend of malaria OPD Cases over the years (HMIS DATA) 18,000,000 16,000,000 14,000,000 12,000,000 Number of cases 10,000,000 8,000,000 16,321,582 Series2 6,000,000 4,000,000 8,966,564 9,791,014 11,260,686 12,197,533 9,901,882 2,000,000 5,247,359 5,470, YEARS ( ) Intermittent Preventive Treatment of Malaria in Pregnancy This strategy aims at achieving a high coverage of intermittent preventive treatment of pregnant women with at least 2 doses of sulfadoxinepyrimethamine (SP) in the 2 nd and 3 rd trimesters under direct observation. The following was achieved: Reduction in stock outs of SP within health facilities; Increased facilitative supervision and peer mentoring in 24 districts; Rolled out standardized recording and monitoring of IPT data through pre-printed antenatal registers in 4 districts. The overall coverage of IPT2 increased from 31% in 2005/06 to 42% in 2006/07. 84

85 ITN Promotion Africa Malaria Day Free Africa from Malaria Now Roll Back Malaria Sembabule District 25 th April 2007 There was a boost in distribution of nets from GFATM and PMI initiatives (1.8 million and 840,000 nets respectively) where 44% (427/971) sub counties benefited. All districts (80) benefited from GFATM nets, while 37 benefited from PMI nets. This resulted into approximately 42% ITN coverage among under-five children, compared to 32% coverage in 2005/06 Greater shift from distribution of untreated nets to long lasting nets (LLINs). It is estimated that 40% of nets in the country are long lasting nets. There was placement of ITNs at Antenatal, young child and HIV clinics to mop up the target groups. Carried out the 3 rd round of net re-treatment exercise in the same year, which realized an increased of 84.8% coverage as shown in Figure 3.9 below in the 19 targeted old districts (now 32 new districts). Figure 3.9: Number of nets re-treated Number of nets re-treated in 32 districts 525,000 net treated 520, , , , ,000 Number 500, , , , , , , , , /05 (1st round) 2005/06 (2nd round) 2006/07 (3rd Round) Period Indoor Residual Spraying The objective of strategy is to improve the quality and coverage of IRS in epidemic prone and endemic districts as well as IDP camps. There was consolidation and extension of IRS in districts of Kabale, Kanungu, Kitgum, and Pader as shown in table 3.18 below 85

86 Table 3.18: IRS performance in selected districts Key IRS indicators Kabale 2nd Round Kanungu 1st Round Kitgum 1st Round Pader Total target houses found 78,020 44,799 88, ,754 Total structures sprayed 76,084 45,321 84, ,458 % of targeted houses partially and fully sprayed Total population protected 364, , , ,752 Number of children < 5yrs protected 60,698 36,222 86, ,605 Number of pregnant women protected 6,022 5,580 14,709 30,339 All these resulted into rapid decline of malaria case admissions and malaria parasitaemia as per blood smear tests as shown in Figure 3.10 below. Figure 3.10: Malaria-positive Blood Smears, Kihihi HC IV, Kanungu District Aug 06-June total blood smears malaria-positive blood smears IRS-Icon o NEMA approved the use of DDT in IRS in December Policy and implementation guidelines for IRS using DDT have been finalized. Malaria Operations Research Carried out pilot Malaria Rapid diagnostic tests in 5 districts. Evaluated the efficacy of Artemether - Lumefantrine and artemetherpiperaquine Artemther Nephthaquine ACTs. 86

87 Results show the high efficacy of the three drugs and the usefulness of the new diagnostic tests (RDTs). Challenges/constraints Delayed procurements of bicycles for Community Medicine Distributors Poor supply management of Coartem leading to artificial shortages in mainly rural health facilities Inadequate and ineffective Monitoring & Evaluation systems to measure the impact of scaled up interventions; Inadequate Infrastructure and supply management systems; Lack of proper disposal mechanisms of the expired HOMAPAK Veterinary Public Health The mandate of Veterinary Public Health is to reduce the burden of zoonotic diseases and animal related food borne infections and ill-health to a level that they are no longer of significant public health importance in the country. This is important because a number of the newly emerging and re-emerging human infections currently threatening global public health are of animal origin (e.g. Avian influenza/ Bird flu, Rift Valley fever, Severe Acute Respiratory Syndrome (SARS), Mad Cow Disease /Bovine Spongiform Encephalopathy and Viral Hemorrhagic fevers such as Ebola and Marburg ). In addition, long established zoonotic diseases like rabies, bovine tuberculosis, brucellosis, anthrax, meat borne parasitic diseases such as cysticercosis and hydatidosis are still of major public health concern in the country. Achievements during FY 2006/2007 Table 3.19: Veterinary Public Health key outputs FY 2006/07 Indicator Baseline FY 2005/06 Target for FY 2006/07 Achieved Comments Central level programme performance indicators Quarterly performance reports Technical Programme meetings N/A N/A N/A VPH Unit has only one technical officer Technical Support supervision to districts Insufficient funds District level (service delivery level) indicators Number of suspected cases given rabies post-exposure treatment Reporting of suspected Avian & pandemic influenza cases 3,750 8,000 5,500 Increased cost of rabies vaccine 0 80 districts 80 districts Weekly IDSR reporting Developed guidelines on rabies Post Exposure Treatment (PET) and vaccine allocation criteria 87

88 Procured a total of 9,600 vials of human rabies vaccine for Post- Exposure Treatment (PET) of human rabies at a cost of UShs. 199 million and supplied them to districts. A total of 5,500 people received post-exposure treatment against the disease. The National Plan of Action on Avian influenza (NPA/AI) for promoting multi-sectoral collaboration and coordination with other sectors was finalized and approved by Cabinet in February Procured 1,000 doses of Oseltamivir phosphate (Tamiflu) for use in Avian Influenza epidemics. Emergency stocks available at NMS with expiry date of Developed capacity for laboratory diagnosis of influenza virus Type A H5 at UVRI, Entebbe Established a National Influenza Centre at UVRI through Centers for Disease Control & Prevention USA/MoH collaboration which has enhanced epidemiological studies and operational research on influenza. Sensitised 42 districts on National Plan of Action for Avian Influenza Investigated over 200 suspected Avian Influenza/Bird flu outbreaks and /or rumours in birds and one in humans. All cases were found negative for influenza virus type A H5N1. Trained a total of 96 hospital and district health teams staff from 12 districts in Northern and North western Uganda on surveillance, monitoring and case management of Avian Influenza. Printed and disseminated 3,000 copies of protocol and 6,000 folders with of Avian Influenza case definition and report forms. Challenges / Constraints There is currently only one professional staff in the VPH Division, this should be improved through establishment and recruitment of more professional staff. Inadequate funding for the divisional activities Lack of reliable transport for field activities Diseases targeted for elimination and/or eradication Uganda is a signatory to international resolutions committed to the elimination and eradication of particular diseases. The diseases targeted for elimination include Leprosy, Guinea Worm, Onchocerciasis. Substantial progress towards the elimination targets was registered during HSSP I. HSSP II therefore continued to target these diseases and support acceleration of their elimination and or eradication. a) Leprosy Uganda achieved the WHO global target for elimination of leprosy as a public health problem in HSSP II therefore aimed at maintaining the required level of interest, skills, commitment and investment in resources to sustain the elimination status. The burden of Leprosy was 423 (MB 293, PB 140) cases by December 2006 out of which 48 are Children. 88

89 Achievements during FY 2006/07 Sustained the elimination rate of leprosy (prevalence rate of less than 1/10,000 population) which was achieved in 1994 nationally. Detected and treated about 1900 new leprosy cases during the last 3 years. Maintained a system for monitoring leprosy elimination at national and district levels. Maintained a regular supply of MDT (anti-leprosy treatment) Put in place a Programme for Social Economic Rehabilitation of people affected by leprosy (integrated with main stream rehabilitation services) Continued with rehabilitative services like foot wear, prostheses and Socio-Economic activities for persons affected by Leprosy in all the six national centres. Procured ample supplies of anti-leprosy medicines and provided supplies for manufacture of rehabilitative materials by grants from the German Leprosy Relief Association GLRA. Challenges/Constraints: Implementation of leprosy control programme in a low endemic state is not cost effective (detection and management of a small continuing trickle of new cases is very expensive). Still experiencing stigma associated with leprosy in the community Low community awareness about leprosy in era of declining prevalence. Low awareness of health service providers on signs of leprosy and its management. b). Uganda Guinea Worm Eradication Programme Uganda is still facing the challenge of re-infection with imported guinea worm cases from the Sudan, which is still the most endemic country in the world contributing about 60% of the current number of guinea worm cases reported in the world. In view of this threat, the programme must exist to ensure that guinea worm is not reintroduced in the country as the certification process is on going. The objectives of the Guinea Worm Eradication Programme are therefore to maintain zero transmission status for indigenous guinea worm cases and contain 100% of any guinea worm cases reported.achievements during FY 2006/07 The targets for indicators of performance for Year two and the entire HSSP II period for the programme have been fully achieved. Table 3.20: Guinea Worm key outputs - FY 2006/07 Indicator Baseline FY 2005/06 Target FY 2006/07 Central level programme performance indicators 100% containment 100% case of all imported 100% case containment guinea worm cases containment Achieved 100% case containment Comments NCC in place and preparing the country for 89

90 No local transmission Zero transmission Zero transmission Maintained zero transmission certification by ICCDE Challenges/Constraints: Cross-border importation from the Sudan as a result of population movement across the common border. This challenge could delay early certification as guinea worm free country. Insecurity in Northern Uganda Inadequate funding in districts for surveillance, vehicle operations as well as maintenance of safe water sources due to misconception that guinea worm is already eradicated. c) Trachoma HSSP II earmarked trachoma for elimination from the 18 affected districts. This was to be achieved through implementation of the SAFE strategy, both at national and district levels through mass community distribution of Tetracycline and Azithromycin, training of Lid rotation surgeons and provision of equipment, promotion of school facial hygiene practices, family sensitisation and improved water supply through the school health programme and capacity building in the communities and schools to address the prevention and control of trachoma. Achievements during FY 2006/07 Conducted a survey on prevalence of trachoma in the districts of Kamuli, Kaliro, Namutumba and Iganga and disseminated the results to stakeholders. Developed the Training of Trainer s Manuals for elimination of Trachoma, which is being implemented in several endemic districts. Developed IEC materials about prevention and control of trachoma and are already for printing and dissemination. Challenges Under staffing d) Human African Trypanosomiasis (Sleeping Sickness) The programme on Human African TRypanosomiasis (HAT) provides support to district health departments to carry out surveillance and case management. There is done in close collaboration with the Veterinary and Entomology sections of MAAIF through COCTU which is the Secretariat for Uganda Trypanosomiasis Control Council established by statute. During FY 2006/07, the programme focus was directed at (a) providing support to districts for surveillance and treatment (b) bringing on board new outbreak districts (c) participating on efforts to halt the possible merger and (d) providing support to ongoing clinical trials at Omugo HC IV and Lwala Mission Hospital; and sample collection for the new diagnostics study at Namungalwe HC III in Iganga District. 90

91 Achievements during FY 2006/07: Supplied drugs Suramin and MelB for T. b. rhodesiense and Pendamidine, MelB and DEMO for the gambiense infection to all treatment centres. Sustained the surveillance on Sleeping sickness Encouraged and supported districts to adopt the integration strategy with other programmes especially in obtaining reagents and supplies through the PHC fund. Prepared and distributed guidelines on the management of T.b. rhodesiense infection to the South Eastern districts. Provided support to new outbreak districts of Lira, Apac and Kalangala to establish treatment centres. Challenges/Constraints The changing role of FITCA, from being a disease control project to more of an agriculture project, has implications for surveillance support to districts. Inadequate funding from government The recent re-allocation of Sleeping Sickness Assistants (SSAs) to other disease programmes is likely to have negative effects on HAT control in general. The slow take off of PATTEC is causing some concern to programme activities because it had been anticipated to bridge some gaps in HAT control. e) Schistosomiasis and soil transmitted helminths The National Schistosomiasis and Worm Control Programme use the strategy of mass annual antihelminthic treatment targeted at school aged children and high risk communities using Praziquantel to treat schistosomiasis and albendazole to treat intestinal worms in order to control the morbidity due to the worms. Preventive measures focus on raising awareness about Schistosomiasis and Soil Transmitted Helminths and health education. Achievements Treated over 1.2 million people annually for Schistosomiasis. De-wormed over 7 million people (mainly children) twice annually during Child Days Plus. As a result, morbidity due to Schistosomiasis and STH has been highly reduced. Awareness of the need for regular deworming has been raised in schools and in all endemic communities. Challenges Under funding of Shistosomiasis and STH control from government. The programme continues to depend entirely (100%) on external donations, which raises issues of sustainability of the programme. 91

92 f) Onchocerciasis Control Onchocerciasis (River Blindness) is a public health and socio-economic problem in 28 districts of Uganda (Adjumani, Amuru, Arua, Bududa, Buliisa, Bushenyi, Gulu, Hoima, Ibanda, Kabale, Kamwenge, Kanungu, Kasese, Kibaale, Kisoro, Kyenjojo, Koboko, Manafwa, Maracha-Terego, Masindi, Mbale, Moyo, Nebbi, Oyam, Sironko and Yumbe) where more than two million people are at risk of acquiring the infection. The main strategies being used to control the disease are community directed treatment with ivermectin and vector elimination in isolated foci using ground application of insecticide (Abate) in fast flowing rivers/streams where the vector black fly breeds. Achievements during FY 2006/07 Table 3.21: Onchocerciasis Control key outputs - FY 2006/07 Indicator Baseline Target FY FY 2005/ /07 Achieved Comment Central level programme performance indicators Quarterly performance reports Technical programme meetings Technical support supervision to districts District level (Service delivery level) indicators Maintain 100% geographical 100% coverage geographical Maintain more than 75% therapeutic coverage coverage More than 75% therapeutic coverage maintained 100% geographical coverage More than 75% therapeutic coverage maintained 100% geographical coverage maintained More than 75% therapeutic coverage maintained The vector black fly which was eliminated in Itwara focus covering the districts of Kyenjojo and Kabarole in 1997 has not been seen again in these districts. The vector black fly which was eliminated in Mpamba-Nkusi focus in Kibale district since January 2007 has not been seen again. More than 70% of Ugandans in affected communities have continued to receive an annual dose of ivermectin, with significant reduction in the prevalence of onchodermatitis, nodules and microfilariae carrier rates in some sentinel sites Continued with the strategy of onchocerciasis elimination through semi-annual treatment with ivermectin in four foci namely: (1) Kigezi Bwindi focus covering Kabale, Kisoro and Kanungu districts; (2) Budongo focus covering Masindi, Hoima and Buliisa districts; (3) Mt. Elgon focus covering Mbale, Sironko, Bududa and Manafwa districts; (4) Kitomi-Kashoya focus covering Ibanda, Kamwenge and Bushenyi districts. Major challenges 92

93 Onchocerciasis control is heavily dependent on donor funding. There is an inadequate financial contribution from government to ensure sustainability. Inadequate health workers at all levels. 3.4 Prevention and Control of Non-communicable Diseases / Conditions Uganda is experiencing dual epidemics of communicable and noncommunicable diseases. There is an increase in the incidence of behavioral and physiological risk factors for non communicable diseases in the population. The non-communicable diseases include the chronic illnesses that are prolonged, do not resolve spontaneously, and are rarely cured completely. The majority of NCDs are preventable through a broad range of simple, cost-effective public health interventions that target NCD risk factors. The priority health care interventions implemented in HSSP II for addressing the non-communicable diseases include; Noncommunicable Diseases, Injuries, Disabilities and Rehabilitative Health, Gender-Based Violence, Mental Health and Control of Substance Abuse and Integrated Essential Clinical Care Non-communicable Diseases The global incidence and prevalence of Non Communicable Diseases (NCDs) is rapidly increasing. The most important NCDs include cardiovascular diseases, stroke, diabetes and cancers (particularly cancer of the cervix and of the Breast). The goal of Non-communicable Disease therefore is to reduce the morbidity and mortality attributable to Non Communicable Diseases through appropriate health interventions that target the entire population. Achievements during FY 2006/07 The Ministry of Health established a Secretariat to spearhead the planning, implementation and coordination of NCD prevention and control efforts in the country, as a first step in response to the threat of an NCD epidemic Table 3.22: Indicator Non-Communicable Diseases key outputs - FY 2006/07 Baseline FY 2005/06 Target FY 2006/07 Achieved Comment Central level programme performance indicators Quarterly performance reports Technical programme meetings Technical support supervision to districts NCD risk factor survey Proportion of districts implementing Understaffed 93

94 social mobilisation for NCDs District level (Service delivery level) indicators Percentage increase in OPD attendance attributed to NCDs Proportion of health facilities with functional basic equipment for NCD screening, detection in OPD (period audit) Challenges/Constraints Lack of awareness at all levels about the prevalence of NCDs and their risk factors leading to the apparent neglect of NCDs by policy makers, donors and researchers; Insufficient local data on NCDs and their risk factors; Absence of a clear policy framework, standards and guidelines for NCD prevention and control Injuries, Disabilities and Rehabilitative Health The Disability Prevention and Rehabilitation programme was established with the mandate of accessing all PWDs, older persons and their caretakers with quality rehabilitative health care services to prevent disability arising from injury, eye, ear disease and increasing access to rehabilitative health care services within an integrated system. Achievements during FY 2006/07 Table 3.23: Disability, Injuries and Rehabilitative Health key outputs - FY 2006/07 Indicator Baseline FY 2005/06 Central level programme performance indicators Proportion of districts providing services for hearing impairment Target for FY 2006/07 Achieved Comments 66% 78% 77% Quarterly performance reports Technical programme meetings Technical support supervision to districts District level (Service delivery level) indicators Proportion of people with disabilities provided with Assistive devices - 20% 15% Proportion of health facilities equipped with diagnostic disability equipment 55% 65% 59% Finalised the Rehabilitative and Health Care Policy on Disability Some ENT departments are still under construction Limited funding to orthopaedic workshops, they operate below capacity Some districts like Yumbe, Nebbi, Dokoro have rehabilitation units which are not equipped at all 94

95 Established the National Surveillance Network (Data-Base) for landmines and other PWDs. Tools for collecting data on landmine survivors and PWDs has been developed and pre-tested in 3 districts Launched the Five Year Strategic Plan for Visual Impairment and Blindness ( ) and is being implemented. Advocated for the construction and equipment of several rehabilitation units at various levels of the districts. E.g. Gulu and Soroti Eye/ENT departments. Physiotherapy and orthopaedic workshops in Adjumani, Yumbe, and Nebbi. Revised the curriculum for health workers, nurses, midwives and allied health professions to incorporate the disability component. Sensitised Community Based Rehabilitation (CBR) workers on the medical rehabilitation component of CBR especially to Persons with Disabilities in Kayunga and Busia Districts. Sensitised about one hundred teachers and Health assistants on handling children with disabilities and those with special needs. They also learnt safety promotion and injury control in schools to minimise injuries and First Aid in schools in 2 districts so far. Challenges Lack of funding to directly support orthopaedic workshops to produce the assistive devices for persons with disabilities. Low priority accorded to disability at all levels Understaffing Gender-based Violence Gender is an important social determinant of health and development, being male or female has a profound impact on an individual s health status as well as access to and utilization of health services. Gender based violence is mainly based on social constructs of gender, gender roles, behaviors, the resultant power relations and patriarchy within the different societies and communities. Gender issues should therefore be systematically considered and addressed in all health service delivery throughout the planning process. The Gender Coordination desk in Ministry of Health is responsible for promoting gender mainstreaming in the health sector through strategic planning and developing monitoring systems and procedures for integrating and addressing gender concerns. Achievements during FY 2006/07 Developed a gender mainstreaming guideline for the health sector for building capacity of health managers on gender mainstreaming Carried out a Baseline Survey on gender-based violence in Northern Uganda. Developed a training manual on clinical management of SGBV survivors for health workers Developed IEC materials for SGBV 95

96 Carried out a training of trainers for health workers on the clinical management of GBV at National level and in 5 districts (Gulu, Lira, Pader, Kitgum, and Apac) Produced a documentary film on SGBV Sensitized district leadership and Village Health Teams on SGBV prevention and response in 5 districts Carried out psychosocial training for IDP camp leaders, LCI secretaries for women affairs, religious leaders and local NGOs involved in handling SGBV survivors Challenges /Constraints Limited conceptual understanding and appreciation of gender issues among policy and decision makers Lack of transport to facilitate fieldwork continues to hamper gendermainstreaming activities. Inadequate financial resource continues to hamper the roll out of gender-mainstreaming capacity building for health workers to more districts Mental Health and Control of Substance Abuse Mental health disorders account for about 12.5% of the global burden of disease. In Uganda, mental health, substance abuse problems and psychological disorders are responsible for a heavy disease burden. The burden of substance abuse disorders especially crude, informally distilled alcohol and adulterated liquor has increased tremendously and resulted in a number of sudden deaths in the year under review. The goal of Mental Health Programme therefore is to ensure access to services for mental health, management of substance abuse prevention and psychosocial disorders and neurological disorders such as epilepsy. Major achievement during FY 2006/07 During FY 2006/07, the Mental Health programme focused on developing and updating policies and interventions to address effects of trauma and violence in Northern Uganda. The following were some of the major achievements: Table 3.24: Mental Health key outputs - FY 2006/07 Indicator Baseline FY 05/06 Target FY 06/07 Achieved Central Level Programme Quarterly performance reports Technical programme meetings Technical support supervision to districts Proportion of Regional referral Hospitals with Mental Units Community access to mental health services Comment I person unit 50% 50% 50% 3 mental units have psychiatrists 20% 50% 40% Recruited Psychiatric Nurses 96

97 HC IVs District level (services delivery level) indicators Proportion of HC IV with Psychiatric Nurse or other Professional 30% 70% 50% Recruitment process in progress Proportion of HC IVs with Mental Health Plans 80% 100% 90% Mental Health incorporated in Proportion of HC IVs with at least one anti- psychotic, one antidepressant and one anti- epileptic AWPs 10% 100% 40% Increased demand for mental health medicines but recurrent stock outs at NMS disrupt supply Integration of mental health into general care and scaling up of mental health services with support of ADB funding. This has created high demand for mental health services. The number of patients with mental health, neurological disorders such as epilepsy and other psychosocial disorders has increased by about 50% in most districts. Ratification of the Framework Convention on Tobacco Control Equipped and staffed Regional Referral Mental Health Units to ensure appropriate functionality. Recruitment of mental health professionals at Hospital and Health Centre IVs by the Local Governments. This will strengthen the institutional capacity for mental health services Conducted interventions to address effects of trauma and violence in conflict communities in Gulu, Kitgum, Amuru, Pader, Lira, Amolatar, Dokolo and Apac Carried out community mobilisation in conflict areas for mental health services Challenges Inadequate staffing at National and Regional Referral levels to address the mandates of the Programme Inadequate supply on the market and gross under funding of mental health medicines which are reported to be expensive Integrated Essential Clinical care Integrated Clinical Care is one of the priority health care interventions of the UNMHCP. The priority interventions within Integrated Clinical Care are basic essential clinical care, including emergency care, and care of 97