Annual Health Sector Performance Report

Transcription

1 THE REPUBLIC OF UGANDA Annual Health Sector Performance Report Financial Year 2003/2004 October 2004

2 Foreword Uganda, frequently referred to as the Pearl of Africa, continues to demonstrate a high disease burden similar to other developing countries. As a result, the intricate relationship between poverty and ill health becomes inescapable. The Government of Uganda and its Health Development Partners have been implementing the Health Sector Strategic Plan (HSSP) for the last four years under the Sector Wide Approach. The thrust of this policy implementation strategy is to contribute to the national Poverty Eradication Action Plan (PEAP) and the Millennium Development Goals (MDGs). The health sector has a big responsibility of exercising accountability at the national and international levels. This fourth consecutive Annual Health Sector Performance Report highlights the progress made during FY 2003/04 towards achieving the overall sector goal as well as the specific targets for the period under report. During this period under review FY 2003/04, the overall health sector resource envelope totalled Ugshs 374 billion. This, in real terms, represented only a 3% increase over the FY 2002/03. The health sector has however utilised these resources in accordance with the HSSP and PEAP priorities and has yet again registered significant improvement in performance. It is gratifying to note that the efforts expended in carrying out the mass measles campaign in October 2003 have yielded immediate results. Once again, the measles wards are empty. I urge all the districts and other partners to do all that is in their power to sustain and improve routine immunisation so that at the end of this FY we surpass the HSSP I target of 85% coverage. The utilisation of Outpatient services at government and NGO facilities has increased from 0.70 visits per person per year to This is a sign that the population is developing more confidence in the health system and in turn, the utilisation continues to rise. The utilisation of the health facilities for safe deliveries registered a 20% performance improvement. This is a welcome development but we should strive to do better. The fight against the major killer, malaria, has continued to yield results mainly in the area of Home Based Management of Fever, Insecticide Treated Nets and their retreatment and even in the quality of case management as demonstrated by the low case fatality rate of 3% at the Regional Referral Hospital level, where the more complicated cases are handled. The plans to use DDT for Indoor Residual Spraying are underway, while at the same time addressing the challenge of changing the mindset of the general population regarding its efficiency, effectiveness and safety. The strategic developments in drugs management through the introduction of credit lines for districts at the National Medical Stores and Joint Medical Stores have continued to yield tremendous results. The fight against the HIV/AIDS epidemic continues with the launch in June 2004 of the programme for Universal Access to Free Antiretroviral Treatment in Uganda while at the same time strengthening the ABC strategy. We are eagerly awaiting the results of the on-going HIV sero-prevalence study to provide information to further strengthen our HIV/AIDS strategies and services. The health sector is hosting the second National Health Assembly in October 2004 and in doing so fulfils the obligation of mobilising the leadership at all levels to advocate for the prioritisation of health investments in Uganda. On behalf of the Government and i

3 people of Uganda, I wish to express appreciation to all health sector stakeholders for the efforts put into the implementation of the HSSP during the year under Report. The District League Table has yet again provided a comparative performance assessment across the country. The district ranking has not remained the same as last year. I urge the district political and technical leadership to critically examine the factors that have affected the improvement or worsening of performance, address the prevailing constraints and use this competitive spirit to improve on the health of our people. Remember the famous adage that Health is Wealth. Hon. Brig. Jim Katugugu Muhwezi MP MINISTER OF HEALTH ii

4 Towards better Health for the people of Uganda A message from the Director General of Health Services. This is the fourth Annual Health Sector Performance Report (AHSPR) for the current five-year HSSP I. It has been prepared side by side with the second Health Sector Strategic Plan (HSSP II) 2005/ /10 and the revision of the PEAP (2004) for Uganda. The priorities and targets that are contained within are aligned with the Millennium Development Goals and the Vision From analysis of this AHSPR, it is gratifying to note that we have continued to make progress and our performance continues to improve as judged by the attainment and in many cases surpassing of our targets and indicators. During 2005 we will be due for another Health and Demographic Survey. The results of that Survey will be a reliable measure of the early impact of the success of the implementation of HSSP I and the PEAP and may call for readjustments in HSSP II. In spite of these promising developments, we need to be continuously reminded that Uganda is still one of the poorest countries with unacceptable indices and that action to address this is urgent. In the area of sustainable Health Systems Development, which is the central thrust of the National Health Policy and the HSSP, I am pleased to note that this year, we faced and overcame a number of challenges and shocks. The leading ones among these are Human Resources Management, management of global initiatives such as the Global Fund to Fight AIDS, TB and Malaria and PEFPAR, harmonizing roles with Civil Society Groups, the war in the North and North East, scaling up access to ARVs, reviewing the Malaria treatment policy and coordination with Health Development Partners. The ability of the health System to handle these challenges and to maintain cohesion and order is a source of encouragement as it has reasserted the importance of the stewardship role of a responsible government and bodes well for the future. During the year, the central Ministry of Health implemented a major change in the arrangements for supervision and support to district health services. This entailed a move from the Quality Assurance Supervision visits to more integrated Area Teams. The Quarterly Performance Review meetings experienced some delays but were still held. Improvement is called for in this area. Dr. F. Runumi now Commissioner of Health Services in charge of Planning, replaced Dr. P. Y. Kadama, who joined WHO, and I wish both of them well in their new positions. In respect to District Health Services, our Vision is to see the Local Authorities owning responsibility, taking leadership and having capacity to fulfil their roles in district health services delivery. Any support given to them from outside should be aimed at accelerating the achievement of that vision and the sooner this is achieved the better. The Constitution, the Local Authorities Act and the SWAp MoU are all in line with that vision. District health services have continued to improve. Many of the districts which had been ranked poorly in the previous year have shown some improvements and targeted action will be needed to support those which remain weak. Credit for this goes to the District political leaders, the Civil Servants and members of Civil Society. The Local Authorities Association has shown a lot of enthusiasm and responsibility in mobilizing its members to be champions for the Health Sector. This will become increasingly important as we all move towards Fiscal Decentralization. I would also like to see acceleration in the iii

5 establishment and empowerment of communities and households through the Village Health Teams and the Parish Development Committees. In this way community ownership and responsibility for their own health will become entrenched as a way of life. This in turn will make the people s health a high priority political issue and will also inevitably lead to improvements in the quality of health services within a strong and stable pro-poor health system. F. G. Omaswa DIRECTOR GENERAL OF HEALTH SERVICES. iv

6 Table of Contents Foreword... i Towards better Health for the people of Uganda... iii Acronyms... vi Illustrations... viii Executive Summary... xi Chapter 1: Introduction The Sector Framework The Annual Health Sector Performance Report FY 2003/ Sources of Information Challenges and Planning for Future Reports Outline of the Report... 4 Chapter 2 Overview of Health Sector Performance FY 2003/ Performance against HSSP Indicators Summary Financial Report for the FY 2003/ Chapter 3 Implementation of the Health Sector Strategic Plan Delivery of the Uganda National Minimum Health Care Package Prevention and Control of Communicable Diseases Maternal and Child Health Prevention and Control of Non-Communicable Diseases and conditions Health Promotion and Disease Prevention Integrated Health Sector Support Systems Health Care Financing Human Resources for Health Health Infrastructure Development and Management Management of Medicines and Health Supplies Monitoring and Mentoring of District Health Systems Laboratory Support Services Blood Transfusion Services Health Information and Research The Stewardship of the Health Sector Chapter 4 The National Health Assembly and 9 th Joint Review Mission The National Health Assembly The 9 th Government of Uganda/Development Partner Joint Review Mission Chapter 5 The 2 nd Health Sector Strategic Plan (HSSP II) Priority Areas for HSSP II Implementation Priorities Priority Outcomes for HSSP II Process for developing HSSP II The costing and financing of HSSP II Annexes: Annex I: The District League Table Annex II: Health Sector Budget Performance FY 2003/ Annex III: Human Resource Inventory FY 2003/ Annex IV: Hospital Performance Assessment FY 2003/ v

7 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 MDGs MIP MNT MoES MoH MoU 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 Millennium Development Goals Malaria in Pregnancy Maternal and Neonatal Tetanus Ministry of Education and Sports Ministry of Health Memorandum of Understanding vi

8 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 VCT VPH WHO WP 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 Voluntary Counselling and Testing Veterinary Public Health World Health Organisation Wettable Powder Formulation vii

9 Illustrations Figures Figure 1.1: Overview of the Sector Programme... 2 Figure 2.1: Variation of New OPD Attendance by District FY 2003/ Figure 2.2: Variation of Pentavalent Vaccine Coverage by district FY 2003/ Figure 2.3: Deliveries in health units by district FY 2003/ Figure 2.4: District PHC-CG Releases against Allocation Figure 2.5: Relating health sector Inputs with Outputs Figure 2.6: District Performance according to the League Table Figure 2.7: Change in overall district Performance Figure 3.1: Comparison of the children <5years treated at health facility and by Community Drug Distributors FY 2003/ Figure 3.2: Comparison between OPD New Attendance for the under 5s for FY 2002/03 and FY 2003/ Figure 3.3: IPT2 coverage by district Figure 3.4: Number of Functional PMTCT sites by District Figure 3.5: Sites offering ART in Uganda Figure 3.6: TB Case Reporting by District Figure 3.7: Progress of Maternal and Neonatal Tetanus in Busoga Region Figure 3.8: Measles morbidity and mortality trends FY 2003/ Figure 3.9: Standard Unit of Output (SUO) by the Regional Referral Hospitals Figure 3.10: Comparison of Efficiency at the Regional Referral Hospitals Figure 3.11: Comparison of Health Workers' Outputs at the Regional Referral Hospitals.. 61 Figure 3.12: Cumulative admissions in a sample of 65% of PNFP Hospitals Figure 3.13: Cumulative Number of Deliveries is a sample of 65% of PNFP Hospitals Figure 3.14: Pit latrine coverage by district Figure 3.15: Completeness of weekly district and health unit reporting, Uganda Figure 3.16a Impact of mass campaigns for measles cases, Uganda Figure 3.16b Impact of mass campaigns for measles cases, Uganda Figure 3.17: Resource Projections for the Ugandan Health Sector Figure 3.18: Allocation of health sector budget FY 2003/ Figure 3.19: FY 2003/04 Approved Budget Estimates and Releases (Bn Shs) Figure 3.20: Percentage expenditure in the public and private sector Figure 3.21: Percentage expenditure on HSSP and Non HSSP inputs: Figure 3.22: PNFP Health Sector Trends in income structure: Figure 3.23: Relative sources of income over time PNFP Hospitals: Figure 3.24: Relative sources of income over time PNFP LLUs Figure 3.25: Percentage of released funds that are spent in the different quarters Figure 3.26: Total Health Expenditure in Uganda FY 1998/99 to FY 2000/ Figure 3.27: Management of Health Sector Resources by Financing Agents Figure 3.28: Performance against indicative budget FY 2003/ viii

10 Tables Table 2.1: Performance against the HSSP Monitoring Indicators Table 2.2: Trends for the 5 PEAP indicators 1999/00 to 2003/ Table 2.3: Total Number of Deliveries in Government and PNFP Units... 9 Table 2.4: Proportion of Approved Posts that are filled by appropriately trained health workers Table 2.5: HSSP Funding for the FY 2003/ Table 2.6: Movements in & out of the Top and Bottom 10 of the League Table Table 2.7: Comparing Drug Management Performance and the League Table Table 2.8: Comparing District Performance on Pentavalent Vaccine Coverage and League Table Ranking Table 2.9: Performance of the Districts with marked Insecurity in FY 2003/ Table 2.10: Performance of the New Districts in FY 2003/ Table 2.11: Performance of the districts in the Karamoja Region Table 3.1: Performance against HSSP Malaria Indicators Table 3.2: The Status of HBMF Implementation in the districts Table 3.3: Partner Support in provision of HOMAPAK Table 3.4: Net sales in Uganda by type, 2002 to the 1st half of Table 3.5: Performance against HSSP STD/HIV/AIDS Indicators Table 3.6: Performance against HSSP TB Control Indicators Table 3.7: CB-DOTS Implementation Coverage Table 3.8: District leprosy prevalence Rate Table 3.9: Performance against HSSP SRH Indicators Table 3.10: Results on a Needs Assessment for EmOC in 37 districts of Uganda Table 3.11: CYP Factors for each Family Planning Method Table 3.12: Performance against HSSP IMCI Indicators Table 3.13: Performance against HSSP Immunisation Indicators Table 3.14: Selected AFP surveillance performance indicators Table 3.15: Performance against HSSP Nutrition Indicators Table 3.16: Mulago Hospital Service Outputs FY 2003/ Table 3.17: Performance against the HSSP Health Education and Promotion Indicators.. 64 Table 3.18: Performance against HSSP Environmental Health Indicators Table 3.19: Performance against HSSP IDSR indicators Table 3.20: Trends of GoU Budget Funding for the Health Sector FY 1999/00 to FY 2000/03 (Billion Ugshs.) Table 3.21: Donor Expenditure FY 2003/04 (US Dollars) Table 3.22: Global Funds approved against disbursed Table 3.23: Sources of Funds Spent in the Health Sector (US $ per capita) Table 3.24: Comparison of Health Expenditure in Other African Countries Table 3.25: Current number of staff in the Health Sector GoU/PNFP Table 3.26: Analysis of Actual Number of Staff (excluding Non-medical staff) and Minimum Staffing Norms All Districts, GoU only Table 3.27: Analysis of Actual Number of Clinical Staff and Minimum Staffing Norms All Districts, GoU only Table 3.28: Distribution of Clinical Staff in HC IIs (GoU) Table 3.29: Analysis of Actual Number of Technical Support Staff and Minimum Staffing Norms All Districts, GoU only Table 3.30: The projected and actual output of ECN and Enrolled Nurses and Midwives 90 Table 3.31: Summary of Health Facilities by level and ownership Table 3.32(a): Status of Medical Buildings at HC IIIs for the 39 Districts Surveyed ix

11 Tables contd: Table 3.32(b): Status of Medical Buildings at HC IV's for the 39 District Surveyed Table 3.33: Medicines budget allocation FY (UGX billions) Table 3.34: Analysis of Performance of National Medical Stores Table 3.35: Medicine availability by indicator drug FY 2002/03 and 2003/ Table 3.36: Medicines availability by level of care, FY 2002/03 and 2003/ Table 3.37: Research conducted by UNHRO Table 3.38: Estimates of additional costs to enhance PNFP health worker salaries in the medium term Table 4.1: Progress on the National Health Assembly Resolutions Table 4.2: Progress on the Undertakings of the 9th Joint Review Mission Boxes : Box 3.1: TB Treatment Success: The story of Apac district Box 3.2: Improved Sanitation Coverage The Success Story of Busia District Box 3.3: The strengths and weaknesses of the Area Team Strategy identified during the start up phase Box 3.4: Successful HMIS Management: The case of Gulu District x

12 Executive Summary The implementation process for the Health Sector Strategic Plan (HSSP), 2000/ /05, has completed four years and in fulfilment of the provisions of the Memorandum of Understanding (MoU) that guides the partners in the implementation of the plan, the Ministry of Health presents the fourth Annual Health Sector Performance Report for FY 2003/04. This report is an assessment of health sector performance given previously agreed annual targets set in light of the overall HSSP Monitoring Framework. The report focuses on: Assessment of overall health sector performance against the 18 HSSP Indicators; Information on individual district performance against 10 of the HSSP indicators, and using this to build up a League Table ranking district performance Progress on the delivery of the Uganda National Minimum Health Care Package (UNMHCP) at the various levels; Hospital performance as an integral component of the Minimum Health Care Package The performance of the Integrated Health Sector Support systems; Progress in the implementation of the resolutions of the first National Health Assembly and undertakings of the 9th Joint Review Mission (JRM) Provision of a synopsis of the second Health Sector Strategic Plan (HSSP II) Overall Health Sector Performance Overall, the health sector has registered yet another year of improved performance. As in the past, the assessment is based on performance against HSSP indicators and agreed targets for the FY 2003/04. In particular performance against the 5 Poverty Erdication Action Plan (PEAP) indicators has been assessed and the performance trends noted over the four years of the HSSP. The analysis indicates that: New Outpatient (OPD) attendance has registered further improvement and at 0.79 visits per person per year has already exceeded the annual and the 2005 HSSP target of 0.7; The approved posts filled by trained health workers stands at 68% using HSSP norms excluding Nursing Assistants, and using HSSP minimum staffing norms is at 86%; Deliveries taking place at health facilities have registered a modest improvement from 20% to 24.4%. Couple Years of Protection (CYP) as a measure of effectiveness of Family Planning services over time has remained rather constant The achieved DPT3/HepBHib coverage of 83% is close to the target of 85% expected at the end of HSSP HIV national average sero-prevalence rates as determined from Antenatal Care (ANC) surveillance sites is estimated at 6.2%, this indicator has stabilised between 6 and 7% since the beginning of the HSSP. The resource envelope available to the health sector during the period under report was Ugshs billion, which is equivalent to US$ 7.83 per capita. This still remains far below the Health Financing Strategy estimate of US$ 28 per capita per year (excluding xi

13 Anti-Retroviral Therapy and pentavalent vaccine). For the third year running, the GoU contribution to the sector resource envelope was higher than the donor project component. The actual releases to the sector amounted to Ugshs billion, constituting 94% budget performance. The overall resources available to the sector increased by 11% over the FY 2002/03 levels. However, in real terms, there was only a marginal 3% increase taking into account the inflation and population growth factors. The formula for allocation of funds to the districts was further refined to improve equity and efficiency by taking into consideration project funding and hospital coverage. As a result, the districts most in need received more funds per capita than the richer ones. District Performance and the League Table For the second year running, performance of individual districts has been assessed using a set of HSSP management and service delivery indicators. The purpose of conducting this assessment and ranking the districts is several-fold: To bring to light the contributions of the various districts to the overall performance of the health sector; Providing information to enable analytical assessment of reasons behind good and poor district performance; Enable the process of planning for and offering preferential support to poor performers; To provide a basis for discussion of the district and overall health sector performance by the Local Government leadership and other stakeholders at the National Health Assembly. To provide a challenge and an incentive to the districts for improved performance To encourage good practices by recognising good performance, innovation and appropriate reporting. For purposes of comparability, the League Table indicators used in the FY 2002/03 performance assessment were maintained. A number of districts have shown profound improvements in the rankings as compared to the previous reporting period. The League Table provides opportunity for districts to conduct a critical assessment of their performance and lay the appropriate strategies. The top 10 districts in order of ranking are; Gulu, Jinja, Adjumani, Moyo, Tororo, Rukungiri, Mpigi, Bushenyi, Kampala and Busia. The bottom 10 districts from the last are; Kotido, Pader, Yumbe, Kamwenge, Iganga, Wakiso, Masindi, Lira, Moroto and Mubende. The factors influencing performance include the management of the district, insecurity, infrastructure such as in the new districts and peculiar circumstances such as in the Karamoja Region. At individual district level, Gulu, Kampala, Mukono, Mbale and Apac show an improvement of more than 50%, whereas Luwero, Kaberamaido, Mubende, Ntungamo, Nebbi and Pallisa show a decline of more than 30%. As a general observation, during the period under review, the functionality of some Health Sub-districts and particularly the referral facilities at Health Centre IV level, was xii

14 lower than expected. This largely affected the performance of individual districts. Unless there is improvement in the functionality of these Health Sub-Districts within the district health system, the sector is unlikely to register much difference in the attainment of district and sector targets. The delivery of the National Minimum Health Care Package The 12 elements of the Uganda National Minimum Health Care Package (UNMHCP) have been grouped into four clusters in the HSSP and also in this report as a move towards integrated assessment and analysis. Within the clusters, performance assessment for the package elements has been done with particular emphasis on HSSP indicators and targets. Activities carried out are related to the intended objectives of the programmes to determine whether the activity did actually contribute towards the objectives and therefore attainment of the targets. There is registered improvement in target setting, though some of the indicators have remained difficult to assess due to the nature of the sources of information. The following sector achievements in the FY 2003/04 are highlighted: Malaria Control Prevention the policy on Insecticide Treated Nets (ITNs) has shifted in favour of the poor and the most vulnerable through the provision of free nets. A recently conducted Net re-treatment exercise found that the household net coverage was higher than had been estimated. Case management at community and facility level Home Based Management of Fever (HBMF) is currently implemented in 43 out of 56 districts. The remaining districts are to be covered during FY 2004/05. The available results indicate high utilisation rates for the service; a Malaria Case Fatality Rate at hospital level that is in tandem with the HSSP target; the Anti-malarial Drug Policy, guided by research findings, is undergoing a transition; while the preventive treatment of malaria in pregnancy has fallen short of attaining the sector target. STD/HIV/AIDS Control Voluntary Counselling and Testing (VCT) services are now available in all the 56 districts of Uganda, while Prevention of Mother-to-child-Transmission (PMTCT) services are now available at 71 sites in 49 districts and Anti-Retroviral Therapy at all the 11 Regional Referral Hospitals. Immunisation The DPT3/HepBHib coverage at 83% is close to the HSSP target of 85% and other antigens showed similar performance. The success of the mass measles campaign is already evident in the weekly reports; TT2 for pregnant women at 50% was the same as for the previous year and fell short of the annual target of 59%. Sexual and Reproductive Health and Rights This has been maintained as a sector priority and the proportion of mothers delivering in government and NGO facilities showed some improvement from 20% to 24.4% with evidence that more improvements could have been achieved. There is need to employ xiii

15 strategic thinking in order to improve on this service delivery area and the biggest challenge lies within the district health systems. Environmental Health Advocacy for the Kampala Declaration on Sanitation (KDS) has been given priority and pit latrine coverage has improved from 47% to 57%. Integrated Health Sector Support Systems The overall disbursement of the PHC Non-wage component to the districts was at 94.5% The human resources available to the sector registered minimal increment due to the limited resource envelope. Progress was made in the discussions with stakeholders in the improvement of the remuneration of the existing health sector workforce The Pull System, established to streamline drug procurement and management, was solidly established and most districts registered high rates of Credit Line utilisation. The per capita expenditure on drugs has therefore increased from US$ 1.2 per capita during FY 2002/03 to US$ 1.6 per capita during the period under review. Infrastructure development has ensured that 110 Operating Theatres are complete; equipment provided to 68 Theatres, 128 doctors houses completed and multi-purpose vehicles availed to about 50% of the Health Centre IV facilities. Information management has continued to register a steady improvement with timeliness and completeness of HMIS reports at 85% and 90% respectively. The various arms of health sector regulation have registered significant achievements especially in drugs, nursing and clinical practice. Resolutions of the NHA and Undertakings of the 9th JRM The resolutions of the first National Health Assembly, held in November 2003, focussed on improving the requisite sector inputs in order to realise meaningful outputs that will contribute to elevating the health status of the people of Uganda. In the course of FY 2003/04, the attention paid to these important national decisions earned greater results in the following areas; Improvement of drug supplies and management Provision of better health services for the Internally Displaced Persons as demonstrated by the performance of Gulu and other insecurity affected districts in the League Table Advocacy for Reproductive Health Monitoring and mentoring of district health systems through the deployment of Area Teams Improved information management in terms of quantity and quality. The National Health Assembly was followed by the 9 th Government of Uganda/Development Partners Joint Review Mission (JRM) also held in November The progress made with respect to the Resolutions of the National Health xiv

16 Assembly and the 9 th JRM Undertakings is summarised in Chapter 4 of this report. Most of the resolutions were adequately addressed and significant progress was made towards the achievement of the 9 th JRM undertakings. The second Health Sector Strategic Plan (2005/ /10). The preparation of the second Health Sector Strategic Plan (2005/ /10) is nearing completion. The preparation of this plan has benefited from wide stakeholder consultations and therefore enjoys a very high level of ownership. Compared to HSSP I, the new strategic plan document is constructed to reflect more clearly, the maxim that the primary purpose of the National Health System (NHS) is to achieve improved health of the people. Individual programme outputs are seen as the means to achieving the desired health outcomes and not as an end in themselves. The programme overview has therefore been amended to show that implementing the Uganda National Minimum Health Care Package (UNMHCP) is the main approach for achieving the sector programme goal and development objective. This will be accompanied by a strong focus on health promotion and disease prevention. The focus of the plan remains on how to make maximum contribution to the national PEAP and the MDGs. Efforts have been made to better integrate services and programmes to enable efficiencies to be realised in both delivery and support. The October 2004 National Health Assembly and Joint Review Mission are expected to provide the final inputs into HSSP II before its presentation to cabinet for approval. xv

17 Chapter 1: Introduction 1.1 The Sector Framework The overall objective of the health sector is to reduce morbidity and mortality from the major causes of ill health and the disparities therein. The National Health Policy (NHP) and the Health Sector Strategic Plan (HSSP) based on the Poverty Eradication Action Plan (PEAP) provide the framework for facilitating this achievement. Figure 1.1 illustrates the contribution of the sector to reduced morbidity, mortality and fertility and thereby to the national goal of Expanded Economic Growth and Poverty Eradication. The HSSP has five outputs namely: Delivering the Uganda National Minimum Health Care Package (UNMHCP), deliberately and targeting the most vulnerable members of the population Strengthening the health care delivery system at the national, district and Health Sub-district levels Strengthening and operationalising the legal and regulatory framework Strengthening integrated support systems for improved service delivery Development of strategic policies, research and information management systems that support effective planning and service delivery. Decentralisation of health services and the Sector Wide Approach (SWAp) are the focal implementation modalities for the HSSP. The different stakeholders in the sector have different mandates from the Constitution, the Local Governments Act and the NHP and HSSP. In particular there are different responsibilities for the Central and Local Governments. The core functions of the Central Government against which performance is determined are: Policy formulation, standard setting and quality assurance; Resource mobilisation; Training, Capacity development and Technical support; Provision of nationally coordinated services, e.g. Epidemic Control; Coordination of health services; Monitoring and Evaluation of overall sector performance and The responsibilities of the Local Governments (districts and delegated to Health sub- Districts) are: Implementation of national health policies; Planning and management of district health services; Provision of disease prevention, health promotion, curative and rehabilitative services with emphasis on the UNMHCP; Vector Control; Health Education; Ensuring provision of safe water and environment sanitation and Health data collection, management, interpretation, dissemination and utilisation. 1

18 Figure 1.1: Overview of the Sector Programme Programme Goal Expanded Economic Growth Increased Social Development Poverty Eradication Programme Development Objective Reduced Morbidity and Mortality from major causes of ill health and reduced disparity therein Program output 1 Program output 2 Program output 3 Program output 4 Program output 5 Minimum Health Care Health Care Delivery Package implemented, system strengthened Elements 1. Control of Communicable Diseases - Malaria - STD/HIV/AIDS - TB 2. Integrated Management of Childhood Illness 3. Sexual and Reproductive Health & Rights 4. Immunisation 5. Environmental Health 6. Health Education and Promotion 7. School Health 8. Epidemics and Disaster Preparedness & Response 9. Nutrition 10. Interventions against Diseases Targeted for Elimination or Eradication 11. Mental Health 12. Essential Clinical Care Legal and regulatory framework strengthened and operational Integrated support systems strengthened and operational Elements Elements Elements Elements Restructured Ministry of Health and support institutions Decentralised health care delivery system Partnership with private sector. Inter-sectoral linkages strengthened Health Acts Professional Councils Private sector regulated Traditional practitioners regulated 1. Human Resources for Health 2. Health Care Financing 3. Health Infrastructure 4. Laboratory Services 5. Procurement and management of drugs, medical supplies and logistics Policy, planning & information management system operational; Research and development implemented 1. Policy & Planning 2. Quality Assurance 3. Health Information System 4. Research and Development 2

19 For each HSSP implementation year, and as part of the strategic thinking and planning process, the GoU and stakeholders in the sector, examine the performance of the health sector against set targets and for the different levels against their responsibilities. The analysis also takes into consideration the contributions of the sector in the overall context of poverty eradication and national development. The Annual Health Sector Performance for the FY 2003/04 forms the subject content for this report. 1.2 The Annual Health Sector Performance Report FY 2003/04 The period under report is the fourth year of HSSP implementation, the Financial Year 2003/04. The process of compiling this report has greatly benefited from the experiences of the previous years of HSSP implementation. As in the other preceding reports, the emphasis remains on assessing the implementation of the HSSP both in the perspective of the period under report and in relation to the overall sector achievements and strategic planning. Within this framework, efforts have been made to: Focus more on performance at the district level and making comparisons among the districts by use of a League Table Highlight the individual and collective contribution of the National and Regional Referral Hospitals as well as the PNFP hospitals at similar levels, into the broader picture of delivering the Uganda National Minimum Health Care Package. Include the donor expenditure analysis within the Financial Report Review the progress made towards the specific commitments made at the last National Health Assembly and Joint Review Mission Take cognisance of the conceptual and operational changes that are expected with the transition from HSSP I to HSSP II. 1.3 Sources of Information 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 HMIS. There were deliberate attempts to obtain information from the districts to supplement and validate the HMIS. Use has also been made of information from undertakings of partners as well as their regular performance reports. The contribution of the central support sub-sector was mainly obtained from the quarterly and annual performance assessment reports. Other sources of information included: Reports of Undertakings sanctioned by the November 2003 JRM and National Health Assembly sessions. Research and other studies undertaken by various stakeholder institutions 3

20 1.4 Challenges and Planning for Future Reports The lessons learnt from the compilation of previous reports have gone a long way to improve on the quantity and quality of the information required for the process. The following areas have demonstrated significant improvements; The ability of the Resource Centre to analyse the information from the districts according to identified needs The provision of expertise by Integrated Disease Surveillance and Response (IDSR) to various programmes in the analysis of their data for national and subnational surveillance purposes Involvement of district and hospital managers in the conceptualisation and data handling for this report There is need for improvement in the following areas; The submission of monthly, quarterly and annual reports by the National and Regional Referral hospitals; The submission of the quarterly and annual performance reports by the districts Central programmes and departments submitting their quarterly and annual performance reports using the formats provided; The culture of utilising the available data and information by the Central programmes and departments Donor Projects providing appropriate annual reports timely; The overall picture points towards the attainment of the ultimate goal of obtaining the appropriate quantities of quality data and information in a timely manner so as to make the Annual Performance Reporting exercise easier and more meaningful and a crucial part of the Monitoring and Evaluation of the Sector. 1.5 Outline of the Report The Report is divided into five chapters. Chapter 1 of the Report is an Introduction; Chapter 2 covers an Overview of Sector Performance with national and district level performance against HSSP indicators. Chapter 3 is a more detailed discussion of Implementation of the HSSP looking at performance against different elements of the Uganda National Minimum Health Care Package (UNMHCP) and the Support systems to the UNMHCP. Chapter 4 recapitulates the deliberations of the first National Health Assembly with emphasis on the various resolutions, the actions taken to operationalise those resolutions and the way forward. The Chapter also looks at the Undertakings that were adopted at the 9 th Joint Review Mission and provides a broad picture of the progress made during the period under report. Chapter 5 summarises the progress made in the strategic planning process at the national level and the status of the second Health Sector Strategic Plan. 4

21 Chapter 2 Overview of Health Sector Performance FY 2003/ Performance against HSSP Indicators The health sector stakeholders agreed to a set of indicators for the monitoring of the HSSP at the national and the district levels. Targets for these indicators for the HSSP period were agreed, and annual targets have been derived from these. As part of a dynamic process, these benchmarks have undergone revision particularly in view of the fact that the resources required for the implementation of the HSSP have not been available in the quantities required. The targets for the national level indicators for the FY 2003/04 were reviewed and agreed upon at the Mid-Term Review of the HSSP (MTR) in April The performance against the 18 HSSP monitoring indicators for FY 2003/04 is shown in Table 2.1. In addition, this Report details out the variation of performance amongst districts and for the first time presents a framework for objective assessment of hospital performance. District performance is discussed in this section and more analytically under Chapter 2.3; with the help of a League Table while the hospital performance is discussed in detail in Chapter 3. The health sector performance has continued to improve as shown by a number of the indicators whose performance have surpassed FY 2002/03 levels (OPD attendance, the number of deliveries in health facilities, the proportion of approved posts filled by trained health workers, HMIS completeness and timeliness). There is no change registered in the DPT3/Pentavalent vaccine coverage (from 84% to 83%), and the proportion of indicative PHC-CG drug budget used for drugs has registered a decline (from 66% to 51%). Five indicators were previously chosen from the longer list of HSSP indicators to provide a global view of sector performance, and are used to measure sector performance at the level of the Poverty Eradication Action Plan (PEAP). These are included together with global development indicators and indicators of other sectors in the Poverty Monitoring and Evaluation Strategy (PMES). The trends in the performance for the PEAP indicators for the FY 1999/00 to FY 2003/04 as presented in Table 2.2 are used in this Report to assess overall Health Sector Performance in FY 2003/04, Year 4 of the HSSP, in relation to the previous years and in comparison to the HSSP 2005 targets. Other indicators are mentioned in this chapter, but more detailed discussion is available under the appropriate sections of the UNMHCP in Chapter 3 of this Report. 5

22 Categor y Indicator Table 2.1: Performance against the HSSP Monitoring Indicators. Purpose (What it measures) Baseline (1999/00) National Value 2002 / / 04 Data source Target Achieved Target Achieved 1 Input Percentage of GOU budget allocated to health sector Commitment of GOU to health 7.3 % 9.6% 9.0% 10% 9.6% MoH/ MoFPED 2 Input Percentage of PHC CG funds released on time to the sector ( Non salary Level of Govt. honouring its recurrent and capital ) commitment to the sector 100% 97% 100% HPD MoH MoFPED 3 Input Total public (GoU and donor) allocation to health per capita Equity of health resource allocation $ 4.80 $8.0 $ 7.2 $8.0 $7.83 MoH MoFPED 4 Process Percentage of disbursed PHC-CGs that are expended Absorption capacity at the district level 50 % 95% 100% Monitoring Reports 5 Process Proportion of districts submitting complete HMIS monthly returns to MOH in Management capacity for the 15.6 % 75% 70 % 85% 85% HMIS reports time reporting system 6 Process Percentage of facilities without any stock-outs of chloroquine, ORS, cotrimoxazole and measles vaccine Drug management protocols 29.1 % 60% 80% HMIS/ Records review 7. Process Percentage of population residing within 5 km of a health facility (public or Equity and access 57 % 72% 72%* Mapping exercise PNFP) providing the MHCP by district (Implementation of the UNMHCP) 8 Output Percentage of children < 1 yr receiving DPT 3 according to schedule by district Utilisation (PEAP Indicator) 41.4 % 70% 84 % 85% 83% 9 Output Proportion of approved posts that are filled by trained health personnel Level of staffing implementation of HRD policy 33 %* 42% 66% 68%* HMIS/Staff Inventories 10 Output Contraceptive Prevalence Rate (CPR) Couple Years of Protection (CYP) Utilisation 15 % NA NA 228, ,686 UDHS HMIS 11 Output Proportion of surveyed population expressing satisfaction with the health services Quality of care NA NA NA NA NA Community surveys 12 Output Urban / Rural specific HIV sero-prevalence rates HIV infection 10.9 % Urban 5.8% 6.2% Average 6.2%** ACP reports 4.3 % Rural 6.8 %Average Average 13 Output Percentage of deliveries taking place in a health facility (Govt. and NGO ) Utilisation ( PEAP ) 25.2 % 28% 20.3 % 30% 24.4% HMIS Reports Deliveries supervised by health workers 38 % UDHS 14 Output Total Govt. and NGO OPD utilisation per person per year Utilisation ( PEAP ) HMIS Reports 15 Output Health facility level specific number of C/Sections per 1000 deliveries within the catchment area of the facility Level of surgical obstetric care at HC IV 14.0 per 1000 live births NA NA NA NA HMIS Records 16 Output Proportion of TB cases notified compared to expected Effectiveness of surveillance system 50 % 70% 99.7% 70% 49%*** NTLP Reports 17 Malaria case fatality rate among children < 5 yrs old Quality of case management 3% 3% **** Population. Surveys 18 Percentage of fever/uncomplicated malaria cases ( all ages ) correctly managed at Access to effective malaria case NA NA NA NA NA Facility based health facilities management surveys *has not been updated since 2002/03;** 2002/03 & 2003/04 figures not really comparable to the baseline; *** the 2002/03 & 2003/04 figures not comparable as measurement changed; ****estimate from RRH 6

23 Table 2.2: Trends for the 5 PEAP indicators 1999/00 to 2003/04 Indicator Baseline 1999/ / / / / /05 Target OPD Utilisation DPT 3/Pentavalent vaccine coverage Deliveries at Health Facilities GoU and PNFP Approved Posts filled by Trained Health Workers National Average HIV Sero prevalence as captured from ANC Surveillance sites 41% 48% 63% 84% 83% 85% 25.2% 22.6% 19% 20.3% 24.4% 35% 33% 40% 42% 66% 68% 52% 6.8% 6.1% 6.5% 6.2% NA 5% New Outpatient Attendance in Government and PNFP Health Units New Outpatient Attendance (OPD) in Government and PNFP units is used as a measure of utilisation of health services, and therefore is a measure of the quality and quantity of services (supply side) and the health seeking behaviour of the population (demand side). There has been a steady increase in new OPD attendees since the launching of the NHP and HSSP. Per capita attendance has risen from 0.4 in FY 1999/00 to 0.79 in FY 2003/04, which is a 97.5% increase over the period. This level of achievement surpasses the FY 2004/05 target of 0.7. The increase is even more apparent using absolute figures with new OPD attendees increasing from 9.3 million in FY 1999/00 to 20.1 million in FY 2003/04 (116% increase). The large increases in OPD attendance can be attributed to: Improved sector management and advocacy at all levels; Improvements in sector funding levels (budget) and management with increased efficiency and equity; The abolition of User Fees in public units (except for private wings in hospitals) as of March 2001 and decreased fees in some of the PNFP units; Improving geographical access to services with construction of new health units especially in previously under-served areas; The improved quality of services more drugs and other health supplies, and more trained health workers. The increased availability of drugs in the FY 2003/04 is likely to have played a particularly important role in maintaining and further increasing the high OPD utilisation rates. The best five performing districts on this indicator are; Moyo, Adjumani, Gulu, Kabale and Kisoro while the least performing districts are: Kibale, Bugiri, Kotido, Iganga and Mubende districts (see Figure 2.1). All the five best performing districts are border districts, with the first two (Moyo and Adjumani) also playing host to large numbers of refugees 1 while Gulu is characterised by Internally Displaced Populations concentrated in camps. The performance ranges from 0.46 attendances per person per year in Kibale to 1 outpatient attendance has previously been noted to be much higher amongst refugee compared to native populations 7

24 1.43 in Moyo and Adjumani. Last year (FY 2002/03) Kampala was the least performer with 0.4 visits per person per year in this indicator mainly due to incomplete reporting that has largely been corrected; hence the improved performance for FY 2003/04 of 0.65 visits per person per year. On the other hand the high utilisation of OPD services along the borders of the country especially in the North and West of the country, seems to indicate that people from the neighbouring countries come here seeking the better quality services. It is important to note the factors which may have worked in the opposite direction decreasing OPD utilisation which include the increasing coverage of Home Based Interventions especially Home Based Management of Fever (HBMF) in the country. The increasing number of children being managed for fevers in the community would imply that fewer of these children end up in health centres and hospitals for In-Patient and Out-Patient visits. Currently there are still gaps in the data of the number of children that have been treated under this programme see Chapter 3. In some districts however this has already been related to declines in OPD attendance, as seen in Adjumani District. Figure 2.1: Variation of New OPD Attendance by District FY 2003/ Kibaale Bugiri Kotido Iganga Mubende Tororo Kayunga Apac Mayuge Nakapiripirit Kamwenge Rukungiri Masindi Wakiso Kamuli Kampala Lira Katakwi Moroto Mukono Pader Mbarara Kanungu Luwero Kiboga Sironko Sembabule Kapchorwa Mbale National Ntungamo Kyenjojo Yumbe Masaka Busia Nebbi Kitgum Hoima Arua Kumi Kasese Bushenyi Kaberamaido Mpigi Kabarole Soroti Kalangala Pallisa Bundibugyo Nakasongola Jinja Rakai Kisoro Kabale Gulu Adjumani Moyo DPT 3/Pentavalent Vaccine Coverage The Pentavalent Vaccine coverage (formerly DPT3 coverage) is used as a proxy measure for immunisation performance and general health sector performance. The national coverage for the reporting period is 83%, which is a 1.2% drop from last FY performance of 84%. This stagnation may be attributed to a plateau effect (more efforts may be needed to see equivalent increases that were seen at lower levels of coverage), and National Immunisation Days (NIDs) fatigue. At 83% the performance of the indicator has surpassed the annual target of 80% and it is still possible that the HSSP 8

25 target of 85% will be reached, however particular efforts will be needed to ensure this. A more detailed discussion on immunisation is in Chapter 3. The district performance against this indicator varies from 44% in Pader district to 139% in Mbale district (see Figure 2.2). The five best performing districts are; Mbale, Kumi, Sironko, Kalangala and Kabarole while the least performing districts are; Pader, Lira, Katakwi, Kitgum and Nakapiripirit. All the very poorly performing districts experience some insecurity and this is likely to be a major contributing factor to the low coverage. Figure 2.2: Variation of Pentavalent Vaccine Coverage by district FY 2003/ % Pader Kitgum Lira Katakwi Nakapiripirit Kotido Kapchorwa Masindi Luwero Moyo Sembabule Kamwenge Kiboga Yumbe Wakiso Kyenjojo Hoima Moroto Kibaale Bugiri Kampala Iganga Kisoro Mayuge Kasese Adjumani Tororo Mubende Masaka Rakai Rukungiri Mbarara Kaberamaido Arua National Ntungamo Kanungu Jinja Pallisa Bundibugyo Nakasongola Kabale Apac Kamuli Mukono Kayunga Mpigi Busia Nebbi Bushenyi Soroti Gulu Kabarole Kalangala Sironko Kumi Mbale Deliveries in Health Facilities Whereas an improvement has been registered in performance against this indicator in the year under review as compared to FY 2002/03, the utilisation of the health facilities for safe deliveries remains unacceptably low. The proportion of expecting women who deliver in government and PNFP health units has risen by 20% from 20.3% to 24.4% between FY 2002/03 and FY 2003/04 (see Table 2.3). Table 2.3: Total Number of Deliveries in Government and PNFP Units Financial Year 2001/ / /04 % Increase between the years 2001/02 to 2002/ /03 to 2003/04 Number of deliveries 214, , ,799 20% 16% Proportion of all expectant women delivering in GoU & PNFP units 19% 20.3% 24.4% 7% 20% 9

26 The coverage for this indicator shows marked variation across the country. A large proportion of the deliveries are contributed by a few districts on the right hand side of the national average as shown in Figure 2.3, while many districts are well below the national average of 24.4% to the left of the graph. Figure 2.3: Deliveries in health units by district FY 2003/ % Nakapiripirit Kotido Kamwenge Katakwi Kalangala Kyenjojo Yumbe Sembabule Kapchorwa Mubende Moroto Bugiri Kaberamaido Kabale Mayuge Bundibugyo Kibaale Apac Sironko Wakiso Mbarara Ntungamo Arua Kitgum Adjumani Pader Kanungu Rakai Bushenyi Masindi Moyo Masaka Busia Lira Kayunga Kasese Nakasongola Tororo Kiboga National Mbale Hoima Mpigi Iganga Luwero Gulu Rukungiri Kamuli Mukono Kabarole Kisoro Pallisa Nebbi Soroti Jinja Kumi Kampala The best performing districts are Kampala, Kumi, Jinja, Soroti and Nebbi and the least performers are Nakapiripirit, Kotido, Kamwenge, Katakwi and Kalangala. All the best performing districts have at least 2 hospitals each, and apart from Nakapiripirit and Kotido, which are both in Karamoja where communities have peculiar cultural beliefs related to Reproductive Health, the other 3 least performers have no hospitals. The availability of hospital services is a major determinant for pregnant women s choice to deliver in a health facility. It has been noted that in most districts over 30% of the deliveries in health facilities actually occur in the hospital(s). This may be a reflection of the failure to-date of the HC IV to take up their due function as centres for Comprehensive Emergency Obstetric Care (CEmOC) and HC IIIs for Basic Emergency Obstetric Care (BEmOC). It is interesting to note that Kampala has emerged the best performer for this indicator in the period under review. This is mainly as a result of the more complete data submitted by Kampala district for FY 2003/04 especially on deliveries from Mulago Hospital and the major PNFP hospitals (Nsambya, Rubaga and Mengo). More on this indicator is covered under Chapter 3 on Sexual and Reproductive Health and Rights. The reasons for the low turn up of mothers have been studied and include: Perceived poor quality of services particularly lack of equipment, supplies, water, light and privacy; 10

27 Cost to the clients as quite often mothers are asked to bring gloves, cotton, and mackintoshes; Poor attitude of health workers, with midwives particularly reported to be rude to mothers; Cultural barriers and use of TBAs and other alternatives in the society; Reproductive health supplies are often lacking at the health units which can be attributed to general under-funding, but also due to the fact that these supplies are not prioritised by the health units, HSDs and districts. Discussions have been held at various fora on maternal health and in particular the low turn up of mothers for deliveries in health units despite good Antenatal Care attendance. The performance well below target shows that there is still a big need for improvement, particularly if the sector is to contribute to improvements in health outcomes like maternal and child mortality. This is discussed further under Sexual and Reproductive Health and Rights in Chapter 3 of the Report Approved Posts filled by Trained Health Workers The availability of trained service providers is very crucial for the attainment of the HSSP objectives. A Health Workers Inventory (HWI), which has been long overdue and was emphasised as an essential undertaking by the HSSP Mid Term Review, was compiled in the FY 2002/03. The data is regularly updated. The HSSP baseline of 33% was based on the Uganda National Human Resource Requirements for HC II, III, and IV Report compiled by MoH (January 1999), which excluded Hospitals. The staffing standards in the report differ from the HSSP staff norms in the following ways: Nursing Assistants were not included in the standards used in 1999; 1999 staff standards were more generous with 1 Clinical Officer, 1 Enrolled Nurse and I Enrolled Midwife at the HC II against 1 Enrolled Comprehensive Nurse in the HSSP norms. The staffing level of 68% reflected as the HSSP Indicator in Tables 2.1 and 2.2 is based on the HWI as of October 2004 and compares the staffing norms with actual numbers of health staff (non-medical staff are not included) excluding Nursing Assistants. As highlighted in Table 2.4 when Nursing Assistants are included in the calculations the staffing level improves to 86%. The staffing levels in the AHSPR of FY 2002/03 have since been updated. These estimates (FY 2002/03 and FY 2003/04) differ from previous estimates in that: The inventory over the last two years has been exhaustive, whereas previous figures seem to have been under-estimates, as some districts were indicated with as few staff as 10; There has been recruitment over the four years of the HSSP; The centralised payroll has improved capture of information about health workers and has been used to validate the inventory. 11

28 Table 2.4: Proportion of Approved Posts that are filled by appropriately trained health workers Type of Norms HC II HC III HCIV Total District Total PHC level Hospital HSSP staff norms (GoU) 90% 78% 92% 85% 91% 86% HSSP norms, exclude 109% 58% 75% 69% 66% 68% Nursing Assts. (GoU) HSSP norms include PNFPs 98% 84% 93% 90% 94% 91% There has hardly been any improvement in this indicator with 66% performance in FY 2002/03 and 68% in the FY 2003/04. This is not surprising since there was hardly any recruitment in FY 2003/04. The changes are more likely to be due to more complete data (see Annex III and Chapter 3 for more details on Human Resources for Health). The best performing districts are Kampala, Adjumani, Kalangala, Ntungamo and Arua. The least performers are Kamwenge, Pader, Kanungu, Sironko and Kabale. Apart from Kabale all the least performers for this indicator are new districts. This is because new districts may not have as many Health units, usually lack hospitals and may not be in a position to attract health workers. This is important to note for future resource allocation. The challenges for human resources management in the sector in the FY 2003/04 centred on discussion with other sector stakeholders including MoFPED, MoPS and health workers representatives. The improvement in health workers salaries had implications on the wage bill and as such did not make it possible to recruit health workers by the different districts. The HWI has highlighted inequities for example the proportion of staff positions filled by appropriately trained health workers ranges from 40% in Kamwenge to 265% in Kampala district (including Nursing Assistants). Affirmative action is urgently required during resource allocation to enable the poorly covered districts to catch up. Many of the districts with poor performance against this indicator have previously failed to attract health workers even when provided with a budget for recruitment. An incentive package to attract health workers to these districts was proposed by the MoH and presented to MoPS. The MoPS indicates that a comprehensive approach to human resource management is being pursued National Average HIV Sero-prevalence The national HIV sero-prevalence (from ANC Sentinel sites) has stabilised between 6% and 7% for the last 4 years. It was recognised that there is need to have an estimate that is more representative of the general population. Hence, the MoH commissioned an HIV sero-survey and data collection is currently ongoing. More information regarding the STD/HIV/AIDS programme appears in Chapter 3 of this Report. It is recognised that other sectors contribute to the performance of this indicator. The health sector retains the responsibility of collecting information and reporting on it while the responsibility for performance is at the level of the PEAP. However, given the increased availability of Anti-Retroviral Therapy it is recognised that different indicators may need to be used to track any changes in prevalence/incidence that may occur as a result of this. 12

29 2.2 Summary Financial Report for the FY 2003/ The financing target and the HSSP Resource Envelope The Health Financing Strategy (HFS) estimated that the total annual cost of the HSSP, in the medium term, as US$ 28 per capita. In order to maximise efficiency, the bulk of this financing would be channelled through the GoU budget as this has been shown to enable the sector to target funding against set priorities. Despite inflation rates and some adjustments in the composition of the UNMHCP 2, it is estimated that the US$ 28 per capita remains a realistic target and the HFS outlined a strategy to achieve this financing goal by the FY 2019/20. The HFS is being updated in the HSSP II formulation process. The Uganda National Health Accounts for the 1998/99 to 2000/01 completed in FY 2003/04 have shown that when all sources of funding for the health sector are considered, Total Health Expenditure (THE) is slightly less than US $20 per capita - see Chapter 3 Health Financing Section for more detail. Most of the expenditure is by the households and within the private sector, where the spending is not necessarily on HSSP priorities. Public sources (GoU and donor) contribute less than 50% of Total Health Expenditure FY 2003/04 Budget Performance and Management In FY 2003/04, the approved budget including donor projects was Ugshs billion, equivalent to US$ 8.4 per capita. Of this, a total of Ugshs 361 billion is estimated to have been spent equivalent to US$ 7.83 per capita. This is an improvement from the FY 2002/03 during which an estimated US$ 7.2 per capita was spent in the health sector by government and donors. This expenditure remains much less than the requirement of US$ 28 per capita. Table 2.5 and Chapter 3 provide more information. Performance against the budget was 94% with the government budget showing performance of 95% and the donor projects 92% 3. As in FY 2002/03 the GoU budget including donor budget support exceeded donor project funding. Table 2.5: HSSP Funding for the FY 2003/04 Source Budget Expenditure Performance Comment GoU % Compiled from government budget expenditure documents Donor % Estimated from submission Projects from 8 donors Total % The health sector has made efforts to use the available resources in the most efficient and equitable manner. The increasing channelling of most resources through the budget has enabled the use of the government and SWAP procedures for management of these resources. The Health Sector Working Group is mandated to make resource allocation proposals, which are then concretised in the Budget Framework Paper. For the FY 2 Particularly regarding the wide scale provision of anti-retroviral drugs for HIV, the Pentavalent vaccine and Home Based Management of Fever 3 Donor Project performance is 92% against the MTEF figures of billion of July 2003/04 13

30 2003/04 the sector policy priorities and spending priorities as highlighted in the Budget Framework Paper were to address efficiency and equity in the bid to contribute to Poverty Eradication. In the FY 2003/04 this was operationalised in the following ways: Allocating resources to target the poor and most vulnerable members of society in line with the PEAP was done by continuing to allocate more financial resources at the Primary Health Care level where most of the poor in the country obtain their services. Funds to districts were allocated after putting into consideration a number of factors including: need for health care; availability of other sources of health care funding like: donor projects and availability of other vertical funding like to hospitals. In addition, in order to further decrease cost to the users, the budget for PNFP hospitals and health units was increased to enable these providers provide good quality services at a lower cost to the community. Efforts were made to target health care inputs with a large impact on quality of services especially drugs and supplies. For the FY 2003/04 both the level of funding for drugs and supplies and the mode of funding were targeted. The drug credit lines previously introduced in FY 2002/03 were scaled up in magnitude and in addition included General and Regional Referral Hospitals. In terms of programme priorities, the need to increase availability of Reproductive Health services led to the emphasis on infrastructure HC IVs, HC IIIs and multipurpose vehicles- that would facilitate the provision of these services. The sector sought and was granted PAF status for the general hospitals, which is likely to improve budget performance at this level and also better synchronisation with the rest of the district health services. For National and Regional Referral Hospitals the emphasis was on preparation of appropriate Costed Business Plans to enable due prioritisation and accountability. Annex II and Chapter 3 provide more detail on the GoU budget performance. The wage component realised 98% performance, non-wage component 98% and Domestic Development 84%. Mulago Hospital had the highest budget performance at 112% and the Regional Referral Hospitals the lowest at 82%. Disbursement of Budget Funds to the Local Governments The performance of MoH, MoFPED and Local Governments in disbursing PHC funds was not as good as in FY 2002/03. The analysis from 22 districts that submitted complete data showed that the disbursement performance was good for the PHC-CG Non-wage grant (utilised by the DDHS and HSD for management and service delivery) and the NGO grant at 89%. This was followed by the wage grant performance at 88% and the lowest performance was noted for the PHC-CG Development performance at 72% (see Figure 2.4). The budget performance in these 22 districts seems to be lower that the national averages in Annex II. This illustrates the variations across the country. The variation in performance is usually due to the variations in submitting reports and requests for PHC funds. 14

31 Figure 2.4: District PHC-CG Releases against Allocation 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 88% 94% 95% 89% 72% 35% PHC wage DDHS HSDs NGOs PHC Dev. Loc. Gov't Relating Inputs with Outputs The reforms undertaken by the health sector continue to achieve results. When the improvements in the sector outputs (represented by OPD attendance) are plotted against the GoU budget for the health sector, it is apparent that with every increase in the budget the curve grows even steeper Figure 2.5. This is in agreement with observations that the sector is improving utilisation of its infrastructural and human resources by availing more drugs and supplies. This has attracted more Ugandans to the health centres, thus improved efficiency all around. Figure 2.5: Relating health sector Inputs with Outputs Ugandan health financing reforms delivering output results Out-patient attendances (millions) The increasing gradient of this graph proves that the the sector is becoming more efficient at turning its budget into health care outputs 1997/ / / / / / / GoU Budget Expenditure (Billions of Shillings 2003/04 Prices) 15

32 2.2.3 Financial Management Ministry of Health Headquarters - Programme 9 Tracking Study In accordance with an undertaking from the October 2002 Joint Review Mission a Tracking Study was performed during FY 2002/03 on the MoH s PAF funds allocated to Programme 9: National Service Delivery Programmes. The health sector stakeholders have discussed the Report and follow up actions were agreed and are being implemented including: sorting out delays in the release of funds within the MoH due to various bottlenecks; decreased reallocation between programmes at the MoH: and countering the low levels of reporting and accountability on Programme 9 and other funds from the various sub-programmes Districts Financial Management Monitoring The Monitoring for the PHC-CG has shown improvements in financial management at district and lower levels. However there are still some challenges particularly with compliance with guidelines. The following have been observed: Proportion of budget to be spent on various areas: this is still a challenge as shown using the 50% indicative budget for drugs see under Drug Management. Poorer performance on timeliness and completeness of reporting in FY 2003/04 compared to FY 2002/03. This has in turn led to delayed release of funds by MoFPED. For example in Quarter 1 of FY 2003/04 in 18 districts studied, only 59% of the funds expected were released. This improved to 82% in the second quarter. Inaccurate information in Quarterly Reports: the reports submitted for consideration by the MoH before funds can be released for the subsequent quarter, may differ from the information in the book of accounts. In particular the expenditure is often overstated to create the impression that the funds are exhausted. Handling of Capital Development Funds: in most districts construction and training of Nursing Assistants have taken off very slowly because the funds come in small instalments, and the complicated tender procedures. This has been worsened by poor release of funds by MoFPED against this the PHC Development Grant. 2.3 Measuring District Performance against the HSSP Indicators This report (FY 2003/04) is the second time that an assessment of individual districts performance against the agreed district HSSP Monitoring Indicators has been carried out with the help of a District League table. The information from this assessment is used to rank districts. For the FY 2003/04 report it was agreed that the same indicators for the League Table as for FY 2002/03 report be used to allow for fair comparison between the years. It has been easier this time round to assemble the necessary data to make up the League Table, which as a result is more complete than the previous one. Some districts however did not provide information on some of the indicators such as drug procurement (especially in the Private-for-Profit sub-sector) and financial management. This has counted against these districts. 16

33 What makes up the League Table? A number of both HSSP and non-hssp district monitoring indicators have been used for the league table. These are: Information Indicators: District population; Number of HSDs and Number of hospitals. Management Indicators: Management of the PHC-CG measured by timeliness of reporting/requests; Management of health data measured by completeness and timeliness of HMIS reporting; Expenditure on key inputs measured by proportion of indicative PHC-CG budgets spent on drugs; and Management of inputs proportion of staff norms appropriately filled. Service Delivery Output Indicators: Pentavalent vaccine coverage; OPD new 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 the 2 nd dose of Fansidar in Pregnancy (IPT2); and Pit Latrine coverage. The information indicators are not accorded a score as these are not determined by the district but by historical circumstances, central level, and development partners. However these indicators do influence outputs and therefore are included for perspective. The magnitude of contribution for each of the indicators has been determined mainly by 3 factors: Importance of factor in terms of its contribution to the overall health outcomes - For example the indicator on drugs scores 10, whereas timeliness of HMIS is 5. Magnitude of district influence on the performance of the indicator - For example the indicator on staff norms although very important, the contribution by the district is relatively small thus the score of 5. The HSSP indicators that are also used as PEAP indicators are awarded the highest scores of 12.5 each. The Purpose of the League Table The League Table has been put in place to facilitate the following: Compare sector performance between districts and therefore determine good and poor performers; Provide information to facilitate the analysis of circumstances behind good and poor performance at the district level, and thus enable appropriate corrective measures which may range from increasing the amount of resources (such as funds, infrastructure, equipment or staff) or more frequent and regular support supervision; Increase Local Government ownership for achievements the AHSPR is discussed at the NHA where political, administrative and technical leadership of the districts will be in attendance; Encourage good practices good management, innovations and timely reporting. The League Table is not meant to embarrass Local Governments 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. The districts that have shown marked improvement or decline are assisted to see how they are performing against other districts. 17

34 The League Table Scores The top 10 districts in order of ranking are: Gulu, Jinja, Adjumani, Moyo, Tororo, Rukungiri, Mpigi, Bushenyi, Kampala and Busia. The bottom 10 districts from the last are: Kotido, Pader, Yumbe, Kamwenge, Iganga, Wakiso, Masindi, Lira, Moroto and Mubende. The detailed League Table is included in this Report as Annex I and Figure 2.6 is a map highlighting the top 10 and the bottom 10 performers. The good and poor performers are spread across the country. Figure 2.6: District Performance according to the League Table When the League Tables for FY 2002/03 and for FY 2003/04 are compared it is noted that the overall score in FY 2002/03 was higher (63.1 compared to 60.2) and this has been contributed to by lower scores on top of the table (the top score was 85 in FY 2002/03 compared to 77.6 in FY 2003/04) and the bottom districts did worse in FY 2002/03 compared to FY 2003/04 (7 districts in FY 2003/04 scored less than 41.7 the least score in FY 2002/03). This indicates when the aggregate PEAP indicators are considered, an improvement is noted but when the output and some management indicators are analysed at the district level, a decline is noted. At individual district level Gulu, Kampala, Mukono, Mbale and Apac show an improvement of more than 50%, whereas Luwero, Kaberamaido, Mubende, Ntungamo, Nebbi and Pallisa show a decline of more than 30% (see Figure 2.7). The stakeholders and particularly the districts concerned should note the factors causing movement up or down the League Table. Three of the worst 10 performers in the FY 2002/03 League 18

35 Table have made remarkable improvements and are no longer in the bottom bracket (see Table 2.6). These are Kampala from 47 th to 9 th position, Bundibugyo from 51 st to 35 th position, Apac from 54 th to 25 th position and Katakwi from 53 rd to 44 th position. Figure 2.7: Change in overall district Performance Gulu Kampala Mukono Apac Kabale Bundibugyo Bushenyi Busia Tororo Kyenjojo Adjumani Hoima Mbale Sironko Katakwi Nakasongola Mpigi Soroti Nakapiripirit Kitgum Masaka Rukungiri Sembabule Masindi Pader Kasese Jinja Bugiri Kotido Moyo Kamuli Kibaale Yumbe Mayuge Kiboga Mbarara Rakai Wakiso Kabarole Kumi Lira Arua Iganga Kapchorwa Kisoro Kanungu Kayunga Kalangala Moroto Kamwenge Pallisa Nebbi Ntungamo Mubende Kaberamaido Luwero Table 2.6: Movements in & out of the Top and Bottom 10 of the League Table Stayed in the same group New Entrant in Group Top 10 Bottom 10 Jinja, Moyo, Rukungiri Adjumani, Bushenyi, Busia, Gulu, Kampala, Mpigi, Tororo Kotido, Masindi, Pader, Yumbe Iganga, Kamwenge, Mubende, Lira, Moroto, Wakiso Factors Influencing District Performance In order to begin to determine the likely reasons behind good and poor performance some cross analyses have been done. This analysis considered the following variables; a) Performance against Management Indicators for example the proportion of indicative drug budget spent b) Performance against Service Delivery/Output Indicators particularly immunisation c) Peculiar circumstances which include: Districts with insecurity in FY 2003/04 New districts since 2000; and Karamoja Region the nomadic culture District Management Performance Overall district management practices can be represented by some proxies. Study of both League Tables FY 2002/03 and 2003/04, shows that good performance on the League Table tends to be closely linked to drug management as shown by the proportion of the indicative budget for drugs that has actually been spent on drugs in the FY under review. 19

36 Table 2.7: District Comparing Drug Management Performance and the League Table Proportion of Indicative PHC Budget used for drugs Drug Funding Rank League Table Score League Table Rank Kitgum 120% % 29 Moyo 109% % 4 Adjumani 102% % 3 Gulu 102% % 1 Tororo 96% % 5 Nakasongola 93% % 17 Kyenjoojo 92% % 16 Busia 86% % 10 Sironko 85% % 30 Soroti 83% % 24 As shown in Table 2.7, five of the top 10 performers on the League Table are among the top 10 performers in drug management. The proportion of the drug budget spent on drugs is likely to affect district performance through improved availability of drugs, and therefore more utilisation of services by the population. It is hence likely that well managed district health services in all other aspects are likely to coincide with the appropriate emphasis on providing the necessary inputs. Service Delivery Capacity: The indicator Proportion of children <1 receiving 3 doses of pentavalent vaccine according to schedule was closely related to overall good performance as shown in Table 2.8. This suggests that districts which have high immunization coverage, measured by Pentavalent vaccine coverage, are likely to be good performers overall. This indicator could therefore be used as a proxy indicator for overall district performance except in cases where the population numbers are questionable. A successful immunisation programme involves a lot of planning and management skills and hence districts that excel in this are likely to apply the same skills across all services leading to high overall performance. Table 2.8: Comparing District Performance on Pentavalent Vaccine Coverage and League Table Ranking Pentavalent Vaccine Coverage % Rank League Table Score League Table Rank District Mbale Kumi Sironko Kalangala Gulu Kabarole Soroti Bushenyi Nebbi Busia

37 Districts with marked Insecurity Among the 7 districts of Northern and North Eastern Uganda which suffered marked insecurity and displacement of persons in the FY 2003/04, Gulu performed best, followed by Soroti in 1 st and 24 th positions respectively on the League Table and are in the top half of the League Table. The rest are in the bottom half with Lira and Pader districts at 49 th and 55 th position respectively in the bottom 10 districts on the League Table (see Table 2.9). Table 2.9: Performance of the Districts with marked Insecurity in FY 2003/04 District with Insecurity League Table District Rank Score Rank Gulu Soroti Kitgum Kitgum Katakwi Lira Pader The performance of Gulu district particularly needs special mention. A number of factors contributed to the spectacularly good performance in Gulu district. These include: The majority of the people live in Internally Displaced People s Camps or within the Municipality. This has enabled service delivery as most IDP Camps have health units; Good management of the district health services which can be illustrated by the good information management (see later under HMIS) and use of the drug budgets to procure drugs; Support by partners in addressing the population needs; On the other hand Pader is still close to the bottom of the League Table and this can be attributed to: Persistent insecurity leading to migration of health workers from the district and a mobile population; Being a new district, Pader still has limitations in terms of human, logistic and infrastructural capacity. The health sector stakeholders agreed to a resolution regarding districts with insecurity at the 1 st National Health Assembly. The follow-up to this is reported in Chapter 4. New Districts Districts that have only been in existence for less than 4 years are likely to be more disadvantaged in terms of infrastructure, logistics and human resource, since marginalisation was the justification for the creation of most of these districts. In the FY 2002/03 analysis was done to see the best performing and the worst performing amongst the new districts. In FY 2002/03, Kaberamaido was the best performer, followed closely by Kanungu and Kyenjojo, with Pader, Yumbe and 21

38 Nakapiripirit in the bottom positions. This situation has not changed much; except for the decline by Kaberamaido (was overrun by insecurity for a number of months) and the climb by Sironko from 7 th to 3 rd Only Kyenjojo and Kanungu districts are in the top half of the League Table. The rest are in the bottom half of the League Table with Wakiso, Kamwenge, Yumbe and Pader holding 4 of the bottom 6 position of the Table (see Table 2.10). The poor performance of Wakiso district is a concern given that there is no obvious disadvantage such as poor infrastructure or logistical capacity. Table 2.10: Performance of the New Districts in FY 2003/04 New Districts FY 2002/03 Rank New Districts FY 2003/04 Rank League District Table Score Rank Kyenjojo Kanungu Sironko Kaberamaido Mayuge Kayunga Nakapiripirit Wakiso Kamwenge Yumbe Pader Karamoja Region: The Karamoja Region is characterised by peculiarities which have implications for health service delivery. These include nomadism whereby a large proportion of the population, particularly the young males are very mobile, travelling with the animals looking for pasture. The cultural norms of the Karamojong are very negative towards women having deliveries in health units and the use of latrines for faecal disposal. This is illustrated by the poor performance of the Karamoja districts against the key HSSP indicators such as OPD utilisation, deliveries in health units and latrine coverage (see Table 2.11). Table 2.11: Performance of the districts in the Karamoja Region District Latrine coverage Deliveries in health units OPD utilisation District League Table Score Rank Score Rank Score Rank Overall Rank Score Nakapiripirit 3% 55 3% Moroto 10% 53 12% Kotido 2% 56 7% Ranked 44 th out of 56 in the League Table, Nakapiripirit district is the best performer of the three districts. This level of performance shows that special effort has to be made if the people of Kamaroja are to enjoy the same health services and standards as the rest of the country. 22

39 The Future of the League Table The District League Table although only introduced in the AHSPR for the first time in 2002/03 has been of immense value in unpacking health sector performance and highlighting the variations between districts. Although no Gold Standard has been used, just comparing districts amongst each other helps to show areas for improvement. However as sector Monitoring and Evaluation matures, and during the development of HSSP II, there is need to judge whether there is scope for further improvement of the League Table as a Monitoring and Evaluation tool. The Joint Review Mission of October could be a forum for this discussion. Among the issues to be discussed should be the following: Should the League Table maintain the same indicators in future? If not which indicators should be discarded and which new ones should brought on board. There have been some proposals for these, which include: New indicators to consider: Couple Years of Protection (CYP) and Malaria Case management possibly use of Case Fatality Rate; Indicators to get out HMIS timeliness and completeness as they are approaching 100%; Human Resources for Health as a scored indicator, to an information indicator as the district can do little to make changes in this; A different concern though is the linkage between good performance on the League Table and the health status of the population. Is there any relationship? Should there be a relationship? What about the data from National and Regional Referral Hospitals should this continue to be included in its entirety under the districts these hospitals are situated in? 23

40 Chapter 3 Implementation of the Health Sector Strategic Plan 3.1 Delivery of the Uganda National Minimum Health Care Package The Uganda National Minimum Health Care Package (UNMHCP) addresses the priority components of the national disease burden. The 12 elements of the UNMHCP constitute the most cost effective interventions considered to have the highest impact on decreasing population morbidity and mortality. For purposes of demonstrating integration at the implementation level, the elements have been clustered into the following sub-packages; i) Prevention and Control of Communicable Diseases ii) Maternal and Child Health iii) Prevention and Control of Non-Communicable Diseases iv) Health Promotion and Disease Prevention For each element within the sub-package, there is a review of the annual targets, an assessment of the achievements made at the national and district levels and the challenges and constraints encountered. Specific efforts are made to relate the reported activities to the expected outputs Prevention and Control of Communicable Diseases The Burden of Disease Study of 1995 indicated that communicable diseases contributed more than 65% of the national disease burden. The HMIS data analysed over the years indicate that this continues to be the case. The main focus of the HSSP is on malaria, HIV/AIDS and TB as indicated by their contribution to the national disease burden. (1) Malaria Malaria remains the number one cause of morbidity and mortality among the population of Uganda with serious economic and social consequences. During FY 2003/04, malaria accounted for 52% of the OPD attendance while over 400,000 cases were treated by the Community Drug Distributors (CDDs) as part of Home Based Management of Fevers. Malaria still accounts for 30% of inpatient admissions and 9-14% of inpatient deaths (20-23% of deaths of children under 5 years of age). The focus for Malaria Control is: Prompt and effective malaria case management at the health facility, community and household levels Vector control including insecticide treated mosquito nets (ITNs), indoor residual insecticide spraying (IRS) and environmental management Malaria in pregnancy care including intermittent preventive treatment (IPT). Malaria epidemic preparedness and response including the prediction, early detection and containment of epidemics The performance for FY 2003/04 is indicated in the Table 3.1. Key indicators such as the utilisation of ITNs have been difficult to monitor because the data can only be obtained from surveys. The performance indicator positions have therefore been derived from nationally representative surveys and are elaborated on in the various sections. 24

41 Table 3.1: Indicator Performance against HSSP Malaria Indicators 1 The proportion of the population that receive effective treatment for malaria within 24 hrs of onset of symptoms 2 Proportion of pregnant women who receive protection against malaria through IPT with SP 3 The proportion of children under five protected by ITNs 4 Reduced malaria Case Fatality at hospital level to below baseline levels *Valid for children in HBMF district as at June 2003 **Valid for 6 HBMF districts as at June 2003 ***This is derived from data covering 10 Regional Referral Hospitals Baseline Achieved Target Achieved Target Value 2002/ / / % 48%* 55% 60% 0% 20.3% 40% 24% 60% 5% 3.8%** 25% 50% 5% - 3% 3%*** 3% Effective Malaria Case Management: This strategy is two-pronged, targeting case management at the facility and community levels. Community Level Implementation of the home-based management of fever (HBMF) strategy is at various stages of implementation in 43 out of 56 districts (see Table 3.2). The HBMF strategy shall be initiated in the remaining 13 districts in FY 2004/05. The dispensing of HOMAPAK at community level is ongoing in 33 districts with district wide coverage in 27 districts and partial coverage in 6 districts. It is envisaged that by the end of FY 2004/05, there shall be district-wide coverage in all districts with the support of the Global Fund. Table 3.2: The Status of HBMF Implementation in the districts Step Output Districts 1. Sensitization and planning at district Supportive district leaders & a 43 level district implementation plan 2. Training of district trainers District trainers/supervisors of drug 43 distributors 3. Orientation of health workers Supportive health workers & health 33 facilities 4. Sensitization and planning at sub-county Supportive leaders & Community 33 level mobilisers 5. Sensitization of communities at level LC Sensitized communities and 33 I level and selection of volunteers to be trained as drug distributors volunteers to be trained as drug distributors 6. Training drug distributors Trained drug distributors Treatment of children by trained Children with fever being treated 33 volunteers (drug distributors) 8. Supervision of drug distributors Supervised drug distributors 33 25

42 During the course of the year, procurement and distribution of 8,582,724 doses of HOMAPAK to the implementing districts was supported by various partners as indicated in Table 3.3. Table 3.3: Partner Support in provision of HOMAPAK Partner Doses of HOMAPAK Support to the HSSP (ADB) in 11 districts of Northern 3,500,000 Uganda UPHOLD (USAID) in 20 districts 1,582,724 Malaria Consortium/DfID covering IDP camps 3,500,000 Total 8,582,724 The reports from some of the districts which have attained full HBMF coverage indicate that a substantial number of children with fever have been treated by the community drug distributors. Figure 3.1 compares the children treated at health facilities with those treated by the drug distributors for the districts of Rukungiri, Nakasongola, Kyenjojo, Gulu and Adjumani for FY 2003/04. Figure 3.1: Comparison of the children <5years treated at health facility and by Community Drug Distributors FY 2003/04 Comparison of number of children <5yrs treated at health facility and by drug distributors 2003/04 Rukungiri Nakasongola District Kyenjojo Gulu Adjumani Number of Children No. treated at H/U No.treated by Drug Distributors Under 5s OPD Attendance and the HBMF strategy According to the data available from 8 HBMF districts, there has been a general increase in OPD attendance of children <5yr over the past 2 years. Figure 3.2 shows the trends in <5yr OPD attendance for 2 consecutive years (FY 2002/03 to FY 2003/04). This increase could be attributed to the following factors; Increased availability of drugs with consequent increased utilization of services. 26

43 Increased access to services through opening up of new health centres in remote areas. HBMF intervention may be reaching the hard-to-reach population, which had previously engaged in self-medication and hence despite the high number of children treated, there is little or no impact on OPD attendance. Improved completeness in reporting. Figure 3.2: Comparison between OPD New Attendance for the under 5s for FY 2002/03 and FY 2003/ No. of new att. under 4yrs / / Adjumani Gulu Kabarole Kiboga Kumi Kyenjojo Nakasongola Rukungiri District Studies done in Rukungiri district indicate a high level of community knowledge of HBMF and community satisfaction with the programme. The community drug distributors (CDDs) are motivated by the trust the communities have put in them in appreciation of their services. Analysis of data from the initial 10 HBMF implementing districts reveals a relatively well-established system. There is a high rate (79%-99%) of recovery of the treated children, >52% children are treated within 24 hours of onset of fever, <0.3% of the children seen died and the attrition rate of drug distributors ranges from 1.5%-21.2%. The major challenges in implementation of HBMF which need immediate attention are; a weak reporting system, inadequate supervision of the CDDs, logistical problems in the delivery of drugs to the CDDs, low community support and attrition of CDDs. Facility Level The health facility provides a continuum of care from the community level, and during the period under review, the following were done to strengthen effective malaria case management. Training workshops on management of severe malaria were conducted for the hospitals that remained uncovered during FY 2002/03 On-site sensitisation of health workers on the issues of the antimalarial drug policy 27

44 Ensuring a constant supply of antimalarials at the health facility level Antimalarial Drug Policy Change. Since 1997, MCP has been collecting data on antimalarial drug efficacy at 8 sites that are geographically and epidemiologically representative of the malaria ecological strata in Uganda. Data from these sites was used in revision of the antimalarial drug policy in 2000 and In May 2004, the Case Management Working Group (CMWG) of the ICC for Malaria reviewed antimalarial drug efficacy data from these sites. These data showed a mean treatment failure for CQ/SP after 14 days of follow-up of 21.4% (range 3-45%), which is higher than the 15% level at which WHO recommends a change in the drug policy. The CMWG hence recommended that CQ/SP should be replaced by Artemether- Lumefantrine (Coartem) as 1 st line treatment for uncomplicated malaria, oral Quinine as Second line treatment and parenteral Quinine for the treatment of severe and complicated malaria. A proposal to fund this change in policy was submitted to Round 4 of the Global Fund and has been provisionally approved. Plans for rolling out the new policy in the last quarter of 2005 are underway. Malaria in Pregnancy (MIP) The strategy aims at all pregnant women receiving 2 doses of SP as intermittent preventive treatment for malaria. The emphasis during the year was to ensure availability of SP at the health unit level, to build an environment of provider confidence to deliver the services and to mobilise communities to utilise ANC services where IPT is provided. The overall coverage for IPT2 for FY2003/04 was 24% (see Figure 3.3). Although this is an increase (of 4%) from FY 2002/03 levels, it is very much below the FY 2003/04 target of 40%. The performance range for the indicator is from 55% for Moyo to 7% for Kampala. The best performers are Moyo, Gulu, Nebbi, Soroti and Kamwenge. The least performers are Kampala, Nakapiripirit, Katakwi, Kibale and Lira. During the course of the year, the following were achieved; Training of district trainers/supervisors in 12 districts in addition to the 40 districts already covered. Sensitisation of district leaders to MIP in last 12 districts. Monitoring the supplies of SP to the health units through the PHC and credit line purchase systems and the Area Team monitoring process Piloting pragmatic indicators for monitoring of MIP in the districts of Luwero and Soroti in collaboration with WHO. The pilot was evaluated and recommendations made will influence the Monitoring and Evaluation of MIP in Sub-Saharan Africa. Piloting of the community MIP strategy to increase ANC attendance and IPT uptake in the district of Mubende. 28

45 Figure 3.3: IPT2 coverage by district % Kampala Nakapiripirit Katakwi Kibaale Lira Kotido Wakiso Masaka Bundibugyo Sembabule Kisoro Kanungu Kapchorwa Pallisa Kayunga Rukungiri Nakasongola Mubende Iganga Kitgum Ntungamo Mbale Apac Mbarara Kalangala Kaberamaido Mayuge Moroto Bugiri Masindi Kiboga National Mpigi Kabarole Kabale Kyenjojo Pader Rakai Yumbe Bushenyi Jinja Hoima Luwero Kasese Kamuli Sironko Tororo Busia Mukono Adjumani Arua Kumi Kamwenge Soroti Nebbi Gulu Moyo Insecticide Treated Nets (ITNs) Use of Insecticide treated nets (ITNs) is one of the most cost effective methods of malaria prevention in highly endemic areas. The target is to have all children under 5 years and pregnant women sleeping under ITNs. Following the release of the GFATM funds to Uganda, a decision was taken to distribute all the ITNs free of charge to the target groups. The mechanisms for distributing the free nets are still being worked out. ITNs sales and distribution: In 2003 a total of 467,081 nets were sold/distributed, an increase of almost 187,000 nets or 67% compared to 2002 figures and a more than doubling of the 2001 totals (see Table 3.4). Of these 51% were long-lasting nets, 34% nets bundled with an insecticide treatment kit and only 15% were untreated nets. No exact figures are available for nets sold in the informal sector (drug sellers/drug shops). In the period January to June 2004, 280,470 nets of all types have been sold, of which 67 % are LLIN. The number of re-treatments sold in the 1 st 6 months of 2004 was 501,314. Table 3.4: Net sales in Uganda by type, 2002 to the 1st half of Period Half 2004 Item Number % Number % Number % Untreated nets 73, , ,962 9 ITN Bundled* 130, , , Long-Lasting Insecticide Treated Nets (LLIN)** 77, , , Total (All types) 281, , , *ITN Bundled nets are untreated mosquito nets bundled together with one treatment dose **LLIN are nets that are factory treated and may not require re-treatment during its lifespan. 29

46 The ITNs Subsidy Scheme in Northern Uganda by PSI is on-going whereby ITNs (Smartnet) are sold at Ugshs 5,000 to the general population. Net Coverage: Based on various data sources, the mean net coverage in FY 2000/01 was 9.9% in rural areas and 33.3% in urban areas. In the same areas estimates for FY 2003/04 were 23.5% in rural and 48.8% in urban areas. This represents a 2.8 fold increase of net coverage in rural and 1.7 fold increase in urban areas within the last 3 years. Clear estimates of the true coverage will be available after the UDHS The National Mass Net Re-treatment exercise was conducted in 20 districts in April to early June 2004 with a total of 481,800 out of the targeted 650,000 nets (74%) re-treated. Net re-treatment picture Indoor Residual Spraying: Insecticide for Indoor-Residual-Spraying (IRS) was distributed as wettable powder formulation (WP) and included lambdacyhalothrin and deltamethrin. A total of 11,272 units (each unit represents about 200m²) were distributed. IRS was conducted in various institutions such as boarding schools within FY 2003/04. Malaria Epidemic Preparedness and Response: The Highland Malaria (HIMAL) project, which started in September 2002 and is expected to last 4 years, is being implemented in Kabale and Rukungiri districts with data collection in 5 sentinel Health Centres (HCs) per district. At an intensive sentinel site in each district, clinical outpatient morbidity and inpatient morbidity and mortality, entomological and parasitogical data is collected, while at the other non-intensive sites only clinical outpatient morbidity and inpatient morbidity and mortality data is collected. An automatic weather station has been established in 2 intensive sentinel HCs, Bufundi HC III in Kabale and in Kebisoni HC IV in Rukungiri District which automatically collects data on rainfall, temperature and relative humidity. 30

47 Data analysis and feedback to participating sentinel HCs on a weekly basis is fully operational. The same data is sent to the MCP, the London School of Hygiene and Tropical Medicine, various offices in the MoH and to WHO Country Office. The surveillance system is now fully operational and able to detect early any malaria upsurges/epidemics in the two districts. During this year, we have experienced the expected seasonal upsurges throughout the country but there were no epidemics. Challenges in malaria control Resource Limitations Even though significant gains have been registered especially in the areas of HBMF and IPT, serious challenges remain in the provision of the required supplies at the facility and community levels. There are high stock-outs of SP as the available SP is used for both IPT and management of clinical malaria. At the subsidised rate of Ugshs 5,000, the cost of ITNs remains out of reach of the intended beneficiaries. Kampala Pharmaceutical Industries (KPI) is failing to meet current demands for manufacture of Homapack for the 33 districts. This is likely to be more problematic with scaling up to cover the entire country. Supervision and Monitoring The current HMIS tools do not capture some of the information needed to monitor malaria interventions (e.g. IRS and ITN). There is inadequate analysis of the HBMF data recorded by the drug distributors and the HMIS at all levels. Capacity to supervise the community interventions (e.g. HBMF, ITN retreatment and use) is inadequate in some districts. There is a high attrition of drug distributors, who are volunteers, as their demands for incentives are yet to be addressed. (2) STD/HIV/AIDS Almost two decades after the first reported case and HIV/AIDS still remains a significant public health challenge contributing significantly to morbidity and mortality in Uganda. Significant achievements have been made in the last decade in addressing the problem with reported epidemic contraction and sexual behavioural change. The STD/AIDS Control Programme in the health sector is part of the multi-sectoral strategy for HIV/AIDS prevention and control in Uganda and is responsible for implementing the public health response to the epidemic. The objectives of the programme are: To prevent the further transmission of the STD/HIV/AIDS epidemic To mitigate the impact of HIV/AIDS through the provision of care and support to the infected and affected To strengthen capacity for HIV/AIDS prevention and control at the national, district and community levels. 31

48 In order to achieve the above objectives, a number of interventions are being implemented. The outputs achieved as a result of these interventions during the FY 2003/04 are summarised in Table 3.5 below. Table 3.5: Indicator Performance against HSSP STD/HIV/AIDS Indicators Baseline Value 1999/00 Achieved 2002/03 Target 2003/0 4 Achieved 2003/04 Target Antenatal HIV sero-prevalence rates 6.8 % 6.2 % N/A 5.1 % 2 Knowledge of two methods of 85 % 90 % N/A 95 % prevention of HIV transmission 3 Condom availability at central level (millions) 4 Condom use at last sex with a nonregular 50 % 60 % N/A 75 % partner 5 Median age at first sex (Years) N/A 17 6 Proportion of STI patients who are appropriately managed according to guidelines 21 % 25 % N/A 50 % 7 Number of districts with at least one VCT outlet 8 Number of districts with at least one PMTCT outlet 9 Number of Regional Referral Hospitals providing ART services IEC/Behaviour Change Communication IEC strategies in Uganda remain the backbone of HIV/AIDS prevention and control interventions in the absence of an effective cure for the disease. The IEC activities implemented continue to focus on creating awareness, knowledge and subsequently behavior change. The following were the key IEC outputs for the period of reporting: In line with the revised IEC strategy, advocacy materials were developed for VCT, PMTCT, Infection Control under Universal Precautions and promotion of ABC preventive options. IEC messages disseminated through Radio and Television Talk Shows Condom promotion, distribution and Use Condom promotion, distribution and use is one of the three elements (ABC) of the Uganda HIV/AIDS prevention and control strategy. Condom promotion and distribution is done through the public sector by the MoH working together with social marketing groups and private distributors. In FY 2003/04: The National condom policy was finalised and the printing process started Condom promotion is ongoing through IEC and social marketing groups. 80 million pieces of condoms were procured through the World Bank HIV/AIDS control project. 60 million pieces of condoms (ENGABU) were distributed by the MoH and NGOs, 30 million pieces were distributed through social marketing groups and 5 million through private vendors. 32

49 A national condom distribution plan together with guidelines was developed. Mapping of distribution sites to make condoms more available and accessible is in progress. Voluntary Counselling and Testing Voluntary Counselling and Testing (VCT) is an important component of the comprehensive strategy to address HIV/AIDS in Uganda. Knowledge of one s serostatus helps the individual to make an informed decision on sexual and social behavioural patterns. It is important for the health sector to meet the demands for quality VCT services and to ensure that they are accessible and being utilised. During the reporting period, the following outputs were achieved: The 4 remaining districts (Kanungu, Bugiri, Nakapiripirit and Bundibugyo) were facilitated to start VCT services, thus covering all the districts in the country. VCT policy implementation guidelines were developed, adopted and disseminated. They are being reviewed for legal implications of offering VCT services to children and how a consensus position could be reached. In FY 2003/04; approximately 560,000 people were tested for HIV in VCT centres around the country (compared to 150,000 people tested in FY 2002/03) and 280,000 HIV testing kits were procured for use in VCT service provision 300 new counsellors and 250 laboratory staff were trained for VCT service provision. 50 new static VCT sites and 100 outreach sites were started. Prevention of Mother to Child Transmission (PMTCT) The transmission of HIV from mother to child is the second most common means of transmission of the virus in this country. There has been a lot of effort from the national and international community to focus on this modality of HIV control. At the national level MoH is promoting a four pronged strategy that consists of primary prevention of HIV/AIDS, prevention of unintended pregnancies among HIV positive women, use of a comprehensive package that includes ARV drugs in HIV infected pregnant mothers to reduce Mother to Child transmission of HIV and comprehensive care to the mother and her family. During the reporting period the following key outputs were achieved: Access to services increased from 71 sites in 31 districts in FY 2002/03 to 140 sites in 49 districts in FY 2003/04, an increase of almost 100%. The sites are spread across the country (see Figure 3.4). About 101,195 out of the 176,368 pregnant women who were offered counselling at PMTCT sites (57%) accepted to take the HIV test. Approximately 10% of those tested turned out to be positive for HIV. About 5,486 of the HIV positive mothers were given antiretroviral drugs for prevention of mother to child transmission of HIV. 33

50 Figure 3.4: Number of Functional PMTCT sites by District Infection Control: The STD/AIDS control programme infection control interventions are conducted to complement the efforts of the Clinical Services and Quality Assurance Departments. This component involves preventing transmission of nosocomial infections, with special emphasis on blood borne pathogens. In FY 2003/04, the following were the main achievements: Infection control practice and on job training was done following an outbreak in Mbarara Hospital Based on the initiative from Mbale and Kayunga Hospitals, infection control practice was carried out and 60 health workers were trained from both hospitals. 74 members of the Federation of Uganda Employers (FUE) were sensitised on universal precautions. Care and Support including Anti-retroviral Therapy (ART) The MoH has continued to provide a package of Care services including clinical management, psychosocial support (counselling) and home based care across a continuum. During FY 2003/04, 58 health facilities in 20 districts from both the public and private sectors have been accredited to provide antiretroviral drugs. 48 of these facilities are currently providing ART (see Figure 3.5). An estimated 24,500 patients are currently accessing ART from the different public outlets. The public sector ART programme was officially launched in June 2004 with drugs for treating 2,700 adults that were procured under the World Bank funded Uganda AIDS Control Project. The drugs were distributed to 26 health facilities, including all the 11 34

51 Regional Referral Hospitals. To facilitate the programme, 381 doctors, 63 clinical officers, 238 nurse/ midwives, 200 laboratory staff, 1,000 counselors and 60 nursing assistants were trained in HIV/AIDS management including ART and 96 trainers, 330 supervisors and 390 community volunteers were trained for Home Based Care Figure 3.5: Sites offering ART in Uganda * Several Private for profit Facilities are not captured in the Map Monitoring and Evaluation including Surveillance The STD/AIDS control programme keeps track of the progress of the HIV/AIDS epidemic through a series of surveillance activities. These activities include sentinel surveillance and KABP surveys for behavioural data collection within the concept of second generation surveillance. Additional data on STD/HIV/AIDS is obtained from collaborating partners like MRC, Rakai Project, GTZ, AIC, and CDC. This enables the programme to compile a comprehensive database. The following were the key outputs during the FY 2003/04; New sentinel sites were opened up to complement the existing ones and to improve the rural representation. There are currently 25 operational sites in the country. National sero-behavioural survey preparations were completed and the survey is currently on-going 35