THE REPUBLIC OF UGANDA. Annual Health Sector Performance Report

Transcription

1 THE REPUBLIC OF UGANDA Annual Health Sector Performance Report Financial Year 2009/2010

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3 Foreword The for provides a review of sector performance in the financial year, and an overall assessment of sector performance against the targets set in the second Health Sector Strategic Plan (HSSP II). It also reports on implementation progress against the sector priorities set at the 7 th National Health Assembly and the 15 th Joint Review Mission with stakeholders. The Government of Uganda recognizes the contribution of Health Development Partners, Civil Society, the Private Sector and all Ugandans in the achievement of the progress reported in the sector performance. The sector also appreciates the constructive criticism, useful guidance and inputs that the said stakeholders put in correcting inadequacies in the health sector. The sector cannot afford to continue with the usual way of doing things in the face of unacceptable failure to improve indicators in maternal and child health. This report coincides with the launching of the new National Health Policy II (NHP II) and the Health Sector Strategic and Investment Plan (HSSIP). These have been aligned to the National Development Plan to enable holistic implementation of the Development agenda of Government. The sector will continue to prioritize interventions defined in the Uganda National Minimum Health Care Package under a Sector-Wide Approach arrangement, so as to maximize gains from invested resources. This will further be supported by the International Health Partnerships Plus framework. However, this will require concerted efforts by all stakeholders in health systems strengthening, including, crucially, the leadership and management capacity development in the sector. It is only by strengthening the health system that we can deliver on strategies in the HSSIP and NDP. Dr. Stephen O. Mallinga, MP MINISTER OF HEALTH iii

4 Dr. Stephen Mallinga, MP Minister of Health Hon James Kakooza MP Minister of State for Health, (Primary Health Care) Dr. Richard Nduhuura MP Minister of State for Health ( General Duties) iv

5 Dr. Asuman Lukwago Ag. Permanent Secretary / Deputy PS Dr. Nathan Kenya-Mugisha Ag. Director General of Health Services Dr. Isaac Ezati Director Health Services Planning and Development v

6 Table of Contents List of Tables... vii List of Figures and boxes...ix Annexes...xi Acronyms... xii Executive Summary... xvii Chapter One: Introduction Background The framework for achieving sector goals & objectives The FY 2009/ The drafting process Sources of Information Outline of the Report... 3 Chapter Two: Overview of Health Sector Performance (Summative Evaluation of HSSP II) Performance against HSSP II Indicators Performance for the HSSP II indicators Summary Financial Report for the HSSP II Comparing Local Government Performance Hospitals performance assessment Conclusion Chapter Three: Delivery of the Uganda National Minimum Health Care Package Health promotion, disease prevention and community health initiatives Maternal and child health Prevention and control of communicable diseases Non communicable diseases/conditions cluster Chapter Four: Integrated Health Sector Support Systems Health Financing Human Resources for Health Health Infrastructure Development and Management Management of Essential Medicines and Supplies Diagnostic and Blood transfusion services Information for decision making Health policy, research and development Legal and Regulatory Framework Public Private Partnership in Health Chapter 5: Implementation Monitoring of the HSSP II Monitoring of the HSSP II Indicators Quality of Care Health Services and health status in recovery areas Functionality of Health Centre IVs vi

7 List of Tables TABLE 1: PERFORMANCE AGAINST THE 8 PEAP INDICATORS FOR THE HSSP II PERIOD... xvii TABLE 2.1: PERFORMANCE AGAINST THE 8 PEAP INDICATORS FOR THE HSSP II PERIOD... 5 TABLE 2.2: PERFORMANCE OF THE HSSP II INDICATORS TABLE 2.3: HSSP II INDICATORS WITH NO INFORMATION TABLE 2.4: MTEF ALLOCATION TO THE HEALTH SECTOR DURING THE HSSP II PERIOD TABLE 2.5: DISTRICT RANKING AND LEAGUE TABLE TABLE 2.6: DISTRICT RANKING FOR NEW DISTRICTS TABLE 2.7: DISTRICT RANKING FOR HARD TO REACH DISTRICTS TABLE 3.1: HEALTH PROMOTION AND EDUCATION ACHIEVEMENTS OVER THE HSSP II PERIOD TABLE 3.2: ACHIEVEMENTS OF THE ENVIRONMENTAL HEALTH PROGRAMME DURING THE HSSP II PERID.. 25 TABLE 3.3 ACHIEVEMENTS OF THE CDD PROGRAMME TABLE 3.4: ACHIEVEMENTS OF THE SCHOOL HEALTH PROGRAMME TABLE 3.5: INTEGRATED DISEASE SURVEILLANCE AND RESPONSE INDICATORS TABLE 3.6: MAJOR OUTBREAKS INVESTIGATED IN UGANDA FROM JULY 2009 TO JUNE TABLE 3.7: ACHIEVEMENTS OF THE OCCUPATIONAL HEALTH AND SAFETY PROGRAMME TABLE 3.8: SEXUAL REPRODUCTIVE HEALTH AND RIGHTS KEY OUTPUTS TABLE 3.9 BI-ANNUAL CHILD DAYS PERFORMANCE TABLE 3.10: PERFORMANCE AGAINST NEWBORN HEALTH AND SURVIVAL INDICATORS OVER THE HSSP II PERIOD..56 TABLE 3.11: IMCI PROGRAMME PERFORMANCE OVER THE HSSP II PERIOD TABLE 3.12: UGANDA NATIONAL EXPANDED PROGRAMME ON IMMUNIZATION KEY OPUTS TABLE 3.13: NUTRITION PROGRAMME KEY OUTPUTS TABLE 3. 14: THE HIV/AIDS EPIDEMIOLOGY IN TABLE 3.15: ACHIEVEMENTS OF THE ACP OVER THE HSSP II PERIOD TABLE 3.16: ACHIEVEMENTS OF THE TB CONTROL PROGRAMME TABLE 3.17: THE PERFORMANCE OF THE MALARIA SPECIFIC HSSP II INDICATORS OVER THE PAST FIVE YEARS...78 TABLE3.18: THE IMPLEMENTING PARTNERS AND FUNDING SOURCES FOR NETS TABLE 3.19: PERFORMANCE OF IRS TABLE 3.20: IRS PERSONNEL TRAINED IN 2009/ TABLE 3.21: UGANDA POLICE BARRACKS SPRAYED FROM JUNE TO AUGUST TABLE 3.22: VETERINARY PUBLIC HEALTH KEY OUTPUTS FY 2009/ TABLE 3.23 : ACHIEVEMENTS OF THE GUINEA WORM ERADICATION PROGRAMME TABLE 3.24: PROGRESS OF LEPROSY CASE NOTIFICATION OVER THE HSSP II PERIOD TABLE 3.25: ACHIEVEMENTS OF THE ONCHOCERCIASIS CONTROL PROGRAMME FROM 2005 TO TABLE 3.26: THERAPEUTIC COVERAGE FOR PEOPLE AFFECTED BY LYMPHATIC FILARIASIS TABLE 3.27: PERFORMANCE ACCORDING TO SET TARGETS FOR ELIMINATION OF LYMPHATIC FILARIASIS TABLE 3.28: PERFORMANCE TO SET TARGETS FOR ELIMINATION OF SLEEPING SICKNESS TABLE 3.29: PERFORMANCE ACCORDING TO SELECTED INDICATORS FOR SCHISTO/STH COTROL TABLE 3.30: PROGRESS ON IMPLEMENTATION OF INTERVENTIONS PLANNED IN HSSP II TABLE 3.31: PROGRESS ON IMPLEMENTATION OF INTERVENTION PLANNED IN HSSP II TABLE 3.32: SUMMARIZES THE PROGRESS OF OTHER IMPORTANT MILESTONES TABLE 3.33: PROGRESS ON IMPLEMENTATIONS PLANNED IN THE HSSP II TABLE 3.34: HOSPITALS IN UGANDA 2009/ TABLE 3.35:. STAFFING POSITIONS IN GENERAL HOSPITALS TABLE 3.36: OUTPUTS FROM THE GENERAL HOSPITALS FY 2009/ TABLE 3.37: SELECTED EFFICIENCY PARAMETERS 2009/ TABLE 3.38: STAFF IN 14 REGIONAL REFERRAL AND LARGE PNFP HOSPITALS TABLE 3.39: OUTPUTS OF REGIONAL REFERRAL AND LARGE PNFP HOSPITALS vii

8 TABLE 3.40: EFFICIENCY PARAMETERS OF REGIONAL REFERRAL HOSPITALS AND LARGE PNFP HOSPITALS TABLE 3.41: SUMMARY OF REPRODUCTIVE AND MENTAL HEALTH ACTIVITIES IN BUTABIKA HOSPITAL TABLE 3.42: BUDGET PERFORMANCE FOR THE FY 2009/2010: TABLE 3.43: PERFORMANCE AGAINST ORAL HEALTH PROGRAMME INDICATORS TABLE 4.1: MTEF ALLOCATION TO THE HEALTH SECTOR FROM TABLE 4.2: CENTRAL GOVERNMENT TRANSFERS FY 2009/ TABLE 4.3: DISTRICTS WITH SIGNIFICANT CHANGES IN EFFICIENCY SCORES BETWEEN 2008/0 AND 2009/ TABLE 4.4: MAIN ACHIEVEMENTS OF THE HUMAN RESOURCE MANAGEMENT AND DEVELOPMENT DIVISIONS TABLE 4.6 (I): POST BASIC / POSTGRADUATE 1ST. YEARS GOU SCHOLARSHIPS AWARDS IN FY 2009/ TABLE 4.7: POSTBASIC AND POSTGRADUATE GOVERNMENT SPONSORSHIP IN HTIS FY 2009/ TABLE 4.8: THE ACHIEVEMENTS ON KEY HRD INDICATORS FY 2009/ TABLE 4.9: POSTBASIC AND POSTGRADUATE GOVERNMENT SPONSORSHIP TABLE 4.10: HUMAN RESOURCES FOR HEALTH TABLE 4.11: THE TOTAL NUMBER OF HEALTH WORKERS RECRUITED PER FINANCIAL YEAR OVER A PERIOD OF 6 YEARS TABLE 4.12: STAFFING LEVELS FOR DIFFERENT SELECTED NRHS & RRHS TABLE 4.11: ACHIEVEMENTS IN HEALTH INFRASTRUCTURE OVER THE HSSP II PERIOD TABLE 4.12: AVAILABILITY OF ESSENTIAL MEDICINES AT VARIOUS HEALTH FACILITY LEVELS TABLE 4.13: AVAILABILITY OF ESSENTIAL MEDICINES BY HSSP INDICATOR DRUG TABLE 4.14: FUNDING FOR ESSENTIAL MEDICINES AND HEALTH SUPPLIES IN 2009/ TABLE 4.15: UTILIZATION OF VOTE 116 IN 2009/ TABLE 4.16: LABORATORY CREDIT LINE OVERVIEW BY BENEFICIARIES TABLE 4.17: LABORATORY CREDIT LINE OVERVIEW BY LEVEL OF CARE TABLE 4.18: LABORATORY CREDIT LINE OVERVIEW BY AUTHORITY TABLE 4.19: ESSENTIAL MEDICINES AND HEALTH SUPPLIES UTILIZATION BY AUTHORITY TABLE 4.20 ESSENTIAL MEDICINES AND HEALTH SUPPLIES SUMMARY OF UTILIZATION TABLE 4.21 PERCENTAGE UTILIZATION TREND OVER FOUR FINANCIAL YEARS TABLE 4.22: ACHIEVEMENTS OF THE CPHL DURING THE HSSP II PERIOD TABLE 4.24: HEALTH POLICIES/BILLS AND THEIR STATUS TABLE 4.25: ACHIEVEMENTS OF THE UGANDA VIRUS RESEARCH INSTITUTE IN 2009/ TABLE 4.26: ANALYZED DRUG SAMPLES AT THE LABORATORY TABLE 4.27: A SUMMARY OF ADVERSE EVENT REPORTS TABLE 4.28: A SUMMARY OF PERFORMANCE FOR EACH BUDGET LINE DURING THE FINANCIAL YEAR 2009/ TABLE 4.29: HEALTH SECTOR ANNUAL PERFORMANCE REPORT FOR 2009/ TABLE 4.30: ACHIEVEMENTS OF THE PHARMACY COUNCIL TABLE 4.34: PHARMACY COUNCIL TABLE 4.31: SUMMARY OF THE MAIN ACHIEVEMENTS OF THE COUNCIL DURING THE FY 2009/ TABLE 4.32: ACTIVITIES CARRIED OUT DURING 2009/2010 FISCAL YEAR TABLE 5.1: GROUPING OF THE FORTY DISTRICTS IN NORTHERN UGANDA UNDER PRDP AS OF TABLE 5.2: PROVISION OF SELECTED KEY HEALTH SERVICES BY HC IVS FY 2009/ TABLE 5.3: INDICATORS SHOWING THE FUNCTIONALITY OF H/C IVS FY 2009/ TABLE 5.4: HUMAN RESOURCE IN HC IV 2009/ viii

9 List of Figures and Boxes FIGURE 2.1: MEDICINES SPENDING BY DISTRICTS AT NMS FY 2009/ FIGURE 2.2: VARIATIONS IN OPD ATTENDANCE BY DISTRICT... 8 FIGURE 2.3: PROPORTION OF EXPECTANT MOTHERS DELIVERING IN HEALTH UNITS FY 2009/ FIGURE 2.4: VARIATIONS IN DPT3/PENTAVALENT VACCINE COVERAGE BY DISTRICT FY 2009/ FIGURE 2.5: VARIATIONS IN HOUSEHOLD LATRINE COVERAGE BY DISTRICT FY 2009/ FIGURE 2.6: DISTRICTS WITH AN EFFICIENCY SCORE BELOW 80%: FIGURE 2.7: DISTRICT LEAGUE TABLE 15 TOP AND BOTTOM PERFORMERS FY 2009/ FIGURE 3.1: HOUSEHOLD LATRINE COVERAGE BY DISTRICT FIGURE 3.2: NATIONWIDE SANITATION COVERAGE OF SELECTED DISTRICTS FIGURE: 3.3: DYSENTRY CASES VS SANITATION COVERAGE FIGURE 3.4: DYSENTRY CASES VS SANITATION COVERAGE FIGURE 3.5: DYSENTRY CASES VS SANITATION COVERAGE FIGURE 3.6: MAP OF UGANDA SHOWING DISTRICTS WHICH HAD CDD TECHNICAL SUPPORT SUPERVISION VISITS DURING FY2009/ FIGURE 3.7: HON. MINSTER FOR HEALTH GIVING A SPEECH AT THE COMMEMORATION OF THE WORLD BREAST-FEEDING WEEK FIGURE 3.8: MALARIA CASES SEEN IN OPD FROM 2000/01 TO 2009/ FIGURE 3.9: THE DISTRIBUTION OF NEW LEPROSY CASES AND HIGHLIGHTING THE LEPROSY HOT SPOTS IN RED FIGURE 3.10: VOLUME OF OUTPUTS FOR REGIONAL REFERRAL AND LARGE PNFP HOSPITALS FIGURE 3.11: ADMISSIONS AND OUTPATIENT VISITS IN 2009/ FIGURE 3.12: TRENDS OF ADMISSIONS AND OUTPATIENT ATTENDANCES FROM FIGURE 3.13: ADMISSIONS IN BUTABIKA HOSPITAL FROM 2007/08 TO 2009/ FIGURE 4.1: GRAPHICAL ILLUSTRATION OF GOVERNMENT S ALLOCATION TO THE HEALTH SECTOR \ FROM FIGURE 4.2: DONOR SUPPORT TO THE HEALTH SECTOR 2007 TO FIGURE 4.3 : CENTRAL GOVERNMENT TRANSFERS PERFORMANCE FY 2009/ FIGURE 4.4 : CENTRAL GOVERNMENT GRANTS PERCENTAGE SHARE OF VARIOUS GRANTS FY 2009/ FIGURE 4.5: DISTRICTS WITH AN EFFICIENCY SCORE BELOW 80% FIGURE 4.6: TWENTY NINE (29) DISTRICTS WITH AN EFFICIENCY SCORE RANGING BETWEEN 80% - 98% FIGURE 4.7: TRENDS IN INCOME FOR RECURRENT COST IN THE PNFP HEALTH SECTOR (HOSPITALS + LOWER LEVEL FACILITIES) FIGURE 4.8: RELATIVE SOURCES OF INCOME OVER TIME FB PNFP HOSPITALS FIGURE 4.9: RELATIVE SOURCES OF INCOME OVER TIME - PNFP LLUS FIG 4.10: GENERAL TREND OF ATTRITION AMONG CLINICAL STAFF IN THE PNFP HOSPITALS FIGURE 4.11: GENERAL TREND IN ATTRITION OF CLINICAL STAFF IN PNFP LOWER LEVEL HEALTH FACILITIES FIGURE 4.12: TREND OF ATTRITION OF KEY CLINICAL CADRES IN PNFP HOSPITALS 2003/04 TO 2009/ FIGURE 4.13: ATTRITION OF KEY CLINICAL CADRES IN LOWER LEVEL PNFP HEALTH FACILITIES FIGURE 4.14: STAFF ATTRITION IN PNFP HOSPITALS IN HARD-TO-REACH DISTRICTS FIGURE 4.15 STAFF ATTRITION RATES IN PNFP LOWER LEVEL UNITS IN 12 HARD-TO-REACH DISTRICTS FIGURE 4.16: VOTE 116 UTILIZATION BY DISTRICTS IN 2009/ ix

10 FIGURE 4.17: VOTE 116 UTILIZATION BY GENERAL HOSPITAL IN 2009/ FIGURE 4.18: VOTE 116 UTILIZATION BY REGIONAL REFERRAL IN 2009/ FIGURE 4.19: VOTE 116 UTILIZATION BY NATIONAL REFERRAL IN 2009/ FIGURE 4.20: DISTRIBUTION OF BENEFICIARIES OF LABORATORY CREDIT LINE FIGURE 4.21: LABORATORY CREDIT LINE UTILIZATION BY AUTHORITIES FIGURE 4.22: EMCL UTILIZATION IN MILLION UGX FIGURE 4.23: EMCL UTILIZATION OVER THE LAST FOUR YEARS FIGURE 4.24: UBTS UNITS COLLECTED PER REGIONAL BLOOD BANK FIGURE 4.25: TRENDS OF HEPATITIS C AMONG BLOOD DONORS JULY 2009 TO JUNE FIGURE 4.26: TRENDS OF MEDICINES TESTED FY FIGURE 4.27: TRENDS OF ANALYSIS OF CONDOMS TESTED FIGURE 4.28: TRENDS OF OUTCOMES OF GLOVES TESTED IN FY FIGURE 4.29: ADVERSE DRUG REACTION REPORTS FROM 2005 TO FIGURE 4.30: ADVERSE DRUG REACTIONS IN FY 2009/ FIGURE 5.1: TRENDS IN NATIONAL PERFORMANCE IN THE DISTRICT LEAGUE TABLE DURING HSSP II FIGURE 5.2: AMURU DISTRICT, ONE OF THE 8 STAFF HOUSES IN FINAL STAGES OF CONSTRUCTION USING PRDP FUNDS FIGURE 5.3: TRENDS IN CAESAREAN SECTION AND BLOOD TRANSFUSIONS IN HC IVS BOX 3.2: SOME OF THE GOOD PRACTICES FOR SANITATION AND HYGIENE IMPROVEMENTS IN SELECTED DISTRICTS BOX 3.3: TIPPY TAP SURVEY BOX 3.4: HEPATITIS E RESPONSE IN NORTHERN UGANDA BY UNICEF BOX 3.5: LESSONS LEARNT FROM THE NULIFE PROJECT x

11 List of Annexes ANNEX I: HSSP II MONITORING INDICATORS ANNEX 1I: GENERAL HOSPITALS OUTPUTS ANNEX III: EFFICIENCY SCORES AND RETURNS TO SCALE FOR THE DIFFERENT DISTRICTS FY 2009/ ANNEX IV: CHANGE IN THE EFFICIENCY SCORE BETWEEN 08/09 AND 09/ ANNEX V: RESOLUTIONS OF THE 7TH NATIONAL HEALTH ASSEMBLY ANNEX VI: PRIORITIES OF THE 15TH JOINT REVIEW MISSION FOR THE HEALTH SECTOR ANNEX VII: AREA TEAM REPORTS xi

12 Acronyms ACT ADB AFP AHSPR AIDS ANC APH ART ARVs AT AZT BCC BCG BFHI BOP CAOS CB-DOTS CDC CDD CDP CMD CPHL CSO CYP DANIDA DCCAs DDT DHO DHT DLT DOTS DPs DPT DTLS EID EMHS EmOC ENT EQA FP FY GAVI Artemisinin Combination Therapies African Development Bank Acute Flaccid Paralysis Acquired Immuno-Deficiency Syndrome Ante Natal Care Ante Partum Haemorrhage Anti-retroviral Therapy Antiretroviral Drugs Area Team Azidothymidine Behavioural Change and Communication BACILLE Calmette Guerin Baby Friendly Health Initiative Best Operational Practices Chief Administrative Officer Community Based TB Directly Observed Treatment Centre for Disease Control Control of Diarrhoeal Diseases Child Days Plus Community Medicine Distributor Central Public Health laboratories Civil Society Organization Couple Years of Protection Danish International Development Assistance District Cold Chain Assistants Dichlorodiphenyltrichloroethane District Health Officer District Health Team District League Table Directly Observed Treatment, short course (for TB) Development Partners Diphtheria, Pertussis (whooping cough) and Tetanus vaccine District TB/Leprosy Supervisor Early Infant Diagnosis Essential Medicines and Health Supplies Emergency Obstetric Care Ear, Nose and Throat External Quality Assessment Family Planning Financial Year Global Alliance for vaccines and Immunisation xii

13 GLRA GoU HAART HBMF HC HCI HCT HDP Hib HIV HMIS HPA HPAC HRH HSD HSD HSSIP HSSP HUMC ICN ICT ICU IDSR IEC IMAM IMCI IST ITNs IVM IYCF JAF JBSF JICA JMS JRM LF LLINs LTIA MCH MDGs MDR MH MMA German Leprosy Relief Association Government of Uganda Highly Active Anti-Retroviral Therapy Home Based Management of Fever Health Centre Health Care Improvement HIV/AIDS Counselling and Testing Health Development Partners Haemophilus Influenzae type B Human Immuno-Deficiency Virus Health Management Information System Hospital /HC IV Performance Assessment Health Policy Advisory Committee Human Resource for Health Health Service District Health Sub-Districts Health Sector Strategic Investment Plan Health Sector Strategic Plan Health Unit Management Committees International Council of Nursing Information Communication Technology Intensive Care Unit Integrated Disease Surveillance and Response Information Education and Communication Integrated Management of Acute Malnutrition Integrated Management of Childhood Illness In-service training Insecticide Treated Nets Integrated Vector Management Infant and Young Child Feeding Joint Assessment Framework Joint Budget Support Framework Japan International Cooperation Agency Joint Medical Stores Joint Review Missions Lymphatic Filariasis Long Lasting Insecticide Treated Nets Long Term Institutional Arrangements Maternal and Child Health Millennium Development Goals Multi-drug Resistant Mental Health Mass Medicine Administration xiii

14 xiv MMR MOFPED MoGLSD MOH MOLG MOPS MOPS MOU MTEF NCD NCRL NCRL NDA NGOs NHA NHP NMCP NMS NTDs NTLP OH &S OPD OPM OPV ORS ORT PEAP PHA PHAST PHC PLWHA PMI PMTCT PNFP PRDP PWD QAD RDT RH RPF RRH RUTF SER SHSSPP Maternal Mortality Rate Ministry of Finance, Planning and Economic Development Ministry of Gender, Labour and Social Development Ministry Of Health Ministry of Local Government Ministry of Planning and Survey Ministry of Public Service Memorandum of Understanding Medium Term Expenditure Framework Non Communicable Diseases National Chemotherapeutic Research Laboratories National Chemotherapeutics Research Laboratory National Drug Authority Non-Governmental Organisations National Health Assembly National Health Policy National Malaria Control Strategic Plan National Medical Stores Neglected Tropical Diseases National Tuberculosis and Leprosy Control Program Occupational Health and Safety Outpatients Department Office of the Prime Minister Oral Polio Vaccine Oral Rehydration Salt Oral Rehydration Therapy Poverty Eradication Action Plan People with HIV/AIDS Participatory Hygiene and Sanitation Transformation Primary Health Care People with HIV/AIDS President's Malaria Initiative Prevention of Mother to Child Transmission Private Not for Profit Peace Recovery and Development Plan Persons with Disabilities Quality Assurance Department Rapid Diagnostic Test Reproductive Health Re-use Prevention Features Regional Referral Hospital Ready to Use Foods Socio- Economic Rehabilitation Support to the Health Sector Strategic Plan Project

15 SIDA SMER SP STI SUO SWAP TB TMC TT TWG UBOS UBTS UCMB UDHS UGFATM UNEPI UNFPA UNHRO UNICEF UNMHCP UPMB USAID UVRI VCT VHT VPH WHO YSP Swedish International Development Agency Supervision, Monitoring, Evaluation and Research Sulfadoxine/Pyrimethamine Sexually Transmitted Infection Standard unit of Output Sector-Wide Approach Tuberculosis Top Management Committee Tetanus Toxoid Technical Working Group Uganda Bureau of Statistics Uganda Blood Transfusion Services Uganda Catholic Medical Bureaux Uganda Demographic and Health Survey Uganda Global Fund for AIDS, TB and Malaria Uganda Expanded Programme on Immunisation United Nations Fund for Population Activities Uganda National Health Research Organisations United Nations Children s Fund Uganda National Minimum Health Care Package Uganda Protestant Medical Bureaux United States Agency for International Development Uganda Virus Research Institute Voluntary Counselling and Testing Village Health Teams Veterinary Public Health World Health Organisation Yellow Star Program xv

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17 Executive Summary Since FY 2009/10 marks the end of the Health Sector Strategic Plan II, this Annual Health Sector Performance Report (AHSPR) not only focuses on the progress of the final year (2009/10) of the HSSP II objectives but also serves to provide an overall summary for the whole of the HSSP II period. As for all the previous reports in the period, the drafting process used a number of strategies to ensure participation of stakeholders including Technical Working Groups, Senior and Top management, Health Policy Advisory Committee, Development Partners and sectors. Overview of the health sector performance Table 1 summarizes the performance of the sector during the HSSP II (2005/ /10) as measured against 8 PEAP targets. Most of the indicators showed an upward trend. This is particularly noted with proportion of districts submitting timely HMIS reports, Couple Years Protected (CYP), percentage of households with at least one insecticide treated net and latrine coverage. This can in part be attributed to improvement in technical efficiency scores for the majority of districts; which shows that with adequate resources, targeted to priorities using evidence, the sector can make marked progress. The target for deliveries managed at government level and PNFP facilities improved slightly from base-line but stagnated throughout the HSSP II period and remained unmet in 2009/10. There was no current information on the national prevalence of HIV although sub-surveys at antenatal clinics indicated that the prevalence had slightly increased. New information on this indicator will be available from the latest HIV/AIDS sero-prevalence survey. Although the target for proportion of positions filled was attained, overall there are still substantial gaps in human resources, coupled with an inequitable distribution related to geographical location and service and delivery needs. Indeed, the lack of human resources contributes largely to the non-attainment of service delivery targets such as facility based child birth and immunization of infants. The Hard to reach strategy has been designed to attract staff to otherwise unappealing areas. Inadequate financial resources also contribute to the end of HSSP II performance. While the level of resources to the sector increased in absolute terms, and an improvement in efficiency of resource use in 2009/10 compared to the previous FY was registered, this funding fell far short of that needed to implement strategies within the HSSP II. For instance, the per capita funding over the last ten years has averaged at USD 8.9 which is barely 25% of what was estimated to fully implement the HSSP II. xvii

18 Table 1: Performance against the 8 PEAP indicators for the HSSP II Period Indicator Proportion of approved Posts filled by Trained Health workers Baseline Achieved Achieved Achieved Achieved Achieved Target FY 2004/05 FY 2005/06 FY 2006/07 FY 2007/08 FY 2008/09 FY 2009/10 HSSP II (09/10) 68% 75% 38.4%[1] 38.40% 56% 56% 65% Proportion of Health facilities without stock out of 5 tracer medicines & supplies OPD Utilization in Govt & PNFP Units Percentage of deliveries taking place in health facilities (Govt and PNFP) Couple Years of protection (CYP)[i] 35% 27% 35% 28% 26% 41%[2] 70% , , , , , , ,908 DPT 3 /Pentavalent vaccine coverage 89% 89% 90% 82% 85% 76% 95% Household latrine coverage 57% 58% 58.50% 62.40% 67.50% % National Average HIV Sero- Prevalence at ANC Surveillance sites 6.20% 6.20% 9.70% 7.00% 5-10%[3] No 6-7% 6.5% data 4.4% [1] There was a change in staffing Norms by MOLG [2] This analysis excludes availability of Coartem which is procured through the Global Fund [3] ANC surveillance data 2008 Local Government Performance Local government health sector performance is assessed by a league table that incorporates 10 areas of core performance information and financial management; selected aspects of service delivery. Over the HSSP II period, an improvement was noted in the overall average score. This FY it was not possible to make a comparison since two parameters were dropped due to lack of data (% of PHC funds expended that are disbursed) and change in policy (FDS flexibility). As for the previous FY, having low latrine coverage is the one characteristic associated with districts being in the lowest position of the league table. Being a new or hard to reach district did not necessarily negatively affect local government performance as one of these such as Abim is ranked in the top ten best performers. Districts with high technical efficiency were among the top performers and the reverse is true. Hospital performance General and regional referral hospitals continued to provide a large output of all outpatient and inpatient services. Probably because the volume of primary level services such as antenatal care and immunizations have shifted to lower levels, hospitals overall registered a lower standard units of output compared to the previous FY. Therefore, this may have created the potential for hospitals to focus on their more complex functions. However, there is a concern about the poor quality of service delivery reflected in the very high numbers of institutional maternal deaths. Hospitals like other service delivery areas in the health sector are severely under-staffed, and this could contribute to gaps in the seamless care needed for a successful birth outcome. Delivery of the Uganda Minimum Health Care Package (UNMHCP) xviii

19 Health promotion, disease prevention and community health initiatives Institution of Village Health Teams (VHT) was identified as the main sector strategy for engaging with communities, in order to awareness and health literacy on disease prevention and promotion of healthy lifestyle. Complementary strategies included the development and production of relevant IEC materials, increasing the participation of political, religious and cultural institutions in promoting health; wider use of the media. The scale up of VHT functionality has been constrained by lack of adequate funding. For instance, in 2008/09 only 13/42 of the planned VHTs were established. In 2009/10, there were plans to establish an additional 42 VHT but less than 50% of the budgeted resources were released. Experiences from functional VHTs demonstrate that they are viable structures with potential to contribute to improved community health. The production of IEC materials also suffered from reduced budgetary disbursement, receiving less than one third of what had been planned. Thus the production of IEC materials depended very much on support from Development Partners. Similarly, although the number of radio stations has increased, there have not been adequate funds to maximise use of this avenue to broadcast health promotion messages. The improvement in latrine coverage from 67.5% in the previous FY to 69.73% has been due to enactment and enforcement of ordinances and bye-laws. Notably, political support plus good coordination of the National Sanitation Working Group (NSWG) has played a big role in this achievement. Over 1,600,000 new people are estimated to now have access to adequate sanitation. However, one of the challenges faced by communities is the lack of sustainability of the toilet facilities constructed. For instance, many of the toilets in water logged districts last 2 to 3 years which makes it expensive to the households to replace them, yet most of them cannot afford to use more permanent materials for construction. The issue is exacerbated in flood prone areas, where toilets were destroyed by the recent floods. In Butaleja district, after the recent floods the sanitation coverage dropped from 90% to 65%. Due to inadequate funding, the target for scaling up water quality surveillance and safe water consumption could not be met. For instance, districts are greatly hindered in their delivery of services by very low staffing levels. Data from 49 districts shows that only 44% of the required environmental health staffs are available, of which only 22% have adequate transport to facilitate their function. Furthermore, although the majority of the districts have improved the latrine coverage, scant attention has been paid to hand washing after toilet use, with the national average of access to hand washing facilities at toilets at 21%. Of the estimated UGX 1.9 billion of the DWSG spent on sanitation, only 4% was spent on promotion of hand washing. A recent survey of tippy taps in 30 districts 1 showed that only 3% of tippy taps have soap and water, therefore the rates of effective hand washing are much lower than the reported 21%. Supervision reports also showed that the hand washing practice in schools had stagnated (25%) and this was even lower among rural schools compared to urban ones. The major impact of improved sanitation and hygiene has been in the reduction in diarrhoeal diseases. An analysis shows that the incidence of diarrhea of the dysentery type has reduced from 2008 with the increase in sanitation coverage. Integrated Disease Surveillance and Response reports are used in tracking the trends of epidemic potential diseases in the country. Working with the District Rapid Response teams, xix

20 the ministry of health was able to investigate all the suspected disease outbreaks that were notified. In addition, case based data was collected for all the confirmed epidemics, which is critical for identification of the risk factors in outbreak that guide the implementation of the appropriate control interventions. The percentage of outbreaks notified to the Ministry timely (within 24 hours) however still fell short of the target (80%). Improvement in outbreak notification was mainly hampered by lack of community based disease surveillance, poor communication means and lack of knowledge on part of peripheral health facility staff. Only 68% of epidemics were responded to the Ministry within 48 hours of notification (target 80%). Maternal and child health A number of core interventions were identified to tackle the unacceptably high maternal mortality rate which stood at 435 deaths/ 100,000 live births at the start of HSSP II. Key among these was the operationalization of Emergency Obstetric Care (EmOC) Services at HC III, IV and hospitals. Others included the establishment of maternal death reviews, scaling up goal oriented antenatal care (ANC) including the provision of Intermittent Preventive Therapy in pregnancy (IPTp); family planning services with special emphasis on improving logistics and increasing availability to adolescents. At the end of 2009/10 63% of districts were implementing strategies outlined in the Roadmap which is an improvement of the previous FY 2008/09 where only 45% were doing so. An example of improved availability of services is demonstrated in the SHSSPP-supported districts where all HC IIIs, HC IVs and hospitals provide Basic EmOC. However, only 15 (2 HC IVs and 13 hospitals) out of 49 health facilities (30.6%) in these districts have capacity for the provision of Comprehensive EmOC (Caesarean sections and blood transfusion). Another important achievement was the revitalization of maternal death audits in 7 hospitals. Reducing the unmet need for FP was addressed by scaling up provision of services through outreach camps, and integration of FP services in other RH services at health unit level. During latter part of HSSP I, concerns about the stagnation of the reduction of child mortality in the country prompted a refocusing on child survival in the HSSP II. A number of interventions to improve child survival were prioritized including revitalization of EPI, Newborn Survival, Child Days Plus (CDP), Integrated Management of Newborn and Child Illness (IMNCI), Home Based Management of Fever, which has evolved into the Integrated Community Case Management (ICCM) and Nutrition especially Infant and Young Child Feeding and HIV/AIDS. Child Days Plus Strategy, involving vitamin A supplementation, deworming, immunization and promotion of key family care practices have been implemented in the months of April and October, since In the FY 2009/10, some slight improvement was realized in some indicators for newborn although this was suboptimal. According to the supervision report of the last quarter, at least fifteen districts had initiated some activities to strengthen newborn health. Slight improvements were also realized in terms of processes to institutionalize IMCI and more innovative ways of implementation. For instance, efforts were stepped up to address the low number of sick children managed using IMCI guidelines by bringing services closer to the community. There was a decline in the DPT-HepB+Hib3 coverage from 82% in FY 2008/09 to 76% in FY 2009/10 which was attributed to: disruption in gas supply; lack of child health cards causing under-reporting; inadequate transport for delivery of supplies to sub-district levels; irregularity of outreaches; lack of IEC materials on EPI. In FY 2009/10, 2 rounds of polio xx

21 campaigns were carried out in August and November 2009 targeting 12 high risk districts of Kaabong, Moyo, Moroto, Adjumani, Pader, Gulu, Amuru, Kotido, Masindi, Nakapiripirit, Abim and Kitgum. The overall coverage was 102% and 101% in round 1 and 2 respectively. There were no cases of confirmed Wild Polio Virus. However, the threat for wild polio virus importation from neighboring still exists and there is need to strengthen routine immunization activity at all levels. Mass polio vaccination may have to be carried out in districts that are high risk whenever recommended. Malnutrition remains a major public health concern in Uganda and affects almost all regions. It remains one of the single direct causes of child morbidity and mortality and the prevalence (under fives) remains unacceptably high at 60% (Lancet Series February 2008), with the set targets not being achieved. Prevention and control of communicable diseases The HIV prevalence from the ANC surveillance in 2008/09 was estimated to range from 5-10%. Approximately 1 million people are infected with HIV with 140,000 of them being children below 15 years of age. Of the 100,000 new infections, 20,000 of them were in children from Mother to Child Transmission. The epidemic has shifted from the single younger-aged individuals to older individuals aged years, who are married or in longterm relationships. Multiple concurrent partnerships, extra-marital relationships, discordance and non-disclosure are among the key factors driving the spread of HIV in Uganda. HIV services were scaled up to many health facilitues both in the public and private. For example HIV care PMTCT and ART services were provided in 66% and 83% of the health facilities respectively. One hundred (100) of the ART sites were in the private health facilities supported by HIPS (Health Initatives in the Private Sector), USAID funded. This is a great achievement enhanced by the MoH PPP Policy. By March 2010, cumulatively about 218,986 (57.5%) of the eligible at this point in time (CD4 200) were active on ART, 66% adults and 24% children. In 2009/10 more than 12,000 new patients were initiated on ART, 1000 of them children. Over 800,000 pregnant women accessed PMTCT through ANC. A lot of success was made in integrating HIV services with others especially TB, RH and MCH. For example HIV Early Infant Diagnosis (EID) was integrated into Child Days Plus. This increased the Number of HIV exposed children that accessed HIV testing (EID) from about 17,000 to 43,000. While 63% of TB patients in Uganda are co-infected with HIV and TB remains the commonest cause of death among PLHIV. The annual TB case notifications have stabilized around 45,000 for several years; with more men (63%) than women. The country targets include: a case detection rate (CDR) and a treatment success rate (TSR) of 70% and 85% and to test 100% of TB cases for HIV and to start all those HIV + on CPT and ART. The coverage of HIV testing in all TB cases was high (91%), 59% had a positive test, 71% received Cotrimoxazole Prophylaxis Therapy (CPT) but only 18.5% received ART. The suboptimal performance for TB service delivery targets is attributed to weaknesses in the implementation of the Stop TB strategy and gaps in delivering services to target populations, which include: inadequate health financing, poor access to DOTS services and inappropriate implementation of DOTS/CBDOTS strategies, limited coverage and implementation of comprehensive TB/HIV collaborative activities, inadequate access to TB services by Special xxi

22 Populations (especially Prisons and Army), inadequate human resources (clinical and laboratory), non-engagement of Private Health Care Providers, non implementation of ACSM strategy for TB and partners not adequately engaged. Programmatic management of drug resistant TB (PMDT) remains elusive, with a number of gaps that include; lack of second line anti-tb medicines (SLDs), lack of established DR-TB isolation unit, lack of personal protection equipments (PPE) for health workers and patients at the proposed DR-TB Isolation Unit, the current lab at the DR-TB isolation Unit lacks equipment and supplies for chemistry analyzers and lack of dedicated and motivated staff to offer DR-TB care. Malaria and malaria-related illnesses contribute 20-23% of deaths among children aged less than five years. Some of the reasons for this poor state included: limited access to effective treatment of malaria/fever; incorrect and/or inadequate malaria treatment at home or within communities. In terms of programmatic performance, most of the service delivery targets were not met apart from spraying of households with IRS. However, the improved reporting may account for the increased number of cases in this FY 2009/10. Dracunculiasis is one of the diseases targeted for eradication nationally and globally. Uganda achieved this goal and the country was certified free of dracunculiasis in 2009 by the World Health Organization. However, the country still faces a challenge of cross-border importation of guinea worm cases from Southern Sudan, the only neighboring country still endemic for the disease. Prevention and control of non-communicable diseases The increase in the incidence of chronic non communicable diseases is predicted to continue over the years fueled by the increasing exposure of our population to unhealthy lifestyles associated with urbanization. The WHO predicts that NCDs will reach epidemic proportions by the year 2025 if NCD preventive, control and surveillance measures are not undertaken immediately. In response to this, the Non communicable disease programme was established during the 2006/07 Financial Year to the plan, implement and coordinate actions aimed at prevention and control of NCDs in Uganda. A national baseline survey on NCD and their risk factors is planned. Hospitals are major contributors to essential clinical care and the recent growth in numbers is mainly from the private and institutional sectors. Compared to last year (2008/09) there has been some improvement in hospital efficiency indicators however the dispersion is great, most of the indicators being propped up by extra busy hospitals. Overall there has been reduction in the standard unit outputs which is largely explained by a shift of antenatal and immunization services to lower level facilities. However there remains a concern over the quality of care at hospitals exemplified by the high institutional maternal deaths averaging 9 annually with one outlier at 105 deaths in one year. Integrated health sector support systems Efforts to improve health financing were guided by concepts of universal coverage and social health protection. The health sector was financed through government revenue, private sources and development assistance under the SWAP arrangement. At the start of HSSP II, the per capita expenditure for health fell far short of the amount needed to finance the UNMHCP. For instance, provision of UNMHCP in all health facilities was xxii

23 estimated at USD 41.2 in 2008/09 and was expected to rise to USD 47.9 in FY 2011/12 (HSLP Africa Limited, 2008). Funds allocated to the Health Sector have steadily increased from Ushs 236 Billion in Financial Year 2006/07 to Ushs 735 Billion in Financial Year 2009/10; they are still inadequate to fund the UNMHCP. An estimated Ushs 1.5 Trillion is required annually to deliver the UNMHCP 2. Whereas resources allocated to health have been increasing steadily, the public per capita expenditure has averaged at 8.9 USD over the last ten years. The percentage of government allocation to health as a proportion of the total GoU budget has not significantly increased. Trends for improving the proportion of approved staffing positions filled by trained health workers was positive however, the target was not attained. In the PNFP sector, there has been some stabilization seen in the staff turnover over the last few years and the trend of attrition in both hospitals and lower level health facilities seem to show a downward trend. One of the strategies in place to ensure that this status in sustained and scaled up include establishment of the Hard To Reach strategy which includes a 30% increment to basic salary allowance with effect from July Some progress was registered against the consolidation of existing health facilities to enhance their functionality as well as increasing accessibility to health services and quality of health care delivery within the available resource envelope. For example since 2007/08, 42/55 hospitals were supplied with ambulances and rehabilitation is ongoing for both regional and district hospitals. There was improvement in availability of essential medicines as reflected in the analysis of some tracer medicines (Cotrimoxazole, ORS and Measles Vaccine). However, the availability situation deteriorated in the case of Medroxy progesterone inj, Sulphadoxine - Pyrimethamine and Artemether Lumefantrine tablets. The improvement in availability of medicines can be partially attributed to the intensified routine monitoring and support supervision to hospitals and districts on medicine management activities, with special focus on forecasting and rational. The National Drug Authority also contributed to ensuring quality of medicines at the operational level through its inspectorate. A major concern for sustaining gains made in the medicines sector in the medium to long term is the withdrawal of DANIDA as a major financing and technical support partner. Timeliness and completeness of HMIS reporting (a key process indicator for the implementation of the HSSP1 and whose 5year target was set at 80%) improved during the HSSPI and II. HMIS reporting has improved from a national average of 21% in 2000, 53% in 2001, 63% in 2002, 79% in 2003 and 84% in FY 2009/10. The major challenge for the HMIS has been harmonization and streamlining of various data sources and ensuring that they are leveraged to provide a better impact measurement of health sector interventions. The on-going analysis of the old HMIS data revealed lack of accuracy, timeliness and completeness of reports, consequently affecting decision making at all levels. Lack of coordination, leadership, clear strategy, policy and guidelines, as well as shortage of skilled human resources, were the key factors affecting the HMIS performance. Furthermore, the effect of parallel reporting with multiple and redundant formats compromised data quality and increased administrative workload. xxiii

24 Supervision & monitoring of the HSSP II The supervision and monitoring of National Referral Hospitals, central level programs and other autonomous or semiautonomous institutions (e.g. Uganda Chemotherapeutic Research Laboratories, Uganda Blood Transfusion Services, National Drug Authority (NDA), National Medical Stores (NMS) and Uganda Virus Research Institute (UVRI) has been carried out within the long term institutional arrangements (LTIA) which is one of the mechanisms adopted by the Top management of the MoH. During the FY under review most of these structures carried out their functions effectively. All the planned four quarterly reviews were conducted (one review per quarter), the TWG, SMC and HPAC meetings were held regularly. The reports of the sector quarterly reviews were finalized in time, printed and disseminated to stakeholders. TMC has also used the process of preparing Ministerial Policy Statements to critically review the performance of MoH programs and institutions. Integrated support supervision, mentoring and monitoring of Local Governments and Referral Hospitals continued to be carried out through the Area Team Strategy in line with the UNMHCP. The participation of members of TMC is in line with the HSSP II Mid Term Review Report which recommended top leadership of the MoH to play a more active role in supervision activities. In addition the Political Leadership of the MoH carried out several impromptu inspections of health facilities. Technical programmes also carried out their own technical support supervision to the Local Governments and referral hospitals. Internal supervision of health facilities though very effective in improving service delivery has not been effectively done during the period under review. There have been attempts to build capacity for internal supervision of health facilities and districts by several quality improvement initiatives/programmes. These programmes have supported the districts to supervise HSDs and lower level facilities. The challenge is lack of harmonized performance measurement tool and supervision framework to guide the different stakeholders. This is compounded by inadequate human resource even at district level and lack of transport. The YSP strategy was designed for this purpose but presently will have to be reviewed and institutionalized in the new sector strategic plan for sustainability. Functionality of Health Centre IV The health sub-district strategy remains crucially important in getting essential services nearer to the people and increase service utilization. The key feature of the HSD Strategy was that each HSD of approximately 100,000 people would have a Hospital or a Health Centre IV with the capacity to provide basic promotive, preventive and curative services, including Emergency Surgical and Obstetric Services and to supervise and support planning and implementation of services by the lower health units in the zone. Just like the previous 2 Financial Years, the factors that constrain functionality are related to the absence of: appropriate infrastructure and equipment; qualified health workers especially medical officers; and weak supervision from local governments. xxiv

25 Chapter One Introduction 1.1 Background The (AHSPR) is an institutional requirement and since 2000 has been very useful in highlighting areas of progress and challenges in the health sector. This AHSPR for the Financial Year 2009/10 also marks the end of the HSSP II strategic period (HSSP II 2005/06 to 2009/10). Therefore this report mainly focuses on the progress of the final year of the HSSP II objectives as well as an overall summary for the whole of the HSSP II period. It takes into consideration the performance through the HSSP II period on 1) The effectiveness, responsiveness and equitableness of the health care delivery system 2) How well the integrated support systems have been strengthened 3) the status of enforcement of the legal and regulatory systems and 4) how well evidence feeds into policy as well as the status of programme planning and overall development mechanisms. These findings will be considered at the 16 th Joint Review Mission in October/November The framework for achieving sector goals & objectives The delivery of the Uganda National Minimum Health Care Package (UNMHCP) was central to the implementation of the Health Sector Strategic Plan (II) and the attainment of the sector goals and objectives. The design of the UNMHCP was set within the overarching policy and strategic framework governing the health sector in Uganda that consists of the National Health Policy II (NHP II) and Poverty Eradication Action Plan (PEAP). Additionally, the UNMHCP core strategies were aligned to the Millennium Development Goals (MDGs), to which Uganda is a signatory. The implementation of the PEAP (through sector plans) and the HSSP II were undertaken in a sector-wide approach (SWAp), which addresses the health sector as a whole in planning and management, and in resource mobilization and allocation. The AHSPR 2009/10 is therefore one of the major SWAp management tools that assess sector progress in achieving the HSSP II outputs and outcomes. 1.3 The FY 2009/10 The objectives AHSPR 2009/10 are twofold: to review the performance of the sector for the HSSP II from FY 2004/05 to FY 2009/10 identifying achievements and constraints; and to provide a summative assessment of the whole of the HSSP II period. 1

26 Thus, the report provides progress on: i) Sector performance and annual trends for the HSSP II 25 annual indicators; ii) Implementation progress on the delivery of the UNMHCP basing on national, and district level indicators; iii) Status of implementation of the Integrated Health Sector Support Systems for the delivery of UNMHCP iv) District League Table that compares performance among districts v) The individual and collective contribution of the National and Regional Referral and General Hospitals as well as the PNFP hospitals at similar levels; vi) Financial Report for the HSSP II period including a donor-expenditure analysis; and vii)progress made towards the 7 th National Health Assembly Resolutions and 15 th Joint Review Mission Undertakings. 1.4 The drafting process The development process of the AHSPR 2009/10 was as for other years widely consultative with stakeholders from all departments of the Ministry of Health and Development Partners. The overall coordination and technical support was provided by a MOH Task Force (TF). The composition of the TF was drawn from all departments of the Ministry of Health and included chairpersons and secretaries of the seven Technical Working Groups. The TF had representation from districts, NGOs, the Civil Society and Health Development Partners. Additional support was provided by a secretariat of staff from both the Health Planning and Quality Assurance Departments. An external full time Lead Facilitator (Consultant) was recruited and provided overall leadership of the preparation process, in close collaboration with the Secretariat and TF. Meetings were held weekly, to assess progress of development of the AHSPR and provide feed-back on the drafts. Draft submissions were made by secretaries of TWGs/heads of Divisions and sections; the lead facilitator then reviewed, analysed and collated reports. Gaps identified were rectified by the relevant submitting authority. The draft was presented to SMC, HPAC and TMC for comments and approval. 1.5 Sources of Information As with the previous reports, this AHSPR relied heavily on the traditional sources of information, in particular the Health Management Information System (HMIS). One of the challenges identified with HMIS data was the inconsistency between district data submitted through the monthly HMIS and that submitted through the district annual reports. The variation for all indicators varies between 15-25%. Whilst this may be partially attributed to continuous data updating throughout the year, it also indicates that the accuracy of information from the HMIS is not foolproof. In order to maintain consistency with previous 2

27 reporting periods, this AHSPR uses the HMIS aggregated monthly reports for the entire financial year. Data errors in the annual reports submitted included (how were these handled?) Other key sources of information included: i) FY 2009/10 quarterly review reports ii) Departmental technical and Area Team supervision reports iii) Ministry of Health Quarterly Submissions to the Ministry of Finance iv) Previous AHSPR for the FY 2004/05, 2005/06, 2006/07 and 2008/09 as well as the Midterm Review of the HSSP II v) Draft HSSIP III vi) MoH programmes and other central level institutions reports were mainly obtained from quarterly and annual reports; vii)additional sources of information are included in the reference list at the end of each chapter/the main document. 1.6 Outline of the Report The AHSPR 2009/10 is divided into five chapters. Chapter 1 is an introduction that covers the background to the HSSP and AHSPR, the process of drafting the AHSPR 2009/10 and a brief description of the report contents. Chapter 2 covers an overview of the sector performance for FY 2009/10 and includes the overall performance of the sector against HSSP indicators; comparison of district performance using the District League Table; comparison of hospital performance using the Hospital League table; a summary of the financial report; and a summative evaluation of the HSSP II which incorporates a conclusive overview and discussion of the attainments of HSSP II goals and objectives. Chapter 3 details implementation status of the Uganda National Minimum Health Care Package whilst. Chapter 4 outlines the performance of the Integrated Health Sector Support Systems. Chapter 5 details the Monitoring of the Implementation of the HSSP II focusing on three areas of particular interest namely: HC IV functionality; status of health services in recovery areas; monitoring of SWAp implementation, and a review of the Supervision, Monitoring and Mentoring framework; Each of chapters 3-5 ends with a section on lessons learned as well as key recommendations for enhanced programmatic performance. 3

28 4

29 Chapter TWO Overview of Health Sector Performance (Summative Evaluation of HSSP II) This chapter presents an overview of the sector performance for FY 2009/10 as well as the four financial years of the HSSP II period. It therefore includes an assessment of the progress of the PEAP and HSSP indicators, comparison of district performance using the district league table, a summary of the financial report and review of hospital performance. In addition, it includes a summative evaluation of the HSSP II which incorporates a conclusive overview of the attainments of HSSP II goals and objectives. 2.1 Performance against HSSP II Indicators Twenty five (25) core indicators with annual targets have provided the basis for monitoring of the HSSP II. Out of these, eight indicators were used to monitor the progress of the health sector towards the Poverty Eradication Plan (PEAP) 3. Table 2.1 summarizes the performance across the HSSP II period for the PEAP indicators. Table 2.1: Performance against the 8 PEAP indicators for the HSSP II Period Indicator Proportion of approved Posts filled by Trained Health workers Baseline Achieved Achieved Achieved Achieved Achieved Target FY 2004/05 FY 2005/06 FY 2006/07 FY 2007/08 FY 2008/09 FY 2009/10 HSSP II (09/10) 68% 75% 38.4%[1] 38.40% 56% 56% 65% Proportion of Health facilities without stock out of 5 tracer medicines & supplies OPD Utilization in Govt & PNFP Units Percentage of deliveries taking place in health facilities (Govt and PNFP) Couple Years of protection (CYP)[i] 35% 27% 35% 28% 26% 41%[2] 70% , , , , , , ,908 DPT 3 /Pentavalent vaccine coverage 89% 89% 90% 82% 85% 76% 95% Household latrine coverage 57% 58% 58.50% 62.40% 67.50% % National Average HIV Sero- Prevalence at ANC Surveillance sites 6.20% 6.20% 9.70% 7.00% 5-10%[3] No data 4.4 [1] There was a change in staffing Norms by MOLG [2] This analysis excludes availability of Coartem which is procured through the Global Fund [3] ANC surveillance data The PEAP Uganda s comprehensive national development framework is linked to a monitoring and evaluation framework the PEAP Matrix which includes health and health-related indicators. 5

30 2.1.1 Proportion of approved posts filled by trained Health Workers The sector has had improvements in ensuring adequate HRH are recruited and retained, however the target has not yet been achieved. This can be attributed to a number of factors including: i) Poor attraction and retention of staff across the country remains critical. The situation gets even worse for cadres like-; Doctors, Midwives, Anesthetic staff, Radiographers Pharmacists and Dispensers. ii) Limited funding for recruitment, Salaries and wages has resulted into high vacancy levels. iii) Inequitable distribution of Health Workers to districts due to peculiar disadvantages of such districts has resulted into some districts not performing to the minimum staffing levels. iv) Inadequate tools and equipment result into staff not applying their skills thus leading to de-motivation. A number of strategies are in place to ensure that approved posts of trained health workers are filled. Most important are: i) Hard To Reach strategy was defined by MOPS, and a 30% of basic salary allowance has been incorporated into salary of health workers in designated Hard To Reach areas with effect from July 2010 ii) Districts were guided to submit recruitment plans to fill up to 65% for the FY 2010/ Proportion of facilities without stock-outs of 6 tracer medicines and supplies There was overall improvement in availability 4 from 26% to 41% when Coartem 5 is not include in the analysis with the improvements seen at level III health centers. When Coartem is included the availability fell to 21%. For comparison when Coartem is dropped from the analysis of 2008/2009 results, the improvement is negligible from 26% to 28% but in 2009/2010 when Coartem is dropped the availability improves from 21% to 41%. This is important to note because availability of Coartem largely depends on the GFATM honoring its obligations and not the performance of NMS or Health facilities. 4 Availability is measured as percentage of facilities with no stock out of any of the 6 tracer drugs (Cotrimoxazole, ORS, Measles Vaccine, Medroxy progesterone inj, Sulphadoxine -Pyrimethamine and Artemether Lumefantrine tablets in a month 5 See table 4.13 that shows that on average, Coartem was absent from half of the facilities on a monthly basis. 6 26

31 Figure 2.1: Medicines spending by districts at NMS FY 2009/10 There was improvement in availability of Cotrimoxazole, ORS and Measles Vaccine. The availability situation deteriorated in the case of Medroxy progesterone inj, Sulphadoxine - Pyrimethamine and Artemether Lumefantrine tablets. The creation of Vote 116 that transferred all funds for procurement of medicine and health supplies from districts to NMS assumed that there would be marked improvements in the supply chain. However, it removed the option of procuring medicines from JMS in the event that NMS failed to supply. Also, not all districts were able to utilize the funds allocated to them. The figure 2.1 shows the performance in use of the medicines (Vote 116) at NMS. The improvement in availability of medicines can be partially attributed to the intensified routine monitoring and support supervision to hospitals and districts on medicine management activities, with special focus on forecasting and rational drug use. The reintroduction of pre-packaged kits at HC II and III where capacity to forecast medicines in a timely manner was an additional factor for improved availability of medicines at this level. Although, the HSSP II target was surpassed, a number of constraints remain which impede efforts to ensure a regular supply of medicines and other supplies. Some of the factors noted included: i) inadequate financing of medicines and health supplies, and ii) poor medicine management at health unit level. A major concern for sustaining gains made in the medicines sector in the medium to long term is the withdrawal of DANIDA as a major financing and technical support partner New outpatient attendance in Government and PNFP health units The national average for OPD attendance almost made the HSSP II target of 1.0 per capita. 32.5% of districts (see League table for all districts) attained the national average target. 7

32 Thirty three percent (33%) of the 16 districts that had below 0.6 attendances per capita were new districts created after 2005(see figure 2.2). Figure 2.2: Variations in OPD attendance by district Family planning uptake The sustained improvement in addressing the unmet need for FP was attained and maintained by scaling up provision of services through outreach camps, and integration of FP services in other RH services at health unit level. The continued support from Development Partners helped to ensure a steady supply of contraceptives. Several health care providers were trained in various reproductive skills in a bid to improve a critical mass of service provides with family planning knowledge Percentage of deliveries taking place in health facilities (Govt and PNFP) A number of strategies were initiated and implemented to scale the proportion of deliveries at health facility level. Key among these was scaling up infrastructure and functionality for the provision of emergency obstetric care. 8

33 Figure 2.3: Proportion of expectant mothers delivering in health units FY 2009/10 Failure to attain the HSSP II target of 50% of deliveries taking place at facility level is largely explained by the HRH gaps for midwives, doctors and anesthetists within the districts which compromise the much needed EmOC service provision. Although 81 (90 %) of 90 hospitals were reported to have carried out Caesarean sections only 20 (15 %) out of 132 HC IVs had done so. The performance of different districts is shown in figure 2.3. Additionally, the inadequate resources to manage ambulances at district level constrain referrals and could further limit access by mothers. In order to attain the target it would be important to also consider if mothers perceptions of quality of health facility services and the costs of the getting services are significant factors in discouraging women from having deliveries in health facilities DPT3 / pentavalent vaccine coverage A number of efforts have been implemented to ensure continuing provision of quality immunization services and the performance of different districts is shown in figure 2.4. However, non-attainment of the HSSP indicators especially in the final year was influenced by several factors which included: 9

34 Figure 2.4: Variations in DPT3/Pentavalent vaccine coverage by district FY 2009/10 i) Irregular gas supplies whereby distribution of vaccines were halted ii) Lack of Child Health Cards and tally sheets for recording child immunization which may be causing under reporting by the health facilities carrying out immunization. iii) Inadequate transport at district level for delivery of supplies to the lower levels. iv) Irregularity of outreaches in almost all districts causing dropouts Latrine coverage A review of the sanitation coverage over the last 5 years shows that the country is on track to meet the national sanitation target of 77%, with an average increment of 2.4 percentage points. A large proportion of the districts, (47%) are unlikely to meet the target. Traditionally, monitoring indicators for rural sanitation have focused on physical outputs such as toilet constructed. However, this means that the focus is on incremental increases in physical achievement (house by house or school by school) rather than collective outcomes such as 100% usage of improved sanitation in a village or community. The figure 2.3 shows the latrine coverage performance of all the districts. Although many districts are doing well in latrine coverage, and are at or over the HSSP II target of 70%, most districts have very poor hand washing coverage as well as school sanitation, which affects the health outcomes. 10

35 Figure 2.5: Variations in household latrine coverage by district FY 2009/10 Special attention needs to be paid to the Karamoja region which is lagging behind the rest of the country (figure 2.3). This could be addressed through funding and implementation of the Karamoja strategy which was developed last year HIV/AIDS The HIV prevalence from the ANC surveillance in 2008/09 was estimated to range from 5-10%. In 2009/10, the ANC HIV prevalence shows that there is an upward trend in the prevalence of infections amongst pregnant mothers. There were more than 100,000 new infections 20,000 of them in children from Mother to Child Transmission. The AIDS Information Survey will provide the most current estimate for the HIV prevalence in the general population. Integrating HIV services with others especially TB, RH and MCH has been successful e.g. example HIV Early Infant Diagnosis (EID) was integrated into Child Days Plus which has increased the Number of HIV exposed children that accessed HIV testing (EID) from about 17,000 to 43,000. Additionally, over 800,000 pregnant women accessed PMTCT through ANC. In 2009/10 more than 12,000 new patients were initiated on ART, 1000 of them children. By March 2010, cumulatively about 218,986 (57.5%) of those who were eligible (< CD4 200) at this point in time were active on ART. 11

36 2.2 Performance for the HSSP II indicators This section outlines the performance trends for HSSP II indicators from 2005/06 to 2009/ Attainment of HSSP II targets for 2009/10 and performance trends The performance of the HSSP II indicators is summarized in table 2.2 that is color coded to show if the target was attained or not attained & whether the trend was positive or stagnated/dropped. Compared to the previous FY 2008/09 where targets were met for three indicators, the target for 1 indicator percentage of disbursed PHC funds that are expended quarterly was attained in 2009/10 and 12 of the core HSSP II indicators showed a positive trend even though the target was not met in most of these cases. There was negative or stagnated performance over the HSSP II period for 7 of the core indicators that had complete information. Further information on the HSSP II monitoring indicators is shown in Annex I. Table 2.2: Performance of the HSSP II indicators Type of indicator Indicator Attainment of Performance 2009/10 target[1] Trend[2] for the HSSP II period Percentage of government of Uganda (GoU) allocated to the health sector 9.6 (13.2) Positive trend Inputs Total public (GoU and donor) allocation to health per capita (USD) Proportion of health facilities with no stocks (%)[3] 21 (80) 11.1 (18.0) Positive trend Positive trend Percentage of population residing within 5km of a health facility (public or PNFP) (85) Inputs Process Proportion of approved posts filled by trained health workers (%) Percentage of PHC conditional grants released -100 on time to the sector (non-wage, recurrent and capital by quarter) Percentage of disbursed PHC funds that are expended quarterly 56 (65) Positive trend 100 (100) Attained Proportion of districts submitting HMIS monthly returns on time 84 (100) Positive trend Proportion of districts submitting quarterly assessment reports in time Process 12

37 OPD utilization in Govt &PNFP units 0.9 (1.0) Flat trend Proportion of deliveries in a health facility (%) 37 (50) Positive trend Caesarean section rate per expected pregnancies (%) 2.8 (7) Flat trend CYP 460,825 (494,908) Positive trend Proportion of pregnant women receiving IPTs (%) 47 (75) Positive trend Outputs Percentage of households with at least one insecticide treated net (%) 54 (70) Positive trend Proportion of children receiving 3 doses of 76 (95) Flat trend DPT3/Pentavalent vaccines (%) Proportion of TB cases notified compared to 56 (70) Positive trend expected (%) TB cure rate (%) - (85) Positive trend Latrine coverage 69.7 (72) Positive trend HIV/AIDS seroprevalence (%) No data (4.4) Flat trend Proportion of children under five years with 13.7 (80) Flat trend fever who receive malaria treatment within 24 hours from a community drug distributor Percentage of fever / uncomplicated malaria 13.7 (85) Flat trend cases correctly managed at health facilities Output [1] The HSSP II target is included in parentheses. Red indicates that the target was not attained, whilst green shows that the HSSP II [2] Key: Yellow Positive trend through the HSSP II period; Red stagnant or generally downward trend [3] 35 health facilities included in survey of which 11 HCII, 13 HC III, 11 HC IV 13

38 Table 2.3: HSSP II indicators with no information Indicator Proxy source of information Remarks (performance) Proportion of population expressing satisfaction with health services Percentage of health units by level providing all components of the UNMHCP Percentage of health units providing EmOC Reproductive Health Division (SHSSPP-supported districts) All HC IIIs, HC IVs and hospitals provide Basic EmOC. However, only 15 (2 HC IVs and 13 hospitals) out of 49 health facilities (30.6%) in these districts have capacity for the provision of Comprehensive EmOC (Caesarean sections and blood transfusion). 2.3 Summary Financial Report for the HSSP II The HSSP II Resource Envelope Table 2.4: MTEF allocation to the Health Sector during the HSSP II period Year GOU DONOR/GHI TOTAL Per capita expenditure in Ushs Per capita expenditure in USD 2005/ , / , / , / , / , Source: MoFPED approved estimates and Budget performance reports. GoU allocation to health as % of total GoU allocation Whereas resources from both Government of Uganda and donor projects that are allocated to health have been increasing steadily, the public per capita expenditure has averaged 8.9 USD over the last ten years. Moreover, the percentage of government allocation to health as a proportion of the total GoU budget has not significantly increased. Thus, throughout the HSSP II period, the sector s budget as a proportion of the GoU budget at 9.6% remained far below the HSSP II target of 13.2% and Abuja target of 15%. Subsequently, working with 14

39 just slightly over 25% of the required resources 9 the health sector has struggled to meet set goals and objectives. Several factors contribute to the failure to meet financing targets. i) High population growth puts pressure on existing resources since some activities are for universal coverage e.g. immunization. ii) The non-alignment of donor project support to HSSP II objectives iii) Unpredictability of donor disbursements due to challenges in fulfilling conditionalities for disbursement, iv) Relationship of budget performance and HSSP II outputs, shortfalls and efficiency measures Efficiency and equity of resources The first efficiency analysis was undertaken in FY 2008/09 and it showed that only 30 districts had an efficiency score of 36%. Between the two years, there has been improvement in technical efficiency scores for the majority of districts. The highest reduction in efficiency score between 2008/09 to 2009/10 was registered in Kibaale at 40% while the highest improvement was registered in Masindi at 43%. Nineteen (19) districts 10 had an efficiency score of below 80% implying that with the current level of inputs, the output level can be increased by 20%. Details for other districts are shown in annex II. Figure 2.6: Districts with an efficiency score below 80%: Financial management monitoring The sector continues to conduct financial management monitoring using laid down frameworks. The budget and finance division conducts quarterly financial management reviews of implementers both at the centre and in the districts. This process is also conducted USD per capita compared to about 41 USD needed to deliver the UNMHCP 10 Pader, Kaabong, Kasese, Amuria, Kaberamaido, Kapchorwa, Amuru, Katakwi, Pallisa, apac, Bugiri, Mubende, Adjumani, Kamuli, Sembabule, Bundibugyo, Rakai, Iganga, Masindi 15

40 by the auditor general at both levels mentioned above in order for an independent opinion to be made. 2.4 Comparing Local Government Performance District league table performance The league table ranks district performance across several management and service delivery indicators. The final ranked score weights the separate parameters into a single composite indicator. The individual parameters provide some indication for district performance. Since there was an adjustment in the number of parameters used to rank districts 11, this report does not make comparisons between the current year and previous years. Nonetheless, three districts Kampala, Lyantonde and Mityana maintain their positions among the top five performers (see figure 2.7). Similarly, Kaabong remains at the bottom of the league table in the 80 th position. Figure 2.7: District League Table 15 top and bottom performers FY 2009/10 Kaabong district that is at the bottom of the league table is both new and hard to reach. It s poor performance was also affected by the very low latrine coverage, percentage of deliveries at facility level factors that could be related to low infrastructure. However, being new and hard to reach does not seem to have affected the performance of other districts such as Abim which is in the 7 th position (see table 2.5). Also, three of the new districts are in the top ten 11 There was no information for two of these parameters i) % of PHC funds that are expended and ii) FDS flexibility gain - so districts are given a similar flat score across board for each of them. The proxy information used for The Proportion of PHC funds spent on drugs (at NMS and JMS) is the % of funds utilized by districts from vote 116 which is for the period of three quarters. 16

41 best performers whilst three of the hard to reach districts are among the best twenty performers. Table 2.5: District ranking and league table District Total Score Rank District Total Score Rank KAMPALA NEBBI LYANTONDE KAYUNGA MITYANA BUSIA TORORO KIBOGA JINJA NTUNGAMO KABAROLE KAMWENGE ABIM MANAFWA RUKUNGIRI KABALE MBALE BUTALEJA MPIGI KITGUM DOKOLO PADER GULU BUSHENYI AMOLATAR NAKASEKE MUKONO BUDUDA KANUNGU KUMI MASAKA AMURU RAKAI IBANDA MBARARA ISINGIRO LIRA KASESE OYAM NAMUTUMBA WAKISO MAYUGE ARUA SIRONKO KALANGALA BUKEDEA LUWERO KOBOKO KISORO SOROTI KAPCHORWA MOROTO APAC BUNDIBUGYO SSEMBABULE YUMBE KIBAALE MOYO NAKASONGOLA HOIMA KATAKWI MUBENDE KABERAMAIDO BUKWO IGANGA NAKAPIRIPIRIT KYENJOJO KAMULI KOTIDO BULIISA BUDAKA NYADRI BUGIRI MASINDI PALLISA ADJUMANI KALIRO AMURIA KIRUHURA KAABONG

42 Table 2.6: District Ranking for New Districts District Total Score Rank National Rank LYANTONDE MITYANA ABIM DOKOLO AMOLATAR OYAM MANAFWA BUTALEJA NAKASEKE BUDUDA AMURU IBANDA ISINGIRO NAMUTUMBA BUDAKA KALIRO KIRUHURA BUKEDEA KOBOKO BUKWO BULIISA NYADRI AMURIA KAABONG Table 2.7: District Ranking for Hard to Reach Districts District Total Score Rank National Rank ABIM GULU KANUNGU KITGUM PADER AMURU KALANGALA KISORO KOTIDO MOROTO BUNDIBUGYO BUKWO NAKAPIRIPIRIT ADJUMANI KAABONG Hospitals performance assessment Hospitals are major contributors to essential clinical care and the recent growth in numbers is mainly from the private and institutional sectors (such as prisons and army). This report includes data from 128 hospitals 12. The Standard Unit of Output (SUO) 13 is a composite measure of outputs that can allow fair comparison of volumes of output of hospitals that have varying capacities in providing the different types of patient care services. However, the absence of complete information from hospitals in health systems inputs such as financial data makes it difficult to measure efficiency and to make meaningful comparisons. Nevertheless, a summary is made of the performance highlights at each level of care. 12 The national hospital policy definition of hospital is not strictly adhered and this number is an estimate 13 SUO stands for standard unit of output an output measure converting all outputs in to outpatient equivalents. SUO total = Σ(IP*15 + OP*1 + Del.*5 + Imm.*0.2 + ANC/MCH/FP*0.5) based on earlier work of cost comparisons. 18

43 2.5.1 General Hospitals Quality of health care is compromised by an overall shortfall in staff, which is worse for the medical cadres. For instance, only 55% of these positions are filled on average. Nursing staff faces the largest gaps in absolute numbers (-3,380) and these positions are filled by nursing aides especially in private hospitals. In spite of this, outputs for core hospital functions such as admissions, outpatient attendances and deliveries have increased compared to the previous year. A reflection of the poor quality of care is reflected in the very high number of maternal deaths which occurred in general hospitals last year e.g. 9 maternal deaths on average per hospital with one outlier, Bugiri Hospital reporting 105 deaths. Also there has been a reduction in the average SUOs which could be attributed to shifting of primary level services such as antenatal care and immunization to lower level units Regional Referral Hospitals Regional referral hospitals are better staffed than the general level with about 72% of positions filled for medical staff. Compared to the year before, there was improvement in the following outputs: Outpatient attendance, admissions and major operations including the overall standard units of output. As for the general hospitals, there are a very high number of maternal deaths at regional referral hospitals with an average of 37 maternal deaths per hospital. Hoima hospital had an extremely high number with 285 maternal deaths in the year National Referral Hospitals Mulago Hospital Mulago Hospital is still the main referral hospital for those who require super specialized health care. During 2009/10, the centre provided care to 614,223 out patients and 120,848 in patients. This has been an increase from those served in the past years. The Hospital has made progress in strengthening of management structures and systems including harmonization of the procurement systems across departments; streamlining and strengthening of the supply chain management process and strengthening of the Hospital security system There have also been efforts made to scale up the integrated super-specialized healthcare package with the training and recruitment of Super specialists; ensuring that continuous Professional Development is taking place and providing a platform to ensure exchange visits with several universities. The hospital has enhanced infrastructural and space capacities to enable Mulago provide more services including super-specialized healthcare. These include establishment of a telemedicine centre, sickle cell clinic; plans for the Mulago III and Uganda Cancer Institute for which bills of quantities have been made; construction of the PPS pharmacy and construction of staff restaurant Progress towards achieving the objective of formalizing collaborative partnerships include the development of monitoring mechanism for collaborations; development of a framework for collaboration and review of existing MoUs using accreditation criteria with a Memorandum of Understanding (MoU) template now in place. 19

44 Butabika Hospital Butabika Hospital is still the only National Referral Mental Health Institution in the country. During 2009/10, the centre provided mental health inpatient care to 4,394 first time admissions and 1,752 readmissions. 95,106 patients were seen in the various clinics at the Outpatients unit. Through the community mental health services programme, a total of 1,225 patients were resettled in to their homes; 2,114 patients were seen at four of the mental health outreach clinics at Nansana, Kitetika, Nkonkonjeru and Maganjo-Nkonkojeru; also, 21 forensic clinics were conducted in Luzira prison; 959 patients were re-integrated with their families whilst another 475 were rehabilitated. One thousand, eight hundred and twelve (1,812) students from various Institutions were trained and technical support supervision to regional referral hospitals. 6 journal articles were published in the areas of mental health. The process of developing a master plan for the hospital has started and various infrastructures were developed and or rehabilitated. Challenges faced were in relation to inadequate staffing across all cadres, inadequate provision of finances to match the growing burden of mental health patients, lack of psychiatric medicines are not readily available in most centres, lack of community and social support for the discharged patients 2.6 Conclusion Measured against the monitoring indicators, the health sector has performed considerably well in view of the shortfalls in the required health system inputs. Most of the indicators showed an upward trend. This is particularly noted with proportion of districts submitting timely HMIS reports, Couple Years Protected (CYP), percentage of households with at least one insecticide treated net and latrine coverage. This can in part be attributed to improvement in technical efficiency scores for the majority of districts; which shows that with adequate resources, targeted to priorities using evidence, the sector can make marked progress. The most notable shortcomings in health system inputs are chronic low under-funding to the sector which affects the procurement of essential health commodities and maintenance of an effective work force. 20

45 Chapter Three Delivery of the Uganda National Minimum Health Care Package The delivery of the Uganda Minimum Health Care Package (UMHCP) is organized around the four clusters of i) Health Promotion, Disease Prevention and Community Health initiatives ii) Maternal and Child Health iii) Prevention and control of Communicable diseases iv) Prevention and Control of Non-Communicable Diseases (NCDs) This section describes and assesses the progress towards the attainment of the set targets over the HSSP II period. In addition it outlines the achievements, challenges faced. 3.1 Health promotion, disease prevention and community health initiatives Health promotion and education The main objective of health promotion and education was to increase community awareness and health literacy on disease prevention and promotion of healthy lifestyle in order to have a healthy and productive population. Thus the implementation of health promotion and education was envisaged as cardinal to the attainment of the overall health sector mandate. Institution of Village Health Teams (VHT) was identified as the main sector strategy for engaging with communities. Complementary strategies included the development and production of relevant IEC materials, increasing the participation of political, religious and cultural institutions in promoting health; wider use of the media. All these were expected to result in a 30% increase of the population seeking health services according to national standards 14. The mid-term report of the HSSP II indicated that unless commensurate resources were provided, it was unlikely that the set targets would be attained by the end end of strategic period would be attained. For instance by 2006/07 the number of fully functional VHTs had not substantially increased from the 2004/05 baseline 15. Table 3.1 summarizes the programmatic performance using indicators that were agreed upon during the HSSP II implementation. Progress The specific priorities identified for this Division during the 15 th JRM included scaling up VHTs from 25 districts to all. During the last year of the HSSP II, scale up has been attained using the following strategies 14 Health Sector Strategic Plan II (2005/ /2010) 15 Mid-term review report of the Health Sector Strategic Plan II 21

46 i) Establishment and training of VHTs in all districts to ensure services reach household including development of motivation and sustainability mechanism in the VHT Strategy and Operational Guidelines ii) Involvement of district political and cultural leaders in health activities iii) Involvement of radio stations in the dissemination of health messages. Although the JRM had desired to scale up functionality of VHTs nationwide, the Ministerial Policy Statement for 2009/10 provided resources to establish teams in 42 districts only. The Division was allotted Shs 1.13b for establishment and training of VHTs but only Shs m was actually released. The Division therefore trained teams in only 13 districts instead of the 42 planned. Table 3.1: Health promotion and education achievements over the HSSP II period Indictor Proportion of districts with VHTs established Proportion of health facilities and community institutions with health promotion materials Proportion of political and cultural leaders promoting health Proportion of media institutions participating in health promotion and education activities 2004/05 baseline 30 districts partially covered with trained VHT (25%) 20% of health facilities with IEC materials 2005/ / / / /10 34 districts supported to train VHTs (25% 50% of all health facilities displaying IEC materials 20 districts fully covered and 40 districts partially covered 100% of all hospitals and health centres display IEC materials 20 districts supported to train VHTs (25%) 50% of health facilities provided with IEC materials 58% 100% (all DLCs sensitized to support Child days 20% 75% of radio stations have formal health programs 30 districts supported to establish and train VHTs 90% of health facilities displaying IEC materials 100% DLCs and cultural leaders sensitized on Child days interventions 75% of radio stations supported to provide information on Child days 13./42 districts were supported to establish and train VHTs (31 %) 75% health facilities displaying IEC materials 100% DLCs and cultural leaders sensitized on Child days interventions 70% of radio stations supported to provide health information HSSP II target 100% coverage with trained VHT 40% of health facilities displaying IEC materials 50% of cultural leaders supported to implement health activities 80% of radio stations running health programs In 2008/09, the MTEF budget catered for the establishment of 13 VHTs. The District leaders i.e. (District councilors and Executive, RDCs and heads of departments, DHMTs, NGOs, Religious and Cultural leaders)and Training of Trainers of VHTs selected from all sub counties in the district were established in the following districts; Iganga, Bugiri, Kaliro, Kamuli, Kayunga, Mayuge,, Namutumba, Pallisa, Rakai and Butaleja, In 2009/10, District leadership sensitization and TOTs were conducted in Kibaale, Buliisa, Hoima, Mityana, Lyantonde, Mubende,Budaka, Busia, Bududa, Kiboga and Nakaseke. HTs have been established and trained in Bududa, Butaleja and Lyantonde districts in the past financial year. Out of shs 500m allotted for General for Health Promotion, only 316 million released. Out of 316m released only 100m was used to support mass media programs. This is not sufficient for full involvement of the media i.e. Radio, Television and Newspapers. In total, 1060 radio spot adverts were run, 3 ministerial statements made on Television, 3 supplements were published in newspapers, 15 Press conferences, and there was coverage for 10 different health related activities were carried out and published in media. 22

47 Box 3.1: Report on support supervision on village health teams in Bushenyi District, May Background Village Health Teams (VHTs) were established by the Ministry of Health (MoH) in 2003 to mobilize communities for health programs, sensitize and educate the community on health matters, as well as home visiting to implement health programs and strengthen the delivery of health services at house hold level. The Ministry of Health has been encouraging Partners, NGOs and other organizations to support the implementation of VHT in Uganda and across the country, a number of NGOs have given a hand in training, and roll out of the VHT program. Uganda Health Cooperative on its part has supported Bushenyi district by implementing Village Health Team in two Health Sub-Districts of Buhweju and Bunyaruguru as they sought to implement three of their projects namely: Malaria Community s Program Child Survival Community Health Financing Reports from Uganda Health Cooperative indicate that a total number of 889 and 856 VHTs in Bunyaruguru and Buhweju respectively were trained and equipped with a Register, VHT Booklet and Flip Chart both in Runyankole, Job Aids and Bags. Support supervision findings during May 2010 showed that: Findings VHTs fill registers with little or no mistakes at all. However VHTs said the exercise of filling the register is so tiresome Most VHT members were selected by the community which is in line with the implementation guidelines. All VHT members have undergone the mandatory VHT basic 5 days training in health promotion and this training was conducted by the trained health workers who had earlier on undergone a Training of Trainers workshop in adult learning methodologies and VHT VHTs know their responsibilities very well and they conduct such activities like Home Visits, Health Meetings, refer patients for treatment, community mobilization, and health education and are also showing a good example. Quarterly meetings are in place conducted by Uganda Health Cooperative with health workers and community leaders. VHTs have started their own saving scheme which has enhanced enhanced team work and togetherness VHTs are so enthusiastic about their responsibilities and they like being VHTs. This is based on the following reasons They see positive changes taking place in the community all attributed to their work They have taught themselves to be clean. This they do by giving each other a hand that is one other day they all come ones place do the cleaning and then another week go to another person s place. They have gained knowledge from the trainings they have undertaken and also from the work they are doing through sharing with fellow VHTs and the community members. IEC materials, extent and use of the electronic media Electronic media plays an important role in creating health awareness. In HSSP I, funding was provided for dissemination of health messages on FM radio stations in each district throughout the year. Unfortunately there has been an increase in the number of district with FM stations and yet there has been no commensurate provision of funding. There has therefore been little use of the radios except during special activities such as Child days with support from UNICEF. 23

48 The Division used to produce IEC materials for all the programmes provided in the MHCP and these were distributed to all health facilities and to some communities that had VHT. There has been a reduction funding for this production and also increasing participation of the partners in production of their own materials. Those programmes that have partners supporting them have such as MCP have therefore continued to produce IEC materials while other programmes that have no partners have hardly produced any materials. Development partners have greatly supported health promotion activities as exemplified from the following partner contributions i) STOP Malaria Project: run radio spots on 4 regional radios for 3 months and provided posters, banners radio talks shows and radio spots for LLINs ii) Voice for a Malaria free Future: provided street pole adverts radio spots on United Against Malaria on 7 radio stations iii) CDFU: runs the weekly radio drama program Rock Point 256 on 15 radio stations,(also translated into 3 local languages) ran 2 rounds of radio talk shows on 15 radio stations to promote True manhood iv) UNICEF; supported media activities for Child days by running 4712 radio spots, 10 radio talk shows and 28 newspaper adverts Human Resources for Health Promotion and Education The Division is short of staff to provide technical support for the MHCP. This is exacerbated by the fact that the Division has lost 2 senior staff to other lucrative ventures and the structure has a limited provision for more Health Educationists The Division has its presence in all the districts in terms of District Heath Educators and Assistant Health Educators at HSD level. With the creation of more districts, the Health Educators at HSD have taken up the role of DHEs in the new districts, leaving the service level depleted. Non recognition of the cadre in some districts also made some of the Health Educators to resort to their earlier professions for career progress. The Division however in collaboration with Uganda Martyrs University has established an Advanced Diploma course in Health Promotion to train Health Educators to provide health education activities in the districts. This has not only provided a professional training ground but also ensures that the districts have quality manpower that can be recruited to provide health promotion services. Challenges and Recommendations i) Continued roll out of the VHTs to cover every community since there is evidenced improvement in health conditions of communities where they are available However; VHTs are still finding problems at the health facility. They are not recognized by the health workers nor are their referrals recognized. This can lead to VHTs getting demotivated or losing the trust of the community members. ii) VHTs should be given skills of how to make use of the information they collect of which the primary use should be to improve the health situation in the community. For example if they collect information related to lack of latrines what happens? Do they keep it in the register and keep on collecting more? iii) Measures should be put in place to sensitize all health workers in the project areas about VHT strategy and the need for functional linkages between VHT and the formal health service. Once health workers don t recognize VHTs in whatever way the program may not achieve its objectives. 24

49 3.1.2 Environmental health The mandate of the health sector in maintaining and improving environmental health during the HSSP II period was on capacity building and the promotion of the Kampala Declaration of Sanitation (KDS). The KDS incorporates the scale up of basic household hygiene practices such as availability and use of latrines; safe water and food consumption 16. The Ministry of Health published the Environmental Health Policy in 2006, spelling out the roles and responsibilities for sanitation, in line with the sanitation Memorandum of Understanding signed in 2001 between MWE, MoH and MoES; but also recognizing the contribution of NGOs, CBOs and the private sector. The 10 year Improved Sanitation and Hygiene Promotion Financing Strategy (MWE 2006) serves as a roadmap for the attainment of the sanitation targets.. It is based on a three pronged approach of (i) increasing demand for improved services, (ii) improving the supply of services to facilitate households to acquire improved sanitation and hygiene, and (iii) addressing the enabling environment. Furthermore, in FY 2008/09, the need for environmental awareness and management to be on the same footing as economic and or social factors was raised. One of the fundamental concerns was the need for health decision-makers and the public to be more responsive to the potential environmental effects of sector activities and to identify ways that environmental damage can be avoided or significantly reduced. Some of the main areas for attention identified included the management of: health care waste e.g. injections and other sharps; solid waste; expired medicines; use of potentially toxic material such as DDT radiation from x-rays; medical and office equipment. The progress towards achieving targets set for the HSSP II period is shown in table 3.2. Table 3.2: Achievements of the environmental health programme during the HSSP II period Indicator 2004/ / / / / /10 HSSP II Target Proportion of 57% 58% 58.5% 62.4% 67.5% 69.73% 70% households with a pit latrine Proportion of districts implementing water quality surveillance and promoting safe water consumption 18% 18% 18.6% 21% 21.4% 21.7% 100% Progress Household latrine coverage During FY 2009/2010 the national sanitation coverage improved from 67.5% to 69.73%. Over 1,600,000 new people are estimated to now have access to adequate sanitation. However, one of the challenges faced by communities is the lack of sustainability of the toilet facilities constructed. Many of the toilets in water logged districts last 2 to 3 years 16 Health Sector Strategic Plan II (2005/ /10) 25

50 which makes it expensive to the households to replace them, yet most of them cannot afford to use more permanent materials for construction. The issue is exacerbated in flood prone areas, where toilets were destroyed by the recent floods. In Butaleja district, after the recent floods the sanitation coverage dropped from 90% to 65%. During the sanitation week, the district carried out activities to increase the coverage to the present 75%. The improvement in latrine coverage has been due to enactment and enforcement of ordinances and bye-laws. Also, political support plus good coordination of the National Sanitation Working Group (NSWG has played a big role in this achievement. The majority of household sanitation facilities in Uganda are constructed by local masons most of whom have not had any formal training. This has compromised the quality of toilets constructed. To address this issue, the sector started supporting the training of masons in a few start up districts. With support from partners, 103 masons were trained in the construction of improved latrines and 78 masons in the construction of ecological toilets. The masons were also equipped with marketing skills, in order to promote their services 26

51 Box 3.2: Some of the good practices for sanitation and hygiene improvements in selected districts Goats and Lists make people build latrines in Koboko District LEAPPS Case # 2009/1 by Aceni Albert, health assistant Lobule Subcounty, Reviewed by Jo Smet IRC, Achiro Brenda NETWAS and Grace Orishaba NETWAS In an attempt to identify appropriate strategies and interventions to combat disease outbreak and also improve hygiene and sanitation in Lobule Sub County Koboko District, the sub county authorities embarked on bye-law enforcement. This case was shared during one of the Learning sessions in 2009 facilitated by Network for Water and Sanitation (NETWAS) Uganda, SNV and IRC international Water and Sanitation Centre in Koboko District Summary of intervention Using Council Resolutions, all households with no latrines had to surrender two goats to the police and upon proven existence of built latrines, the goats would be returned to the respective owners. Secondly a list of all households who had improved their sanitation was read and put in public to encourage and motivate other households to follow the same example. These two approaches greatly contributed to the construction of latrines in Lobule subcounty. Action on defaulters Defaulters names were black listed and follow up was done to bring about change in their practices. This was done with support from local community leaders, whereby defaulters were given ample time, at least one month as set by the local leaders to build their toilets. After which complying families names were then taken off the black list and written on the white list as recognition for their efforts. Goats from persistent defaulters were confiscated and sold to compensate cost of digging pit latrines and facilities by local diggers and masons. Defaulters were also allowed to do community work like digging pits for the unable and female- headed households. Fines were also put in place to charge defaulters. In cases where a defaulter did not have animals or money to pay the fine, he/she would be detained in a police cell for a period not exceeding 24hrs. Households with no latrines had to surrender two goats to the police 27

52 Figure 3.1: Household latrine coverage by district 2010 Safe water and sanitation One of the biggest opportunities for development in the districts is the presence of active District Water and Sanitation Coordination Committees, with 97% (57 out of 59) of Districts reporting having an active committee. A review of the district progress reports show that at least 68% of the District Water Sanitation Coordination Committee met at least three times last financial year, with only 14% meeting once in the financial year. This has improved coordination of activities, as evidenced in the utilisation of budgets from both the Primary Health Care Grant and the District Water and Sanitation Development Grant for sanitation, especially to mark the sanitation week. 28

53 Due to inadequate funding, the target for scaling up water quality surveillance and safe water consumption could not be met. For instance, districts are greatly hindered in their delivery of services by very low staffing levels. Data from 49 districts shows that only 44% of the required environmental health staffs are available, of which only 22% have adequate transport. In addition some of the staffs face housing challenges in the areas they are deployed to and most are not motivated due to the lack of opportunities for career development and promotion within the local government structures. Figure 3.2: Nationwide sanitation coverage of selected districts Although majority of the districts have tried to improve the latrine coverage, scant attention has been paid to hand washing after toilet use, with the national average of access to hand washing facilities at toilets at 21%. Of the estimated UGX 1.9 billion of the DWSG spent on sanitation, only 4% was spent on promotion of hand washing. A recent survey of tippy taps in 30 districts 17 showed that only 3% of tippy taps have soap and water, therefore the rates of effective hand washing are much lower than the reported 21%

54 Box 3.3: Tippy Tap survey Only 30% of existing Tippy Taps have soap and water, by National Hand Washing Secretariat A baseline tippy-tap survey was conducted in 10 randomly selected districts from a total of 30 districts targeted by the national hand-washing campaign roll out. The districts include; Abim, Masaka, Mukono, Mbarara, Kabale, Nebbi, Bundibugyo, Hoima, Lira, and Pallisa. A total of 400 households were surveyed in 10 districts. Household Demographics Over 80% of households surveyed had children aged <5 years as well as those aged 6+ years. Majority of household members had access to free water (boreholes and protected springs/streams), although problems of water scarcity were cited during borehole breakdowns or dry periods Soap availability and usage was very high. Findings 81% (325 of 400) of all households had toilets 58% (232 of 400) reported washing hands with soap and water after using the toilet, 19% (74 of 400) reported to wash hands with water only 3.3% (13 of 400) of all households surveyed had tippy taps. 1% (4 of 400) of all households had functional tippy taps (i.e. had water and soap), 2% (8 of 400) had either water or soap alone but not both while one (1) was broken. Functional tippy-taps existed only in Mukono district. Source: Study report by the National Hand Washing Project The major impact of improved sanitation and hygiene is the reduction in diarrhoeal diseases. There are several factors that contribute to the incidences of disease, but an analysis has been made of the incidences of dysentery 18 in relation to sanitation coverage over the period of 2008 to 2010, presented in the graphs below. Although the correlation is not very good with correlation coefficients of in 2008 and in 2009 and 2010; the coefficients show that the incidences of dysentery decrease with an increase in sanitation coverage. 18 Disease surveillance data from the Ministry of health 30

55 Incidences of dysentery in relation to sanitation coverage over a period of three years

56 Box 3.4: Hepatitis E Response in Northern Uganda by UNICEF From November 2007 Hepatitis E (Hep E) broke out in of Kitgum district, northern Uganda. Hep E is mainly transmitted by the faecal-oral route with drinking-water as the most common vehicle. Most cases were in Kitgum and Pader (10,528 cases of with 168 deaths [CFR 1.60%]. The outbreak then spread to Karamoja region in early Response efforts focused mainly on promoting the importance of safe water, adequate sanitation and personal hygiene. The intensive interventions by the local and central governments, together with partners, using all resources available, including public health law and by-laws resulted in a decline in cases, and final containment by March The key emerging lessons from the response were: Intensive and extensive interventions are required to contain Hep E, considering its long incubation period. Leadership is critical (LC5 LC1), and at all levels and in all (voluntary) ways. Health Assistants and VHTs need to be engaged, through training and be enabled to do their work (bicycle, medicines, water purification inputs, feedback mechanism, etc). Use of VHTs, peer groups and local by-laws can encourage effective sanitation. Empower communities and households through health and hygiene knowledge and engage youth health clubs/ community health clubs. PHAST (and CHAST) is a great tool for quick appreciation of risk and for helping people to move forward for health. Integration of community health care and SLTS helps to empower communities and schools to eliminate open-defecation. Informing the Public on the dangers and protection measures is initially successful, but a new campaign is quickly required to fight complacency. The key challenges observed were: Returning people s priorities are with restoring livelihoods (housing, cultivation) rather than WASH. Poverty is a major contributor to the practices that promote the spread of such diseases. Apathy and dependency syndrome arising from the long displacement into camps with reliance on handouts, negatively affects community based improvement interventions. Inadequate public health outreach (no medicines, no readiness to receive patients in health facilities, no staff) greatly frustrated the response efforts. Recommendations i) Dedicated Budget Line for Sanitation Although the budget line for sanitation was established, it is still not funded and the local government guidelines are not yet completed. The funds spent for sanitation are still very low, with only 22 districts spending at least 6% of the DWSCG on sanitation, 50% of which is spent on facilities in public places. The ring fenced financing will ensure the much need finances. ii) In addition to funds, districts need guidance on cost effective approaches, especially on the implementation of the 10 year financing strategy for Improved Sanitation and Hygiene. iii) Political Support One of the lessons from the international year of sanitation is that political leaders play a key role in the mobilisation of communities and in the enforcement of the ordinances and bylaws. It was also evident thatmore progress was made when there was continued monitoring from MWE, especially from the Minister of State for Water. Therefore there is need for the ministry to continue holding the district leadership accountable for the outputs. Districts also expressed need for increased technical supervision from the Environmental Health Division in the MoH, and also continued capacity building of district staff on new approaches. 32

57 iv) Staffing The number of environmental health staff in the districts is very low, and districts should fill all staffing gaps as soon as possible. It is also important to ensure that the staffs on the ground are well facilitated to enable them to reach out to the communities. v) Open Defecation Free Communities although households are building toilets, in order to realise the health benefits of improved sanitation, it will be necessary to have ODF communities. It is also important to improve the quality and sustainability of facilities through building the capacity of the private sector. vi) Hand Washing- It is necessary to improve the profile of hand washing and increase the funds spent on promotion of hand washing with soap at key junctures Control of diarrheal diseases Diarrheal diseases rank third among the major causes of morbidity in Uganda 19. The strategy adopted by the health sector during the HSSP II to reverse this trend was to support the promotion and implementation of selected interventions known to prevent and control epidemic diarrheal diseases. The four core interventions included an active surveillance and monitoring programme, prompt and appropriate case management in the community and at static health facilities; community education and mobilisation with emphasis on hygiene and sanitation; and the reactivation of the Protocol of Cooperation of Countries in Great Lakes Region to promote cross-border cooperation. Key challenges identified during the mid-term review and the previous year (2009/10) included frequent population cross-border and internal migration especially in northern Uganda; inadequate and poorly motivated field public health personnel and clinical workers. Progress The following activities were implemented to address these challenges as well as ensure progress towards attaining the HSSP II targets. i) Guidelines and standards were provided to the cholera affected districts ii) Training of village health teams and operational level health workers on prevention and management of diarrhoeal diseases was done in the cholera affected districts. iii) Provision of supplies to the cholera affected districts was done. iv) As a special activity supported by UNICEF, two members of the village health team per village and all health workers in Lango area (districts of Amolatar, Apac, Dokolo, Lira and Oyam) were trained on the management and prevention of diarrhoeal diseases with emphasis on the use of zinc and low osmolarity oral rehydration salts (ORS). Also as part of the same project, low osmolarity ORS and dispersible tablets of zinc sulphate were supplied to those districts for use at health facility and community level. 33

58 v) Cholera taskforce meetings at district and central level to coordinate response and mobilise resources vi) During FY 2009/2010 CDD technical support supervision visits were carried out in 71 out of the 80 districts. The districts of Kigezi area (Kabale, Kisoro, Rukungiri and Kanungu) and those of Karamoja area (Kotido, Morotol, Abim, Kaabong and Nakapiripirit) were not visited due to resource constraints. They will be prioritised during the first quarter of FY 2010/2011. Figure 3.6: Map of Uganda showing districts which had CDD technical support supervision visits during FY2009/10 Figure 3.6: Districts which had CDD technical support supervision visits during FY2009/10 34

59 Table 3.3 Achievements of the CDD programme Indicator Incidence epidemic of 2004/ / / / / /10 HSSP II target * 1.5 diarrheal disease per 1000 Cholera specific case 2.5% 2.0% 2.0% 2.1% 2.1% * 1.0 fatality rate (%) Major challenges Key challenges identified included: (i) Climatic change leading to floods and landslides; (ii) Inadequate access to safe water; (iii) Low latrine coverage and use; (iv) Negative cultural practices; (v) Inadequate funding for required supplies and operations; and (vi) Cross-border and internal migration. Recommendations i) Implementation of the Kampala Declaration on Sanitation at district and lower levels should be intensified ii) Health promotion and education on prevention of diarrhoeal diseases especially in which areas that have negative cultural practices should be intensified. iii) Funding for supplies and operations should be increased. iv) Capacity building and technical support supervision focusing on districts with poor indicators School health In partnership with the Ministry of Education and Sports (MoES) and the Department for Water Development, the health sector purposed to integrate the school health programme (SHP) within district level activities. According to the policy (yet to be endorsed), the core interventions include: health education; water and sanitation/hygiene; adolescent and sexual reproductive health; school feeding and nutrition; prevention and protection of children against abuse and violence; provision of basic medical and dental health care services; counseling and guidance; physical education; recreation and sports in all educational institutions and the active participation of parents and community in school health issues. 35

60 Some of the major constraints highlighted during the mid-term review were: the delay in completion; endorsement of the School Health Policy; as well as the Memorandum of understanding between the MoES and MoH. Additionally, the weak enforcement by the Local Governments contributed to the poor attainment of some targets at the mid-term evaluation. Table 3.4 summarizes the performance of key indicators through the HSSP II period. Table 3.4: Achievements of the school health programme Target outputs 2004/ / / / / /10 HSSP II target Proportion of primary schools implementing the main components of health promoting school initiative, including sex education, counselling and life skills 40% 50% 50% 50% 50% 55% 75% Primary School Pupil per latrine stance ratio Secondary school Students per latrine stance ratio Proportion of primary schools with safe water sources within 0.5 Km radius to the school Percentage of secondary schools with safe water sources within 0.5 Km radius of the school Proportion of primary with hand washing facilities Proportion of schools providing basic school health and nutrition services 61:1 45:1 44:1 43:1 No data No data 40:1 or better 25:1 23:1 23:1 25:1 No data No data 25:1 60% 64% 66% 61% No data No data 75% 75% 79% 81% 85% No data No data 95% 20% 23% 25% 25% No data 25% 75% 30% 50% 50% 55% No data 55% 75% Data sources: MoES Planning unit, Water and Environment sector performance report and MoH supervision reports Progress In order to support implementation of the HPSI, 300 copies of the School Health Training manual was printed and distributed to primary/secondary schools during the first quarter of FY 2009/10. In order to support implementation of good nutrition in schools, the School Health guidelines were finalized in the 3 rd quarter of 2009/10 and the World Food Programme (WFP) supported the printing of 5000 copies which were also distributed. 36

61 The pupil per latrine stance ratio has only improved in urban schools than in rural schools while secondary schools continue to exhibit a better pupil per latrine stance ratio than primary schools. Hand washing practice has stagnated (25%) and was reported to be lower among rural schools than urban ones. As for the provision of basic health care and nutrition, it is mostly boarding schools that are providing health care and feeding of school children. Data from Ministry of Education and Sports estimates that the pupil: stance ratio in primary schools stands at 50:1. According to the national standards, the effective coverage is 54:1. The case is much better in private schools which have an access of 1:34, although it is much worse in community schools with a pupil stance ratio of 208:1. However, progress was made to have the school going children (6-14) de-wormed during the bi-annual Child Days plus intervention. School based TT for school girls aged 15 and above was also conducted as part of the routine EPI activities but coverage still remains generally low. Major challenges i) Minister of Education and Sports has delayed to finalise the School Health Policy. This policy is needed to provide a basis for sourcing financial and logistical support plus guiding a coordinated implementation of school health programme by the different stakeholders. This will also ease the retrieval of data since it is controlled by MoES and not MoH ii) The local governments have not fully incorporated school health programme into their district work plans and subsequently, integrating School Health services into the education system remains an area of concern iii) Inadequate staff who are poorly motivated and with a low capacity to implement the school health programme all remain major constraints Recommendations i) Finalisation of the policy and the MoU between MoH and MoES is a priority issue since it is needed to support the various advocacy initiatives that will ensure that school health programme activities are incorporated in the district activities. ii) Proper sanitation and hygiene are one of the key activities for attaining the school health programme goal, hence funding for these activities needs to be availed iii) Advocacy for school health programme needs to be stepped up to ensure leadership support and commitment mostly at district level Epidemic and disaster prevention, preparedness and response Epidemics and disasters upset even the best laid out plans for reducing morbidity and mortality if there is no preparedness for an appropriate response. The HSSP II period purposed to attain appropriate action for confirmed epidemics in less than 48 hours and also to ensure that the case fatality rate was minimized to the best international standards and practices. The core interventions included: institution of appropriate health services in 37

62 conflict and post-conflict situations; establishment of an early warning system for outbreaks and disasters; improving coordination of efforts during emergency situations; ensuring that there were financial and logistical provisions for the management of emergencies and disasters in both national and district work plans. The programmatic response for epidemic and disaster prevention, preparedness and response is coordinated through the Integrated Disease Surveillance and Response (IDSR) division. Implementation progress has been measured based on several indicators. This is summarized in tables 3.5 and 3.6. Progress The National Disease Surveillance System using the Integrated Disease Surveillance and Response strategy was maintained during the Financial Year 2009/2010. Weekly Epidemiological Reports were received from an average of 88% of the districts every week. These reports are used in tracking the trends of epidemic potential diseases in the country (see table 3.5). In addition, the timeliness of reporting reached a weekly average of 81% (target 80%). Working with the District Rapid Response teams, the ministry was able to investigate all the suspected disease outbreaks that were notified. In addition, case based data was collected for all the confirmed epidemics, which is critical for identification of the risk factors in outbreak that guide the implementation of the appropriate control interventions. The percentage of outbreaks notified to the Ministry timely (within 24 hours) however still fell short of the target (80%). Improvement in outbreak notification was mainly hampered by lack of community based disease surveillance, poor communication means and lack of knowledge on part of peripheral health facility staff. Only 68% of epidemics were responded to the Ministry within 48 hours of notification (target 80%). The proportion of districts with functional Epidemic Preparedness and Response (EPR) committees continues to improve steadily, this F/Y year reaching 92%. With functional EPR committees in place, we expected better coordinated epidemic response at district level. The Ministry also compiled all the weekly epidemiological newsletters, however due to financial constraints they were not published in the print media as planned. The quarterly bulletin publications couldn t be made either due to similar challenges. Capacity building for 38

63 Table 3.5: Integrated disease surveillance and response indicators Indicator Programme Performance Indicators FY 2004/05 FY 2006/07 FY 2007/08 FY 2008/09 FY 2009/10 HSSPII target Comments Objective: Strengthen communication so as to improve timeliness and completeness of weekly reports Percentage of districts submitting timely Weekly Surveillance Reports Percentage of districts submitting Weekly Surveillance reports 62% 58% 56% 82% 81% 80 Feedback through the Newspaper has boosted timely reporting 96% 81% 83% 92% 88% 80 Percentage of Feedback through the Newspaper was boosted reporting Objective: Strengthen outbreak detection, investigation and response Proportion of investigated outbreaks that include case based data % of outbreaks notified to MOH within 24 hours of detection % of suspected outbreaks responded to within 48 hours of notification % of districts with functional Epidemic Preparedness and Response (EPR) Committees % 100% % 72% 74% 76% 74% 80 late outbreak detection seen in districts that lack community based disease surveillance 30.00% 52.00% 58% 62% 68% 80 Lack of funds for emergency response 65% 76% 82% 88% 92% 100 More EPR committee became active in preparedness for Influenza outbreaks and in response to cholera and meningitis outbreaks Objective: Improve sharing of surveillance information through regular dissemination and feedback No. of Weekly Epidemiological Newsletter produced No. of Quarterly IDSR bulletin produced Funding constraints could not allow the publications to be made Objective: Strengthen capacity of health workers through training and supervision % District Health Teams trained in IDSR Proportion of Epidemics with lab confirmed diagnosis 50% 73% 76% 81% 86% 100 The training is yet to be done in some of the new districts Objective: Strengthen laboratory networks in all regions and initiate a system of accreditation % 100% 100 All outbreak investigations are laboratory backed Objective: Improve data management, quality and utilization at all levels Proportion of health districts that have current trend analysis for at least one priority disease % 76% 100 Districts are slowing improving towards the target Data Source: Ministry of Health Supervision and Monitoring Reports 39

64 Table 3.6: Major Outbreaks investigated in Uganda from July 2009 to June 2010 Condition District Period No. cases Bacillary dysentery Bacillary dysentery No. deaths CFR (%) Remarks Kyenjojo Jul The cases were reported from Kitongole Village, Rwaitengya Parish in Kihuura Sub-county and Kinyantare village, Nyaibanda Parish in Nyantungo Sub-county The risk factors included: use of visibly dirty swamp water for drinking; all homes visited had no latrines hence open defecation is widely practiced; and poor household hygiene practices. Botulism Botulism Kyenjojo Apr The cases were all from the same household and residents of Nkere village, Myeri Parish, Katooke sub-county. They shared a meal of matooke and white ants on April 28, 2010 before developing symptoms. Blood and stool samples from one of the cases were negative for the toxin following tests done by CDC labs in Atlanta. Plague Plague Arua April The case was detected in Vura HCII, Vura sub-county. Tests done by the plague lab in Aura were negative for plague. Cholera Cholera Amudat May 10 Jul The initial cases were reported from the sub-counties of Karita, Loroo, Amudat, and Kenya sub-county. Vibrio Cholerae El tor Ogawa was isolated from the specimens. The outbreaks attributed to the very low latrine coverage in the district and low access to safe water. Cholera Bugiri Sept 09 Nov The cases were reported from Buluguyi, Bulesa, and Kapayanga sub-counties. Vibrio cholerae Inaba was isolated from the stool specimens. The source is presumed to have been a contaminated stream in Muwayo Trading Centre. Cholera Butaleja May All the cases were from Nabiganda sub-county and epidemiologically linked to the cholera outbreak in Kirewa subcounty, Tororo district. Vibrio Cholerae was isolated from the samples. The spread was attributed to unsupervised burials. Cholera Manafwa Jan 10 Mar The initial cases were reported from Lwakaka Town Council. A total of 8 sub-counties and Lwakaka TC were affected. The source of the outbreak is believed to have been contaminated water from river Lwakaka along the Kenya-Uganda border. Most of the cases were reported from Bumbo sub-county. Vibrio Cholerae Inaba was isolated from stool specimens. Cholera Moroto April 10 Jul The initial cases were reported from Kanakomol village in Nadunget sub-county where there was no single latrine or protected water source. All the cases were reported along Nadunget river. A total of 9 sub-counties/ divisions were affected i.e. Nadunget; South division; Rupa; Lokopo; Lotome; Lopei; Lorengechora; Irriri; North division; Matany and Katikekile. Vibrio Cholerae 01 El tor Ogawa was isolated from the stool specimens. Cholera Pallisa Jun 10 Jul The initial cases were reported from Kapyani Parish, Buseta subcounty and were associated with unsupervised burial of the index case. The most affected villages included: Kapyani II, Kapyani III Kasasira, Katiryo and Nalumbembe. Vibrio Cholerae was isolated from the stool samples. Cholera Tororo May 10 Jun The initial cases were reported from Kirewa sub-county. Further cases were reported from Paya (most affected), Mulanda, Nagongera, and Kisoko. Vibrio Cholerae was isolated from the stool samples. Cholera Wakiso Oct 09 Nov The cases were reported from Bweyogerere, Kireka, Gayaza, Namusera, and Mabumbwe. The cases were managed in the CTC at Mulago hospital. Cholera Busia Jul 09 Aug Most cases were reported from Mugungu and Arubaine in Busia TC. Additional cases were reported from Marach and Mawero in Busia TC and in Buteba sub-county. The latrine coverage in the affected areas is low. Vibrio Cholerae 01 El Tor Ogawa was isolated from stool samples. 40

65 Cholera Luwero May 10 Jun The index patient originated from Bwaise in Kawempe division Kampala. He died at a traditional healer s shrine in Misanje village, Wankanya Parish, Kikyusa sub-county in Luwero district. Vibrio Cholerae was isolated. Cholera Nakaseke May 10 Jun An imported case from Nakulabye in Rubaga division, Kampala and was admitted in Nakaseke hospital. Stool samples tested negative for cholera. Cholera Total 3, Nodding Syndrome Nodding Syndrome Kitgum district 1997 to date At least 194 cases At least 4 The syndrome is characterized by head nodding attacks that are precipitated by the sight of food and cold weather. The head nodding may be associated with epileptic fits. EEG tests revealed the nodding syndrome attacks are atonic seizures. The cases in addition present with progressive mental retardation, growth retardation and variable deformities of the chest and limbs. Up to 194 cases were identified starting 2000, reaching a peak of 33 cases in 2006 and cases sustained at (20-27) cases per year between ( ). Cases were more likely to be yrs old (MOR: (95%CI: ); were males (53.3%); fits (60%); and stunted growth (53.3%). Hepatitis E Hepatitis E Kaabong Aug 09 to date The initial cases were linked to the consumption of Kwete in Kaaboong Town Council. Additional cases were reported from Sidok, Karenga and Kaabong sub-counties. Latrine coverage is low (1%). Hepatitis E Kitgum Oct 07 to date 10, The epidemic that started in October 2007 is on the decline. The current interventions include: house to house sensitizations by a team of environmental staff on basic personal hygiene, ensuring safe faecal disposal and usage of safe water; chlorination is going on in s/counties while others have shortage of supply; radio sensitization is ongoing on the local FM radios; and repair and maintenance of water sources activities are ongoing. Hepatitis E, Moroto Moroto (confirmed) Dec 09 to Mar The cases were identified from Nadunget sub-county, Moroto Town Council, Rupa, Matanyi, Iriri and Katikekele sub-counties. Samples were sent to UVRI and Hepatitis E Virus infection was confirmed. Hepatitis E Pader May 08 to date The initial cases were imported from Orom s-county in Kitgum; subsequent cases were then reported in Pader TC, Atanga s/c, Acholibur s/c, Kilak s/c, Pajule, Paimol, and Laguti. Most cases are reported in sub-counties of Pader TC, Acholi-bur s/c, Pajule s/c & Paimol s/c most of which are either bordering Kitgum district or have many IDP camps. Hepatitis E Abim May 10 Jun Initial cases were reported from Morulem boarding Primary School and Morulem mission. The rapid response team conducted the initial verification that led to the lab confirmation for one of the cases. Hepatitis E Kotido Sep 09 to Mar Initial cases were reported from Kotido sub-county, Panyangara sub-county, and Kotido Town Council. The affected areas have very low latrine coverage of up to 2%. Four cases were confirmed by UVRI. Hepatitis E Total 11, Malaria Malaria Mubende Jan 10 April 10 59, The outbreak affected a total of six (6) sub-counties including Bagezza, Nabingoola, Kasambya, Kigando and Maddu having exceed the epidemic threshold. Children were most affected, & majority died of severe anaemia. Meningitis, meningococcal Meningitis, Arua Jan 10 Mar The initial cases originated from Emvoba village, Oreku Parish meningococcal in Manibe sub-county and had head ache, fever, diarrhea and vomiting. Two of the cases from Manibe sub-county tested Meningitis, meningococcal Meningitis, meningococcal positive for Neisseria meningitidis type A by rapid test. Koboko Jan 10 Mar The cases were initially reported from Mugujai village, Nyambiri Parish, Kuluba sub-county; one from Kerejei village. Cases were last reported from Kuluba and Koboko TC and rapid testing isolated NM type A and W135. Maracha- Terego Jan 10 Mar The initial cases were identified from Abiriyo village, Kijomoro sub-county. The most affected sub-counties, that even exceeded the epidemic threshold were (attack rate in cases per 100,000); were Oluffe (109.1); Oluvu (188.2); Kijomoro (33); and Nyadri (14). Rapid field testing confirmed Neisseria meningitidis in 5 cases and 4 of them were positive for Neisseria Meningitidis type A. Vaccination in Oluvu, Oluffe, Kijomoro and Nyadri was 41

66 Meningitis, meningococcal Moyo Jan 10 Mar The cases were detected from Itula, Dufile and Moyo subcounties. Meningitis Total Methanol poisoning Methanol Kasese Aug 09 Sep The cases were reported from Ibuga, Mobuku, Nyakirango poisoning village in Nyakiyumbu sub-county. Analysis of autopsy specimens and alcohol samples revealed high levels of methanol. Methanol Kamwenge Apr 10 May The cases were reported from Nganiko Parish, Nyabani subcounty and from Kaberebere Parish, Nkoma sub-county. poisoning Methanol poisoning Methanol poisoning Methanol poisoning Methanol poisoning Methanol poisoning Methanol poisoning Gulu Oct 09 Dec The cases were reported from Layibi and Bardege divisions, in Gulu municipality; aged (36-70) years and became ill after drinking liquor from Kabedo-Pong. Samples of the alcohol revealed a methanol content of 3.32% yet the normal levels shouldn t exceed 0.05%. Kabale Apr 10 May The most affected areas were Kabale municipality, Kitumba, Kaharo, and Bubaro sub-counties. Alcohol samples analyzed by the government chemist indicated methanol levels of 300 times higher than the normal range. Kalangala Sep 09 Oct The cases were mainly from Bufumbira, Gyana and Nkese landing sites. Kampala Aug 09 Jan The cases were first detected from Kulambiro Central zone, Kyanja Parish, Nakawa division and eventually from Banda zone 5. Analysis of autopsy specimens and alcohol samples revealed high levels of methanol. Mpigi Aug 09 Sep The cases were reported from Musa parish, Kamengo subcounty. Samples of Viva gin from Kamengo had higher than acceptable levels of methanol. Wakiso Sep 10 Oct The cases were detected from Busambaga LCI, Katabi, Entebbe Municipality. Samples of Rio Vodka alcohol from Buloba in Wakiso district revealed higher than acceptable levels of methanol (50g/100litres). Methanol Total Pandemic Influenza A, H1N1 Pandemic Influenza A, H1N1 Bushenyi Jul 09 Jan Initial cases were confirmed starting July 2009 among Jinja Jul 09 Jan Kabarole Jul 09 Jan Kampala Jul 09 Jan Koboko Jul 09 Jan Luwero Jul 09 Jan Mbarara Jul 09 Jan Mukono Jul 09 Jan Wakiso Jul 09 Jan Total international travellers followed by a phase of local transmission in Schools. The majority (82%)of the confirmed cases were aged (5 29) years. No cases have confirmed in Northern and Karamoja regions. 67% of confirmed cases are from schools while 28% are from the community. Cases had a mild to moderate presentation and responded well to Tamiflu. Acute hemorrhagic conjunctivitis ( Red Eyes ) Acute Bundibugyo Mar 10 Jul A total of 26 districts are affected countywide. The outbreaks hemorrhagic were initially reported from the Central division of Kampala. Specimens analyzed at CDC Atlanta: 13 (45%) were identified as conjunctivitis Coxsackievirus A24 variant and one (3%) as enterovirus 99. ( Red Eyes ) Hoima Mar 10 Jul Kampala Mar 10 Jul 10 1,024 0 Lira Mar 10 Jul Luwero Mar 10 Jul Mpigi Mar 10 Jul Nebbi Mar 10 Jul Wakiso Mar 10 Jul Yumbe Mar 10 Jul Total 2,

67 Typhoid Typhoid Kibaale Aug 09 Dec The initial cases originated from Bwikara and Mpeefu subcounties in the Western part of Kibaale district. Initial samples from the affected patients were negative for S. typhi. Typhoid Masaka Mar 10 Apr The cases were all notified by Kitovu hospital and they all presented with perforation of the small intestines. The cases have been reported from Kyazenga, Kyamukama, Lwamagwa, and Kitamba villages. Typhoid Bukwo Jul 09 Oct The most affected areas being Bukwo s/county, Bukwo TC, & Kabei s/county. Salmonella species was isolated from specimens The affected areas were all located along Bukwo River. Latrine coverage is low in affected sub-counties (54%). Typhoid Kasese Jul 09 Apr sub-counties affected (Kitswamba, Bwera TC and Kyabarungira most affected). Salmonella typhi isolated. Most of the fatalities had ileal perforations. Typhoid Total Viral Hemorrhagic Fever (VHF) VHF Bundibugyo Feb The cluster of suspect VHF patients was reported from Busendwa village, Butholya Parish, Ngamba sub-county, Bughendera HSD. Blood specimens taken from cases were negative for Ebola/ Marburg IgM & Ig G at UVRI. VHF Gulu Oct The suspect case was referred to Lacor hospital from Lira. Lab test in UVRI were negative for Ebola & Marburg by PCR and serology. VHF Kabale Jun A 20 year old female was admitted in Kabale hospital with a presentation suggestive of VHF. Blood samples were negative for VHF. VHF Mbale Aug The suspect case was detected in Mbale hospital. Specimens tested negative for Ebola and Marburg by PCR. ELISA for Ebola & Marburg antigens was negative as well. VHF Mityana Nov The patient was admitted in Mityana hospital. Serology for Ebola/ Marburg IgM & IgG was negative. Suspect VHF Total Cholera Kampala Sept 09 - Feb The cases were reported from all the five divisions of KCC i.e. Makindye, Kawempe, Nakawa, Rubaga and Central divisions with Makindye division being the most affected. The outbreak started when National Water and Sewerage Cooperation turned off 12 out of the 29 communal water taps in Namuwongo. The residents hence resorted to using water from ponds and contaminated water sources. Cholera Kampala Mar 10 Apr The cases were reported from Rubaga and Makindye divisions. Affected areas in Rubaga were slummy & located in a wetland that became flooded following the onset of the rains in March. Cholera Kamwenge Sep 09 - Dec The cases were reported from Bukulungu, Masyolo sub-county on the shores of Lake George. Vibrio cholera Ogawa was isolated from stool samples. The fishing villages in Bukulungu have the lowest latrine coverage (57%) in the district with a high water table and hence the area gets water logged during the rain season. The fishing village has no access to safe water. Cholera Kasese Mar 09 Apr The outbreak was imported from the DRC and cases were initially reported from Nyakiyumbu and Karambi sub-counties in Bwera HSD. The most affected sub-counties were Munkunyu, Karambi and Bwera sub-counties. Vibrio Cholerae 01 El tor Inaba was isolated from the stool specimens Cholera Kayunga Jun 10 Jul % The cases were initially reported from Kawungu Parish in Galilaya sub-county on the shores with Lake Kyoga and eventually from Kayunga Town council. Vibrio Cholerae was isolated from the stool specimens. The affected fishing villages use Lake water for domestic use and the latrine coverage is very low (10%). A total of 36 cases including one death were registered in Kayunga Town council and the rest (68%) were from Galilaya sub-county. Cholera Kotido May 10 Aug The cases were reported from 5-sub-counties i.e. Nakapelemoru; Panyangara; Kotido; Kotido TC; and Regen. The majority of the cases originated from Nakaperemoru and Panyangara subcounties. Vibrio Cholerae isolated from stool specimens sensitive to tetracycline and Ciprofloxacin. The continuous use of water from ponds (Ataparas) as well as open defecation were responsible for outbreak activity in the district. IDSR among the health workers through training is yet to be done in some of the new districts hence the indicator (86%) is below target. Similarly the utilization of surveillance data is at health facility level is still billow target as evidenced by having trend analyses. The proportion of epidemics with laboratory confirmation has steadily improved reaching the target of 100%. Provision of laboratory reagents to health facilities and designation of District laboratory focal persons helped in improving the situation. 43

68 Challenges i) Understaffing: Has there been any change in the human resources required to follow up on community interventions especially during epidemics and disasters? What was done to address the capacity of health workers and communities to respond to epidemics and health related ii) Constrained budget: under-funding for the NDC programs by GoU iii) Delayed release of funds iv) Inadequate means of transport Recommendations 1) There is need to revise the budget for IDSR to cater for response to emergencies and other vital surveillance functions. The key areas that need financial support include: i) The publication of the weekly epidemiological data in the newspapers as it contributes to improved reporting of surveillance data from districts and health facilities ii) The establishment of Community based disease surveillance to improve on the sensitivity of the early warning systems for detecting outbreaks iii) Adequate logistical support to the Epidemiology and Surveillance Division to facilitate epidemic investigation and response through availing appropriate transport, and epidemic investigations kits. iv) Support the use of ICT (mobile phone SMS, internet) to improve the timely transmission of data to the next level for timely decision making to save lives and prevent morbidity. 2) There is also need to improve the capacity of the labs at all levels to confirm disease outbreaks by availing the appropriate human resources, equipment and reagents Occupational health and safety programme The Occupational Health and Safety programme was established to contribute towards the first of all to the reduction of occupational illnesses and disabilities prevalence through prevention of work related accidents, diseases and injuries in health facilities and other workplaces. Secondly it was to ensure that awareness of occupational safety and health issues among workers and employers is at its maximum. The core activities during the HSSP II included the development and dissemination of appropriate policies and guidelines on OH&S developed and disseminated in order that health workers and trade unions are made aware of existing services and how to access them; 44

69 Table 3.7: Achievements of the Occupational Health and safety Programme Indicator 2004/ / / / / /10 HSSP II target % of all health workers in the formal sector accessing occupational health services % of all health workers in the informal health sector accessing Occupational health services % of health facilities with established Occupational health & Safety programmes, % of Trade Unions made aware and educated on Occupational Health and Safety No data No data No data No data No data 5% 50% No data No data No data No data No data 1% 30% No data No data No data No data No data 1% 100% No data No data No data No data No data 0% 100% Progress i) Technical support supervision visits conducted in FY 2009/10 reveal that all; districts in the country make use of the of policies by :- ii) a) Availing protective clothing and equipment for the health workers; b) The Number of Technical support supervision visits conducted to lower Health facility level to support implementation of occupational health regulations; c) The Level of awareness and knowledgeable about OH&S, prevention and control among the Health workers; d) Level of personal hygiene & personal protection practices; The occupational Health Policy and Occupational Health Guidelines have been developed, printed and launched by the Minister of health and disseminated in 100% of the then 80 districts of Uganda. iii) The districts of Oyam, Amolatar and Kabarole have piloted OH and Safety policy. iv) Training of HU in charges, DHTs in the pilot districts in OH&S has been carried out. v) OH&S committees have been formed in the pilot districts up to HC II level. vi) Inspection of Workplaces- vii) Implementation strategy is still in draft form. 45

70 viii)a survey to identify the, number, names and location of Trade Unions is ongoing. This is intended to quantify these unions in order to effectively make a plan of action for awareness creation and education about Occupational health services Challenges i) Understaffing ii) Limited funding iii) Lack of coordination, information sharing and support from line ministries and other stakeholders. Recommendations i) Increased funding. ii) Identify key line ministries; map out their roles and responsibilities for better iii) Involvement of private sector as they are large employment sector. iv) Use of media for advocacy and sensitisation of the public on OH and safety issues v) Training/orientation and retention of health workers in current OH&S is Environmental Legislation Environmental law is concerned with balancing environmental concerns of the public generally, with the rights of property owners (individual, business and governmental) to develop and use their property. It is reflected both in explicit environmental laws and other statutes and regulations, such as local building codes, zoning ordinances, condemnation policies and land use restrictions. State and local environmental laws reflect local policy and priorities, which vary from place to place, resulting in conflicts between localities on environmental laws enforcement and compliance. Environmental Health legislation is a broad category of laws that include laws that specifically address environmental Health issues and more general laws that have a direct impact on environmental health issues. Environmental health law/legislation can be generally defined as the body of laws that contains elements to control the human impact on the Earth and on public health The Public Health Act, (P.H.A) has provisions for the prevention and control of environmental pollution. In addition, the P.H.A CAP (281) PART XVI miscellaneous provisions.sec 138 (General power of Minister to make rules; empowers the Minister to make rules related to the P.H.A The Minister may make rules generally for carrying out the purposes of this Act. The Local Government Act (LGA) Chapter 243 Section 38(1) empowers Districts to enact laws which are referred to as Ordinances which are consistent with the Constitution or any other law enacted by Parliament or laws enacted by the District and Lower Local Governments. Section 40 empower Districts to create offences and penalties 46

71 Progress i) The National Environmental Health Policy was developed and disseminated. ii) 50% of the districts in Uganda have formulated and implement Environmental Legislation. iii) Guidelines for developing environmental health ordinances; bye laws for districts and lower local governments have been developed and disseminated a few districts. iv) The districts of Busia, Tororo, Butaleja, Kitgum Iganga are some of the districts who have developed and implemented Environmental Health by-laws. Challenges i) Lack of awareness about Environmental Health Legislation at all levels. ii) Environmental Legislation enforcement agents are conversant with the law themselves. iii) The law books are expensively priced and environmental health staff cannot afford to buy them. iv) The district political and civic leadership are neither exemplary, no supportive in implementing environmental health legislation. v) Paucity of funds for enforcing the law. Recommendations i) There is need for developing and disseminating a communication strategy to create awareness at all levels about environmental legislation. ii) Specific training for the law enforcement arm will improve law enforcement in the country as the enforcers will be in the know of the legislation they are dealing with. iii) Environmental health legislation book should mass printed and distributed free to all environmental health staff, enforcement, and all local government offices at all levels iv) Advocacy meetings should be regularly held to enhance exemplary leadership and to solicit for commitment and support of all district and civic leadership. v) Increased funding. Food Safety and Hygiene Food safety and Hygiene, nutrition and food security are national priority health determinants because they directly translate in the health outcomes of individuals and the community. The prevalence of food safety related illnesses and problems of its control and management in Uganda is similar to what occurs in other countries globally, in particular the developing world. Food borne illness is recognized to be a significant public health problem in Uganda. Problems of food safety in Uganda are compounded by low levels of sanitation and hygiene, low sanitation and water supply coverage. In towns most foods are supplied to the community through unhygienic transport, storage, preparation and vending systems. Uganda does not at the moment have a single agency responsible for food safety. There is instead a multi-agency system for ensuring food safety. As a result of this arrangement, the food safety, quality and infrastructure are rather fragmented being share between several Ministries, departments and agencies. Examples of these are, Ministry of Health that acts as a 47

72 lead agency, Ministry of agriculture with three semi-independent departments of Animal Production and Animal health, Department of Crop Production and Protection and the Department of Fisheries Resources, the Ministry of Tourism Trade and Industry with the Uganda National Bureau of Standards (UNBS) and the Ministry of Water and Environment with the Directorate of Water Development (DWD) and the National Water and Sewerage Corporation (NW&SC). All the above ministries and departments share responsibility for food safety based on their respective institutional mandates. Due to this fragmented organization, linkages and coordination are not smooth. Together, with limited resources, Uganda has at present limited capacity to implement and integrated and effective national food safety control system. Despite all the above constraints, some progress was recorded in the area of inspection at retail outlets for food fortification. Progress i) The National Food Safety Strategic Plan (NFSSP) was developed and disseminated. ii) All the 80 old districts of Uganda were visited for advocacy and sensitization of Avian and Human Influenza and zoonoses. iii) A total of 40 districts were reached while monitoring for food fortification at retail outlets iv) A total of 601 samples were collected and tested for Vitamin A, Iodine and intrinsic iron. The food vehicles sampled included: 282 samples salt- for iodine. 295 samples of cooking oil for Vitamin A 124 samples of wheat flour for intrinsic iron. v) Ten advocacy &Support supervision visits on food safety and hygiene; covering 40 districts were carried out. Challenges i) Interference by influential people during inspections for compliance enhanced non compliance. ii) Inadequate funds and human resource at all levels in the food safety and hygiene inspection system. iii)inadequate coordination and collaboration by all players in the sub-sector iv)absence of sanitation and hygiene codes for food processing establishments. v) Poor transportation methods of food items vi)consumption by the public of uninspected meat/meat products; poultry and poultry products; agricultural produce 48

73 Recommendations i) Consumer education and information to create awareness ii) Develop a communication strategy of food safety and hygiene iii) Increased staffing at all levels. iv) Training of food inspectors to reach households v) Increased funding for all food safety and hygiene activities vi) Improved collaboration and coordination of all players to avoid duplication. 49

74 3.2 Maternal and child health Through multi-pronged approaches, there have been some improvements in maternal and child health outcomes in Uganda. However at the beginning of the HSSP II in 2005/6, the maternal mortality ratio at 435 deaths/ 100,000 live births was still unacceptably high 20. Also infant and child health had stagnated 76/1000 and 137/1000 respectively [ref]. ]. In order to effectively respond to the challenges of reducing maternal and child morbidity and mortality, a number of interventions have been implemented in the areas of sexual and reproductive health and rights, newborn health and survival, common childhood illnesses, immunization and nutrition Sexual and Reproductive Health and Rights A number of core interventions were identified to tackle the unacceptably high maternal mortality rate. Key among these was the operationalization of Emergency Obstetric Care (EmOC) Services at HC III, IV and hospitals. This would include the establishment of maternal death reviews, scaling up goal oriented antenatal care (ANC) including the provision of Intermittent Preventive Therapy in pregnancy (IPTp); family planning services with special emphasis on improving logistics and increasing availability to adolescents. Additionally, the community outreaches were conducted by health facilities. Other stakeholders were to be mobilized through relevant advocacy and IEC to ensure the SRH remained high on the agenda. The progress on the targets that were set for the HSSP II period is summarized in table 3.8 Progress i) Like in the other years of the HSSP II period, in order to tackle the unacceptably high Maternal Mortality Ratio, core interventions identified in the Roadmap to reduce maternal and neonatal mortality and morbidity were rolled out to more districts. At the end of 2009/10 63% of districts were implementing strategies outlined in the Roadmap which is an improvement of the previous FY 2008/09 where only 45% were doing so. ii) The JRM in 2008/09 emphasized the need to focus on EmOC and reducing the unmet need for FP. Subsequently, the Ministerial Policy Statement of 2009/10 committed resources to scale up EmOC in 50 district hospitals. An additional 8.8% of districts were sensitized on the roadmap. An example of improved availability of services is demonstrated in the SHSSPPsupported districts where all HC IIIs, HC IVs and hospitals provide Basic EmOC. However, only 15 (2 HC IVs and 13 hospitals) out of 49 health facilities (30.6%) in these districts have capacity for the provision of Comprehensive EmOC (Caesarean sections and blood transfusion). iii) 20 Uganda Demographic and Health Survey, 2005/06 50

75 Table 3.8: Sexual reproductive health and rights key outputs Indicator 2004/ / / / / /10 HSSP II target Proportion of deliveries in GoU and PNFP facilities (%) Unmet need for Emergency Obstetric Care (%) Percentage of health facilities providing EmOC (%) Proportion of pregnant women attending four FANC visits (%) Contraceptive Prevalence Rate (Couple Year of Protection) Contraceptive prevalence rate (%) 86 No data No data No data No data No data No data No data , , , , , , , Teenage pregnancy (%) rates 37 No data iv) At health facility level, SRH activity implementation to support attainment of the set targets, continued, with emphasis on scaling up Focused Antenatal Care (FANC) including the provision of Intermittent Preventive Treatment in pregnancy (IPTp); improving Reproductive Health logistics management, counseling and managing survivors of sexual gender based violence, screening for and managing cervical and breast cancer. Misoprostol use in the prevention of post-partum hemorrhage was introduced in 10 districts; service providers in HC IIIs, HC IVs and hospitals were trained on its use. This served to reduce the need for blood transfusion. At the community level, VHT kits were procured for 927 / 3150 (29%). A key intervention was the revitalization of maternal death audits which was done by setting up and training 7 MPDR health facility committees consisting of 97 health workers in 7 hospitals. 21 Information from UNFPA supported districts 72 51

76 v) Service provision to youth in selected tertiary institutions was done by carrying out HIV Counseling and testing, counseling and provision of Family Planning services. For adolescents, community-based activities done included ASRH out reaches during which young people were reached with ASRH information; peer education and information provision on adolescent health issues in schools. vi) Reducing the unmet need for FP was addressed by scaling up provision of services through outreach camps, and integration of FP services in other RH services at health unit level. Development Partners also provided contraceptives that they had procured under their system for distribution to health units. In addition, the Reproductive Health Commodity Security strategy development was finalized and printed. Another strategy to scale up FP use was the integration of HIV with RH service provision by finalization of the strategy, technical support supervision and development of data management tools (Integrated FP registers). This integration was supported by Development partners and developed by the RH division in collaboration with the AIDS Control Program (ACP). In a bid to improve the knowledge and skills of service providers, training on various areas of Reproductive Health covered: vii) a) Short term methods of Family Planning (65 service providers), b) Long Term & Permanent Methods of Family Planning (100 service providers in 18 districts), c) Emergency Obstetrical Care (63 service providers), d) Adolescent Health (60 service providers in 2 districts), Malaria in Pregnancy (30 service providers in 1 district), e) Focused Antenatal Care ( service providers) VHT (12152 in 10 districts), f) SGBV (70 service providers in 3 districts), g) Active Management of third Stage of Labour (12 service providers in 1 district), h) Prevention and management of Obstetrical Fistulae (in 2 hospitals in 2 districts), i) Peer education (30 peer educators). viii) Other efforts to operationalize Emergency Obstetric Care (EmOC) services at HC III, IV and hospitals were carried out through: a) Hands-on skills building using national trainers, Association of Obstetricians and Gynaecologists b) Identifying health facilities with gaps, especially in the SHSSPP districts, on equipment, procurement and distribution of basic EmOC equipment, medicines and related health supplies to those facilities. ix) On the advocacy side, Parliamentarians were supported to hold an International Conference for Parliamentarians from other countries on the Reduction of Maternal and Newborn Morbidity and Mortality. A Campaign for Accelerated Reduction of Maternal Mortality in Uganda (CARMMU) was launched. This campaign had the purpose of renewing the intensity by all stakeholders to scale up implementation of cost effective interventions aimed at speeding up the attainment of MDG5 by the year

77 x) In the area of BCC, materials that were developed included Adolescent Health Job aide, Adolescent Health IEC materials, and IEC materials on Focused ANC. Public awareness was also raised during the preparatory period and the actual commemoration of national health days like Safe Motherhood Day, Africa Malaria Day, National Youth Day, and World Population Day. xi) Support supervision was provided to districts on at least one of the following PMTCT, EmOC, ASRH and FP. In addition to the above areas logistics management was added onto the list during supervision of the 10 SHSSPP II supported districts. xii) Development of guidelines and other RH tools to improve service provision (Standards for Adolescent-friendly services, Documentary film on youth voices) was accomplished. Major challenges i) Funding constraints were in form of delayed release of funds coupled with unpredicted budget cuts. ii) Logistic challenges faced were those on delays in procurement of contraceptives using government funds. iii) Referral of emergencies within the districts was mainly due to insufficient allocated to maintenance and running of ambulances. iv) There are still gaps in midwives, doctors and anaesthetists within the districts; this compromises the much needed EmOC service provision. Recommendations i) Emphasis should be placed on ensuring timely release of funds and streamlining procurement to prevent compromising services at all levels. ii) There is still a need to improve on the human resources available at districts if EmOC service provision is to be improved Integrated child survival During latter part of HSSP I, concerns about the stagnation of the reduction of child mortality in the country prompted a refocusing on child survival in the HSSP II. The overall goal of integrated child survival is the attainment of a good standard of health by all the children through scaling up and sustains high coverage of cost effective interventions and ensure their integrated delivery at family/community and institutional level. A number of interventions to improve child survival were prioritized including revitalization of EPI, Newborn Survival, Child Days Plus (CDP), Integrated Management of Newborn and Child Illness (IMNCI), Home Based Management of Fever, which has evolved into the Integrated Community Case Management (ICCM) and Nutrition especially Infant and Young Child Feeding and HIV/AIDS. 53

78 Progress Introduced in May 2004 the Child Days Plus strategy, involving vitamin A supplementation, de-worming, immunization and promotion of key family care practices have been implemented in the months of April and October. i) Launched the Integrated Community Case Management (ICCM) strategy, including ii) Adaptation of WHO/UNICEF training materials for ICCM for community health workers iii) Newborn health was also integrated into the ICCM strategy and training guidelines iv) Conducted baseline surveys and training VHTs on ICCM v) Finalize the development of the newborn implementation framework, service standards and job aids for health workers vi) Started assessing quality improvement assessment in eight districts vii)children without Worms shipped 9 Million doses of Mebendazole to support Child Days viii) The 1st line treatment policy for pneumonia was reviewed from cotrimoxazole to amoxycillin ix) All districts in Uganda implement two rounds of child health days but with varying degrees of performance. Performance in child health days however deteriorated and actions to strengthen CDP were initiated x) Commemorated the African child & breast feeding week xi) The division staff participated in the African Summit conference held in Uganda, which there was infant, & maternal mortality. Progress in child days plus during HSSP II period is summarized in table 3.9. Table 3.9 Bi-annual Child Days performance Target outputs 2004/ / / / / /10 HSSP II Target HSSP II Indicators Children 6-59 months received two Vitamin A doses 37% 68.5% 61% 56.5% 69.5% 46% 80% Children 1-5 years de-wormed twice 60% 68.7% 61% 62% 37% 100% Central level program performance indicators Central district supervision/monitoring during CDP bi annually Audit CDP data and performance indicators + re-planning Communication & mobilization for CDPs Y - - Y - - Annually Y Y Y Biannually District level (service delivery level) indicators Children 6-14 years de-wormed twice 65% 61% 54% 66.2% 53% 40% 80% Districts with micro plans for CDP 15% 21% 30% 30% 46% 48% 100% Districts with adequate drugs for CDP 30% 40% 45% 50% 50% 55% 100% 54

79 Major challenges i) District capacity to pan and manage child days including mobilizing resources ii) Weak leadership, coordination and management of CDP at national level iii) Inadequate advocacy, communication and community mobilization iv) Inadequate supplies of de-worming drugs v) Inadequate preparation and sensitization for new interventions e.g. HIV testing vi) Poor monitoring and lack of clarity on performance indicators vii)political support and engagement of partners at all levels viii) Weak routine outreaches and lack of post child days interventions ix) Lack common understanding of CDP among national programs, districts and communities x) Inadequate long-term planning for CDP and strategy for capacity building Recommendations i) Strengthen planning, implementation and monitoring especially quality of data ii) Finalize the communication plan, develop and disseminate relevant IEC materials iii) Develop a five year implementation plan and capacity building for CDP iv) Integrated CDP in national budgets and all district plans v) Expand partnerships for CDP including other sectors and private sector vi) Implementation research for CDP vii)develop standard operation tools for CDP and build capacity at all levels Newborn Health and Survival The high contribution of neonatal deaths to national infant mortality prompted a special section dealing with Newborn Health and Survival in the HSSP II. The core interventions identified to improve newborn survival included emphasis of those already in use such as the provision of essential pregnancy and postnatal care; safe and clean deliveries. Some of the new areas included: counseling and education on newborn practices; sensitization and education on danger signs for the newborn; promotion of appropriate care seeking and homecare practices for the newborn. Figure below shows the progress in newborn survival performance indicators in HSSP II, national & district level: Progress in this area during the HSSP II period is summarized in table

80 Table 3.10: Performance against Newborn health and survival indicators over the HSSP II period Target outputs 2004/ / / / / /10 HSSP II target HSSP II indicators Proportion of children with low birth weight <2500g Proportion of neonates seen in health facility with septicemia/severe disease Central level program performance indicators 12% 10% 8% No data 10% 8.9% 30% reduction (8.4% level) 70% 70% 55% 51% 50% 50% 30% reduction (49% level) Quarterly performance reports Four Technical newborn steering Twelve committee meetings Technical support planning and supervision visit to districts 11% 19% 25% 33% 100% District level (service delivery level) indicators District work-plans with core interventions for child survival Proportion of newborns who receive postnatal visit in the first week of life 6% 15% 16% 70% 23% 25% 34% 28% No data 26% 40% Progress In the FY 2009/10, some slight improvement was realized in some indicators for newborn although rather suboptimal. This years target for HSSP II was not attained. Efforts were stepped up to address this poor performance. According to the supervision report of the last quarter, at least fifteen districts had initiated some activities to strengthen newborn health. The following program activities were undertaken to improve the performance i) The national multi-disciplinary advisory committee continued to advocate for and coordinate different efforts to improve newborn health including: participation in the MCH cluster meetings, developed/reviewed policies and guidelines, including planning and evaluation ii) Integrated in-service health worker training package covering newborn examination, resuscitation, recognition and management of a low birth weight baby and sick newborn, death auditing, routine newborn care and how to organize the health facility to make it newborn friendly, including tools for evaluating trainings has been developed as part of the helping babies breathe (HBB) strategy. Some members of the newborn steering committee attended a TOT workshop for HBB conducted during the International Pediatric Association Conference held in South Africa. Two districts have started implementing HBB guidelines as part of the broader newborn health strategy iii) Standards based facility assessment/evaluation and improvement of the quality of newborn care has been initiated in 8 districts and 2 of these have gone ahead to give feedback and start undertaking specific quality improvement action. Seven district level newborn champions have been trained to support the roll out of newborn activities in the regions iv) Efforts to support Kamwenge, Bushenyi, Bududa district and Mityana hospital to improve newborn health through systematic quality improvement approaches has been initiated, including plans for setting up nurseries through centrally coordinated but 56

81 participatory assessment of capacity, action plans for revitalization, resource mobilization, supervision and monitoring. v) Peri-natal death auditing has been initiated in 15 districts as a way of finding and reducing avoidable deaths at the facility, and strengthening quality of care for maternal and newborn services. a national level death audit review team has also been set up. vi) In order to support capacity building for newborn care and survival, guidelines for the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) were adapted from WHO generic material and subsequent training will use revised guidelines. vii)in an effort to increase demand for services, a formative study was conducted and currently a private firm is developing a behavior change strategy to address not only cultural home care practices but also advocacy for newborn rights, social marketing and interpersonal communication skills to improve provider client interaction. Major challenges i) Limited number of national and regional mentors and supervisors for newborn health ii) Most activities for newborn health are supported by partners and newborn activities are not well integrated in district plans and other quality improvement activities iii) Need for a comprehensive costed newborn health roll out plan and mobilization of resources iv) Peri-natal death audit activities are not implemented widely only 15 districts have initiated this and national review teams are not very functional v) Newborn data is not well integrated in routine sources of health information HMIS, surveillance, supervision and monitoring at all levels vi) Lack of equipment and supplies for newborn health service Recommendations i) Establish district clinical audit teams consisting of hospital clinical specialists, district health teams, financial administrators and NGOs to champion and support lower level health facilities and communities in the catchment area to assess newborn health standard, introduce and maintain quality improvement approaches in these units. ii) Conduct rapid assessment of the level of implementation of newborn standards at facility and community level, and use this as a basis for selecting priority areas for initial implementation to improve coverage and quality of services. A criterion based tool and guide for conducting the assessment will be developed based on the Yellow star program and other quality improvement activities e.g. collaborative etc iii) Build capacity for implementation and monitoring of newborn activities through training needs assessment, training health workers and VHTs, supply of job aids, registers and other tools, procurement and distribution of medicines, supplies and equipment for newborn care; and regular supervision. iv) Strengthen postnatal care services including health worker capacity building, disseminating information and tracking children who miss postnatal services v) Mobilize existing resources, including a number of "hidden resources" (local organizations, traditional structures, groups) to integrate or build on newborn activities such as reproductive health, child's health, immunization, HIV, malaria and others. A 57

82 number of actions could help to develop partnerships, such as undertaking an inventory and determining the kinds of support needed to enable them to be more effective in the promotion of newborn health Management of Common Childhood Illnesses The IMCI strategy Ministry of Health was one of the priority programs under the UNMHCP for improving child survival, development and growth. IMCI is a key strategy whose aim is to contribute to the reduction in under-five mortality through improvement of health worker skills in regard to assessment and management of common childhood illness and preventive measures like immunization, counseling on infant and young child feeding, vitamin A supplementation and de-worming all provided in an integrated manner. The 2 nd and 3 rd component of IMCI are related to strengthening health systems needed for child health and family and community health care practices respectively. Table 3.11: IMCI programme performance over the HSSP II period Target outputs 2004/ / / / / /10 HSSP II target HSSP II indicators Proportion of sick under-fives seen by a health worker using IMCI guidelines. Proportion of under fives with fever, diarrhea and pneumonia seeking care within 24 hours Proportion of under-fives with acute diarrhea receiving ORT. Proportion of under-fives with pneumonia receiving appropriate antibiotic treatment Percentage reduction of missed opportunities for immunization among sick under-fives. 60% 45% 62% No data 52% 48% 60% 27% 34% 37% 42% 42% 50% 70% 27% - 37% 40% 44% 45% 70% 18% 30% 27% 42% 42% - 70% 50% 45% - 55% 40% 62% 80% Central level program performance indicators Bi-annual technical IMCI supervision Health facilities accredited as implementing IMCI 42% 55% 55% 57% 60% 60% 80% Training institutions integrating IMCI in their curricula - - 6% 19% 25% 33% 50% District level (service delivery level) indicators District implementing community IMCI % 15% 16% 100% Health facilities with no stock out of IMCI supports and drugs 23% 25% 34% 28% No data 26% 40% Source: Service Provision SPA 2007, Supervision reports, IMCI zonal team reports In 2000 the implementation of IMCI was largely decentralized and although this was meant to register more resources for implementation, in most districts IMCI training seemingly stalled. During HSSP II the main focus was on strengthening pre-service training, alternative training methods and linkages and continuum of care through development of guidelines for 58

83 community case management and newborn care, second referral level quality of care services including newborn care and reviewing treatment policies for pneumonia and diarrhea. The following were some of the main achievements and IMCI performance against the HSSP targets in table Progress In the FY 2009/10, some slight improvement was realized in terms of processes to institutionalize IMCI and more innovative ways of implementation. Efforts were stepped up to address the low number of sick children managed using IMCI guidelines by bringing services closer to the community through ICCM and more and more emphasis is being put on improving quality of care through standards development and facility accreditation methods. According to the supervision report of the last quarter, many districts are beginning to revitalize IMCI. The following program activities were undertaken to improve the performance during period of HSSP II: i) Initiated process for reviewing and scaling policy for community pneumonia treatment through: a study towards improving presumptive diagnosis of childhood malaria and pneumonia, change pneumonia and diarrhea first line drug treatment policies from Cotromixazole to Amoxicillin for pneumonia, and Zinc and low osmolar ORS for diarrhea and a pilot for ICCM was evaluated; and a national ICCM technical committee was established to oversee the process with the MoH. ICCM was eventually launched in July and VHT training has started slowly in eight districts ii) Training of tutors in medical, paramedical and nursing institutions was intensified and schools in the eastern, western and northern region were covered. iii) To support scaling of IMCI, ICCM and other related training, the concept of zonal teams as a support arm to the centre has been revitalized. New TOR and letters of appointment to zonal teams have been issued. Efforts are ongoing to mobilize resources to support the zonal teams to assist districts in their geographical regions iv) The complementary IMCI/HIV training for health workers has continued and during this period trainings were introduced in 6 new districts v) Plans have been initiated to introduce emergency patient triage and management of referred patients Major challenges i) High turnover of staff in districts and health units which affected the attainment of a critical mass of trained staff in the units. ii) Lack of resources for training, production of training and other implementation materials further limited district training, supervision and monitoring activities iii) Few numbers of trainers and supervisors for IMCI to support implementation especially new districts iv) Irregular technical supervision and monitoring activities affecting institutionalization of IMCI and continued improvement of IMCI 59

84 v) Low implementation of community IMCI affecting family care practices including timely and correct care seeking vi) Shortages or irregular supply of drugs especially 1 st line anti-malarial, de-worming drugs and antibiotics vii)low levels of post natal attendance and poor administrative data to support decision making and feedback, and therefore continued improvement in quality of care Recommendations i) Review the IMCI implementation framework to reflect new development and build district management capacity for child health programming in general and implementing IMCI in particular ii) Revitalize and strengthen the implementation of the IMCI referral care package including ETAT iii) Scale up ICCM and community IMCI through mobilization of resources, capacity building, production of implementation guidelines and materials and effective monitoring and supervision iv) Advocacy for early and effective management of newborn and childhood illnesses including integration of preventive services v) Evaluate the program and disseminate information as way of advocating for IMCI and other related interventions vi) Develop centers of excellence and demonstration sites for continued learning in the regions, including introduction of computerized and long distance training (ICAT) Expanded Programme for Immunization Immunization is a nationwide programme targeting mainly infants and women of childbearing age. The mission of UNEPI is to contribute to the reduction of morbidity and mortality due to childhood disease to levels where they are no longer of public health importance. The programme goal and objective in HSSP II was to ensure that all children are fully immunized against the vaccine preventable diseases before their first birthday and all babies are born protected against neonatal tetanus. Progress 1. Ensuring an efficient cold chain system i) Procured cold chain equipment for the Karamoja district through UNICEF support. The equipment included 35 vaccine storage fridges and 20 cold boxes ii) Conducted cold chain maintenance and support supervision in 39 districts of Masaka,Mpigi,Sironko,Mbale,KaseseBundibugyo,Bushenyi,Ibanda,Lyantonde,Kiruhu ra,rakai,sembabule,kaberamaido,soroti,mukono,kayunga,amuria,katakwi, Kabarole,Hoima,Kiboga,Luwero,Kisoro,Kabale,Kalangala,Namutumba,Nakaseke,Neb 60

85 bi,nakasongola,budaka,nakapiripirit,moroto,kabong,abim,kampala,wakiso, Kibale, Kyenjojo,and Kotido for routine activities. iii) Production and printing of 3,000 posters on vaccine management with support from UNICEF and WHO. iv) Carried out inventory of cold chain equipment in all the districts. A report will be made available. 2. Forecasting, procurement and distribution of adequate vaccines and supplies within the Vaccine Independency Initiative framework i) The GOU has continued to contribute 100% towards the procurement of the routine immunization vaccines (BCG, OPV, TT and measles) and their related injection safety materials. GOU contributed US$ (5.4 %) for procurement of DPT-HepB + Hib vaccine. The rest of the vaccines were procured by GAVI. ii) UNEPI has continued to deliver the vaccines, injection safety materials, gas and other EPI logistics to the districts on a monthly basis. The districts and HSDs distribute the logistics to the health facilities that carry out immunization at static and outreach sessions. 3. Social mobilization for immunization including campaigns The Ministry of Health took the leadership in advocacy and sensitization of the public to create awareness on the threat to importation of the wild polio virus from neighboring countries, about the possible spread of the virus. 4. Injection safety promotion UNEPI has continued to use syringes with re-use prevention features (RPF) for both reconstitution and injecting. The generated waste is disposed off by burning and burying, and incineration where the incinerators exist. 5. Surveillance of measles and polio cases EPI disease surveillance is implemented in the context of Integrated Disease Surveillance and Response-IDSR). Several strategies were implemented in 2009/2010 to ensure that WHO quality EPI surveillance performance indicators are attained. These included: i) Regional surveillance review meetings (involving the District Surveillance Focal Person, HMIS Focal Person and HSD Surveillance Focal Person) to assess the progress of quality surveillance performance indicators, the status of implementation of IDSR activities in the district, and sharing new concepts of disease surveillance. ii) All districts conducting quarterly surveillance review meetings involving the District Health Officers (DHOs), District Surveillance Focal Persons (DSFP), HMIS Focal Persons, District Laboratory Coordinators (DLC), Health Sub District Surveillance Focal Persons (HSDSFP) and in charges of the HSD. In 2009/2010, 77 (96%) districts investigated at least 1 AFP case for laboratory confirmation. At the national level, a non AFP rate of 2.9/100,000 children below 15 years o age was attained with district variation between 0.0 and 14.0 AFP rate. Sixty five percent (52 61

86 districts) attained a non polio AFP rate of at least 2/100,000 children below 15 years of age as a recommendation of minimum standard of WHO A total of 588 suspected measles cases were reported in the monthly HMIS and 1083 measles cases had a case based form filled meaning 184% of the cases had blood specimen taken off for investigation than those cases reported through the HMIS. Of the 1083 measles cases, 1.3% (14 cases) tested positive for measles IgM and 10% (104 cases) tested positive for Rubella IgM. Of the conformed measles cases 86% (12 cases) had received at least one dose of measles vaccine 6. Control of Wild Polio Virus In FY 2009/10, 2 rounds of polio campaigns were carried out in August and November 2009 targeting 12 high risk districts of Kaabong, Moyo, Moroto, Adjumani, Pader, Gulu, Amuru, Kotido, Masindi, Nakapiripirit, Abim and Kitgum. The overall coverage was 102% and 101% in round 1 and 2 respectively. There were no cases of confirmed Wild Polio Virus. 7. Implementation of the Reach Every District (RED) strategy Using district monthly HMIS reports, 22 districts that were poorly performing (with the highest number of un-immunized children) or not submitting complete reports were identified. The following activities Micro-planning, Verification of data, and Supervision by the district team and delivering of supplies, social mobilization including radio talk shows were carried out in the districts of Arua, Yumbe, Masindi, Iganga, Kamuli, Luwero with support by WHO while UNICEF supported Nakapiripirit, Kibaale, Adjuman, Amuria, Kabarole, Bugiri, Mayuge, Kanungu, Bulisa, Kaliro, Moroto, Kabong, Kapchorwa, Nakaseke Kaberamaido, and Soroti in Micro-planning and social mobilization. 8. In order to build capacity for service providers so that they are able to deliver quality immunization services, the programme trained; i) 169 Mid Level Managers were trained to build their capacity for EPI management and supervision with support from Africa Field Epidemiology Network (AFENET) through regional workshop in Hoima (Hoima, Kiboga, Masindi, Buliisa and Kibaale districts), Mbarara (Mbarara, Bushenyi, Ibanda, Kiruhura Isingiro districts), Jinja (Jinja, Kamuli, Iganga, Kaliro, Mayuge, Bugiri and Namutumba districts), Kabale (Kabale, Kisoro, Rukungiri, Ntungamo and Kanungu districts) and Masaka (Masaka, Rakai, Sembabule, Lyantonde and Kalangala districts) ii) Conducted OPL training courses in 9 districts of Bundibugyo, Kabarole, Kamwenge, Kasese, Kyenjojo, Apac, Pader, Amolatar, Kitgum iii) Conducted training of tutors from 28 Nurses and Clinical officers training schools on EPI. 9. Two rounds of Human Papilloma Virus (HPV) vaccination targeting girls aged 10 years in the demonstration project districts of Ibanda and Nakasongola were carried out, with dose three coverage of 88% and 106% respectively. After successful completion of demonstration project the bridging phase for HPV vaccination was introduced that delivers the vaccine using the hybrid strategy which targets girls in P4 during Child Days Plus in the same districts of Nakasongola and Ibanda and the coverage achieved for the two doses 62

87 so far received is 96% and 92% respectively. A third dose is yet to be given during the month of October. 10. Strengthening Tetanus Toxoid Immunization in schools was carried in 13 districts of Isingiro, Ibanda, Kiruhura, Mbarara, Masindi, Buliisa, Manafwa, Mbale, Rakai, Lyantonde, Bugiri, Bundibugyo, and Bududa Mubende, Mityana, Busia, Kibaale, Kiboga and Masaka districts were covered with one round of tetanus campaigns in July Sept 2009, with overall coverage was 45% which was below the target of 80%. Table 3.12: Uganda National Expanded Programme on Immunization key outputs HSSPII target/indicators 2004/ / / / / /10 HSSP II target Fully immunized children 41% 46% % DPT-HepB+Hib3 coverage 89% 89% 90% 82% 85% 76% 95% DPT-HepB+Hib 1-3 dropout rate 16% 11% 10% 12% 11.0% 10% Measles coverage 91% 88% 82% 77% 72% 97% Identified cases of Wild Polio Virus HMIS, Case based AFP surveillance Major Challenges 1. There was a decline in the DPT-HepB+Hib3 coverage from 82% in FY 2008/09 to 76% in FY 2009/10. This can be attributed to; i) Delay in payment to Shell (U) Ltd in qrt1 of FY 2009/10 and they halted the supply gas until payment was made. During this period the districts were not supplied with vaccines, since most of the fridges use gas supplied by Shell (U) Ltd for running. This caused a disruption in implementation immunization services at health facility level. ii) Lack of Child Health Cards and tally sheets for recording child immunization which may be causing under reporting by the health facilities carrying out immunization. iii) Inadequate transport at district level for delivery of supplies to the lower levels. iv) Irregularity of outreaches in almost all districts causing dropouts. 63

88 v) Shortage of gas cylinders at the district level causing irregular supply of gas for the cold chain. vi) Inadequate IEC materials on EPI for Health workers and the communities. 2. The threat of importation of the wild poliovirus from neighboring countries where it is still circulating 3. Late release of funds which is affecting delivery of logistics to districts, servicing of vehicles and surveillance activities. 4. Inadequate funding from the GOU for replenishment of spare parts for cold chain equipment, vehicle maintenance/repairs and generator maintenance (fuel and servicing) and training of operational level health workers. 5. Two new cold rooms were installed last year but the other three cold rooms are more than ten years old and have occasional breakdowns. Recommendations i) UNEPI has scheduled an extensive programme review to be carried out in October 2010 to identify factors that are affecting the immunization coverage. ii) There is need to increase the funding for the programme at all levels to fill the existing operational gaps. iii) Provision of basic tools for service delivery such as child health cards and tally sheets should be given priority iv) Districts should earmark funds for integrated outreaches which will ensure continuity of the immunization services and hence give assurance to the parents of the regular availability of immunization services. v) The threat for wild polio virus importation from neighboring still exists and there is need to strengthen routine immunization activity at all levels. Mass polio vaccination may have to be carried out in districts that are high risk whenever recommended Nutrition Adequate nutrition is an essential prerequisite for maintaining health status. Malnutrition remains a major public health concern in Uganda and affects almost all regions. According to the 2006 UDHS, 16% of children under five in Uganda are underweight, 38% are stunted and 6.1% wasted. Micronutrient deficiencies have been and continue to be a silent emergency in the country. Vitamin A, Iron and Zinc deficiencies continue to take a heavy death toll among children. The National Health policy and HSSP recognized the important role of nutrition and hence include it as one of the components of the National Minimum Health Care Package. The Nutrition section has various strategies to reduce the problems of malnutrition in Uganda. The overall objective of the nutrition programme was to improve the nutrition status of the population with emphasis on the vulnerable groups of the children and mothers. Various strategies were put in place to achieve this. Data from the previous three Uganda Demographic Health survey (UDHS) show that the nutrition indicators have not improved 64

89 much over the past 15 years and some indicators have even shown a worsening trend. Also, malnutrition remains one of the single direct causes of child morbidity and mortality and the prevalence (under fives) remains unacceptably high at 60% (Lancet Series February 2008). Micronutrients and the double burden of disease are also on the rise. Progress towards the attainment of HSSP II indicators is shown in table Table 3.13: Nutrition programme key outputs 65

90 Figure 3.7: Hon. Minster of Health officiating at the World Breast-Feeding week Vitamin A supplementation Child Days were the main activity for scaling up vitamin A supplementation. Support supervision was conducted in 80 districts country wide. Yet still it was not possible to attain the 80% Child days intervention coverage, and this was mainly due to many district not owning CDP and therefore lack micro-plans for this, poor reporting on CDP performance from the districts to the centre with many districts populations not stable and may not tally with the figures available at the centre, and subsequently there is delayed feedback to most districts. The majority are not able to implement CDP fully due to challenges like lack of transport within the districts and at health facilities to conduct outreaches, PHC funding to the districts are limited and are received late, while many districts do not allocate funds for CDP. There is also low partner involvement in support of CDP activities at national and district levels, especially the non-health sector and private sector partners. Addressing malnutrition in under-fives This is one of the indicators where the set target was attained at the end of the HSSP II. Various activities as outlined below took place to address under nutrition among children aged less than five years: 1. Development of the Operational Framework for Nutrition in the Child Survival Strategy and the Maternal, Infant and Young Child Nutrition (MYICN) Action plan 2. Handbook on population nutrition developed and produced 3. Quarterly Coaching Visits to 52 sites implementing providing ART services supported by NUlife project. 66

91 Box 3.5: Lessons learnt from the NUlife Project Nutrition assessment, counselling and support can be integrated in routine services however the staffing norms are still very low Provision of Ready to Use Therapeutic Feeds (RUFT) especially to the malnourished persons on ARVS quickens adherence to drugs and maintains nutritional status, but there is a missing link at the community level whereby the weaned clients many times regress and become malnourished again The community health workers if motivated can do a tremendous job where there is active case finding for the malnourished in the communities Multi-sectoral involvement in the implementation of the program is key to the success of any project or program 4. Harmonized and Finalized the Integrated Management of Acute Malnutrition (IMAM) Guidelines, Reviewed the IMAM training Manual, Pretested and Conducted training of trainers course in the harmonized content. 5. Harmonized the Integrated Infant and Young Child Feeding (IYCF) Counseling Course, Conduct training of trainers course in the harmonized content and Scaled IYCF in all two Regions through capacity buildingheld Coordination meetings which were attended by Nutritionists, DHOs, and Nutrition focal points from the different districts with other Nutrition Stakeholders 6. Recently the CHT training guide was revised. The VHT training manual (2010) now includes a nutrition component including screening for malnutrition at the community using mid-upper arm circumference, counselling and referral for management. However, integration of community growth monitoring and promotion by the VHT was not implemented as planned. Also, at facility level, children s anthropometric measurements are taken but in most cases are not plotted on the growth chart. Major challenges 1. Inadequate funding for nutrition activities especially by the Government budget. 2. Most district plans still do not include nutrition activities during planning and this has retarded the implementation of activities at the district 3. There is a huge gap in human resource at the national, regional and district levels to implement the nutrition interventions, while most health workers still have inadequate skills to implement nutrition interventions 4. Low involvement of communities in nutrition interventions mainly because the Ministry has been focusing more on treatment as an approach rather than preventive. 5. Progress data has been a challenge as most of the indicators to be reported on are mainly collected by the UDHS which is conducted once in every five years. 67

92 6. While it is important to have zinc supplementation it is not available and there have been frequent stock outs of iron and folic acid in health facilities. The lack of Zinc is related to limited sources internationally, with only one company supplying, this is not able to satisfy the demand. Recommendations 1. There is need for continuous advocacy for Nutrition interventions to be mainstreamed in all health services 2. Increasing the number of health facilities that are designated as baby friendly 3. Community Growth monitoring and Promotion be revitalized and integrated into the VHT program as a way to reduce malnutrition at early stages 4. Coordination of all nutrition interventions should be by the Ministry of Health and give direction to the different implementing partners 5. Most Districts still need to be encouraged to recruit at least a nutritionist who can spearhead the nutrition activities at the hospital and district level. 6. The funding for nutrition activities also needs to re-visited and more funds allocated for the smooth running and implementation 7. There is need to strengthen monitoring and evaluation strategies that can provide short term data sources such as sentinel sites, thus providing routine nutrition information on a regular basis. The HMIS should also include more nutrition related indicators that can be collected routinely. Furthermore, there is need to set targets and strategies within the HSSP III that will ensure an improvement in the nutrition status of the population. 68

93 3.3 Prevention and control of communicable diseases Prevention and control of STI/HIV/AIDS FY 2009/10 was a period of re thinking, re-planning and revitalization of the HIV response in the Health Sector as both HSSP2 and HSHASP1 (Health Sector HIV Strategic Plan (2005/10)) ended. This year also marked the end of PEPFAR 1 supported HIV programmes most of which were transitioned to PEPFAR 2 under the new administration in Washington under President Obama. This is important for us because 90% of HIV funding is US supported. The ACP therefore had to heavily coordinate this tough period. The HIV prevalence from the ANC surveillance in 2009 was estimated to be 7%.Antenatal HIV prevalence was higher in urban than in rural sites. In sites located in the major urban areas (cities and municipalities), median HIV prevalence was 8.4 percent. In the sites located outside the major urban areas, median HIV prevalence was 5.7 percent. Approximately 1 million people are infected with HIV over 140,000 of them being children below 15 years of age (table 3.14). Of the were 100,000 in children new infections, from Mother 20,000 to Child of them Transmission. were in children from Mother to Child Transmission. Table 3. 14: The HIV/AIDS Epidemiology in 2009 Magnitude of HIV/AIDS In Uganda in No. of HIV Infected Individuals Total 1,192, % Sex Age Group Males 512,070 43% Females 680,301 57% Adults (15 years +) 1,042,711 87% Children 0-14 years) 149,661 13% 2. Number of new HIV infections in 2009 Total 124, % Males 56,079 45% Females 68,182 55% 3. Number of AIDS Related Deaths in 2009 Total 64, % Males 28,812 45% Females 35,205 55% The epidemic has shifted from the single younger-aged individuals to older individuals aged years, who are married or in long-term relationships. Multiple concurrent partnerships, 69

94 extra-marital relationships, discordance and non-disclosure are among the key factors driving the spread of HIV in Uganda. Progress ACP consolidated most of the achievements under HSSP2 and HSHASP1. Most of the Policies for comprehensive HIV prevention, care and treatment were in place and were updated to match and meet the ever changing global changes and challenges especially ART and PMTCT policies. A new National Prevention Policy (NPC) was also developed in the context of the multisectoral approach under Uganda Aids Commission. The Home Based Care policy was finally completed with support from WHO. HIV services were scaled up to many health facilitues both in the public and private. For example HIV care PMTCT and ART services were provided in 66% and 83% of the health facilities respectively. One hundred (100) of the ART sites were in the private health facilities supported by HIPS (Health Initatives in the Private Sector), USAID funded. This is a great achievement enhanced by the MoH PPP Policy. By June 2010, the numbers of active clients enrolled onto antiretroviral therapy were 237,070. Of these, 89 percent were adults aged 15 years+, and, eight percent were children 0-14 years. Based on new Ministry of Health guidelines i.e. adults with < 350 CD-4 T-cells/ul., data from modeling indicates that 540,094 adults and children were in need of ART by December Based on these estimates, and the number of people enrolled on ART, 47 percent of adults and 26 percent of children in need of ART were already enrolled as of June If the previous national ART eligibility criteria of < 250 CD-4 T-cells / ul were considered, modeling data indicated total ART need of 442,103 adults and children indicating that 54 percent adults and children were enrolled on ART by June Over 800,000 pregnant women accessed PMTCT through ANC. A lot of success was made in integrating HIV services with others especially TB, RH and MCH. For example HIV Early Infant Diagnosis (EID) was integrated into Child Days Plus. This increased the Number of HIV exposed children that accessed HIV testing (EID) from about 17,000 to 43,000. While 63% of TB patients in Uganda are co-infected with HIV and TB remains the commonest cause of death among PLHIV. There was success in the implementation of regional HIV programs like GLIA (Great Lakes There was success in the implementation of regional HIV programs like GLIA (Great Lakes Initiative on HIV/AIDS) funded by the WB. IOM conducted hotspots study along northern corridor from Kampala to Juba and the report is available. There were also some IGGAD supported activities that were implemented during this FY. Most of the ACP activities were supported under the CDC/MoH Coag Project. The Global Fund resumed operations in 2009/10 and $ 24m was disbursed out of the year budget of about $30m for emergency procurement of ARVs. UNICEF mainly supported PMTCT and EID services. WHO supported the HSR for HIV, HBC policy and capacity building for ART. UNFPA supported MARPS related HIV activities. Overall 90% of the Health Sector HIV activities were supported by PEPFAR through USAID and CDC. Six new 5 year projects were funded USAID; the SUSTAIN project replaced TREAT which was under JCRC while the latter got the THALAS project; MJAP got a new HCT project for 22 districts; EGPAF, got STAR-SW while STAR E and STAR EC were awarded to MSH and former UPHOLD projects. A new supply chain project - SURE commenced this year. Those supported through CDC will start in 2010/11. GoU funded ARVs procured from CQIs and supported internal travel and operational costs for the ACP. 70

95 Several research studies were conducted or completed. Examples include; i) Planning for the 2010 AIDS Indicator Survey was in final stages ii) Sex and Reproductive Health Choices supported by UNFPA iii) Commercial Sex Workers HIV/RH study iv) Condom Mapping v) HIV EWI survey 2009 vi) Fishing Community HIV prevalence Survey vii)the HIV Health Sector Review (HS HSR) was conducted for the first time in Uganda. viii) The Refugees HIV study ix) 2009 ANC surveillance samples were collected from 24 sentinel sites. Table 3.15: Achievements of the ACP over the HSSP II period Indicator 2004/ / / / / /10 HSSP II target Proportion of population with Comprehensive 90% 36% (UDHS AIDS 95% knowledge (proportion of population who cite 2 correct (HSSP II 2006) information methods of HIV prevention and reject the 3 common estimate) survey due misconceptions of HIV/AIDS transmission) 32% (UHSBS 2004/05) Prevalence of HIV among women attending ANC 6.20% 6.20% 9.70% 7.00% 5-10% ANC surveillance data (2008) 3% Prevalence of HIV among the general population 6.2% (HSSP II 6..3 [ ] 6..3 [ ] 6..2 [ ] 6..2 [ ] AIDS 3% estimate) information survey due Proportion of HC III offering VCT services %[1] 1 Proportion of HC III offering PMTCT services No data Proportion of HC IV offering comprehensive HIV/AIDS No data No data care with ART Challenges Inadequate health systems hindering the expansion of PMTCT service points at HCIII levels Recommendations 1. Develop HIV Health Sector HIV Strategic Plan 2 (HSHASP2) taking into considerations the findings from the Health Sector HIV Review. 71

96 2. Strengthen ACP management and leadership for more effective cordination of Partners and Programmes. 3. Increase numbers of people on ART by 50,000 in 2010/11 4. Begin the implementation of Virtual Elimination (VE) of mother to child transmission of HIV 5. Develop a better R10 GFATM proposal Tuberculosis Tuberculosis remains a major public health problem in Uganda. According to the 2009 WHO Global TB Report, Uganda is ranked 16th among the 22 high burden countries. In addition, the country has an emerging multi drug resistant TB (MDRTB) problem; and a high HIV prevalence (6.4% among the general population and over 50% among TB patients) fuelling TB epidemic. Moreover, TB is the leading cause of death among people living with HIV/AIDS. At National level, TB and Leprosy Control are coordinated by the National TB Leprosy Programme (NTLP) under the Communicable Disease Division of Ministry of Health. To fulfill this mandate, NTLP formulates policies, sets standards, builds capacity, and mobilizes resources for TB and Leprosy Control in the country. At district level, TB control is integrated into Primary Health Care Services and is coordinated by District Health Teams. Tuberculosis is one of the priority diseases included in the national minimum health care package and addressed by Health Sector Strategic Plan II (HSSP II). HSSP II was aimed at reducing the morbidity and mortality due to TB, and set out to attain the following targets: DOTS targets: 70% case detection rate (CDR) and 85% cure/treatment success rate (TSR) TB/HIV targets: 80% of TB patients tested for HIV, 100% of the HIV + TB patients started on cotrimozaxole preventive therapy (CPT) and 20% on anti retroviral therapy (ART) EQA target: 80% concordance. CBDOTS target: 100% geographical coverage sustained Progress This section highlights the DOTS targets, CBDOTS coverage, TB/HIV targets and laboratory related targets NTLP, partners (including GLRA, GFATM, USAID, Italian Corporation and WHO) and districts achieved over the HSSP II period. These are summarized in table XX below. DOTS (CDR and TSR) targets: There was a slight increase in the case detection rate (CDR) and a fluctuation in TSR. CDR that had stagnated around 50% over the first three years increased to over 55% in the last 2 years of HSSP II. Despite the increase, the country has not attained the CDR target of 70%. The overall national TSR performance also remained low, the maximum attained being 75% in 2007/08 and the lowest being 69.6% in 2006/07. However, it is encouraging to note that 15 districts had attained the CDR target in 2009 and the number of districts attaining the TSR target steadily increased from 8 in 2005 to 26 in 72

97 2009. The case fatality rate among smear positive cases has steadily declined to 4.6% short of the targeted 3.1%. CB-DOTS coverage: The country has sustained the 100% CBDOTS geographical coverage attained in April 2005 (when training of Sub-County Health Workers and general health workers and the initial group of community volunteers/treatment supporters in all Sub- Counties in the country was completed). However, due to lack of funding the proportion of patients on Directly Observed Therapy (DOT) remains low. TB/HIV targets: Uganda adapted WHO generic TB/HIV collaborative policy in 2005/06 to guide TB/HIV interventions in the country and trained health workers in a bid to standardize implementation. All districts are now implementing & reporting on TB/HIV collaborative activities. As a result, the proportion of TB patients tested for HIV increased from 28% in 2006/07 to 77% in 2009/10, close to the target of 80%. The proportion of HIV positive TB patients started on CPT rapidly rose from 4% in 2006/07 to 86% in 2009/10; this was short of the set target of 100%. In addition, 22% of TB/HIV patients were started on ART. This surpassed the set target but remains a challenge since the recent WHO recommendation is to start all HIV positive TB patients on ART as soon as it can be tolerated. Table 3.16: Achievements of the TB control programme Target outputs 2004/ / / / / /10 HSSP II Case detection Rate (%) TB cure rate (%)* Proportion of deaths among newly registered smear positives per year (%)* Coverage for CB DOTS (%) Proportion of TB cases notified who are tested for HIV among all TB cases per year (%) Proportion of TB/HIV coinfected patients offered Cotrimoxazole Prophylaxis Therapy (CPT) among all TB cases notified per year (%) Proportion of TB/HIV coinfected patients receiving Anti-Retroviral Therapy (ART) among all TB cases notified per year (%) Source: NTLP Quarterly and Annual Disease Surveillance Reports. * Treatment outcomes (cure and death rates) are obtained after a year target

98 Laboratory related outputs: The National TB Reference Laboratory (NTRL) instituted external quality assurance (EQA) for Sputum smear microscopy in 2008/09 using blinded rechecking with first controller at district level and second controller at NTRL and feedback provided to DTUs quarterly. EQA now covers 97% of microscopy centers; and has improved their proficiency increasing concordance to 87% above the target. EQA also reduced the level of high false negatives (HFN) from 22% in 2008 to 10% and high false positives (HFP) from 12% in 2008 to 2.5% (target HFN and HFP less than 5%). However, the proportion of labs involved in EQA keeps fluctuating and declined to 70% in the third quarter and 35.4% in fourth quarter of 2009/10. Progress in implementing other activities Establishment of programmatic management of drug resistant TB (PMDT): During the HSSP II, NTLP and partners set out to establish a Programmatic management of MDR-TB these included: appointing an MDRTB Focal Person; developing PMDT guidelines; carrying out a drug resistance survey initiated in 2009/10 to establish the magnitude of MDRTB in the country; collaborating with Green Light Committee and securing an approval for 200 MDRTB cases for initiating treatment in the country and with GF R 6 for funding for procuring 300 courses of SLDs. In addition, Ward 5 of Mulago is planned to be used for MDR-TB management, 34 Regional Trainers and 24 health workers trained on PMDT; and a routine surveillance of drug resistant TB system 22 was set up and a total of 124 (cumulative from march 2008-October 2010) MDRTB cases identified awaiting enrolment. Laboratory: The country has a network of 851 TB diagnostics facilities (DTUs), 12 Regional Laboratories and one National TB Reference Laboratory (NTRL). During the HSSP II NTLP and partners strengthened the laboratory network at all levels by renovating and equipping the NTRL and training 931 laboratory personnel (including 31 Lab technicians, 175 lab technicians, 394 Lab Assistants and 122 microscopists). Drug and Logistics Management: The TB medicines have been fully supplied up to the health unit level with no noticeable stock outs countrywide. There were LMIS trainings conducted in the districts of Pallisa, Budaka, Mbale and Manfwa. A total of 120 health workers were trained in the month of March 2010 with the support of the STAR E Project. In April 30 health workers were trained in the districts of Mbale and Manafwa with the support of the TB CAP Project; There were also training in Logistics management at Buluba Hospital for 33 health workers and new district TB and Leprosy supervisors conducted during the month of May Timeliness, completeness and accuracy of recording and reporting (quality of LMIS) is still a challenge, the new districts formed and their health centers have created a challenge in capacity at the new districts to manage TB logistics, some districts and facilities submit their bi-monthly reports and request for drugs late. The country s reliance on donor support for procuring all anti-tb medicines has occasionally led to delays in shipment of medicines to the country; which has led to constraints in full supplies at central level. At facility level management of TB logistics system faces a challenge due to the high rate of staff attrition which leaves a massive capacity gap. 22 This involves referring sputum samples from DRTB suspects (all retreatment cases, failures of cat I and contacts of MDRTB) to NTRL for DST 74

99 Partnerships: The country continued to run the Uganda Stop TB partnership introduced in 2004 to harness and coordinate partner efforts towards NTLP TB control targets. During HSSP II, USTP continued to work through its working groups, and to organize World TB Day Commemorations; the 2009/10 of which was commemorated at Uganda Prisons Luzira. USTP became a legal entity in 2009/10 TB/HIV: During the year, TB/HIV modular training guidelines were update to incorporate components on TB Infection Control, R&R. In addition, Intensified Case Finding Tools and suspect TB registers were developed and disseminated M&E: Under M&E, R&R tools were modified to capture TB/HIV indicators; quarterly reports were received from all districts; quarterly review and planning meetings were held in all zones as well as at the National level. These facilitated standardization of implementation all over the country, sharing of experiences, and cleaning of data Operational Research: TB/HAART Research on barriers on implementing TB/HIV collaborative activities Situation analysis on TB/HIV in 26 districts Situation analysis on PPM Private sector collaboration and compliance with standard treatment guidelines; Very few Private Health Providers (PHPs) are fully engaged in TB control, only three facilities in Kampala engaged fully. Data from districts quarterly reports does not capture the contribution or the level of involving the PHPs in TB control. Challenges The major challenges that led to the non attainment of the set DOTS, TB/HIV and EQA targets can be broken down into health system, health provider and health user challenges. These included: Health System Challenges: The health system challenges can be summed as a weak health system, included: i) Inadequate national funding as evidenced by lack of a dedicated budget line for TB drugs, difficulty implementing such critical activities as support supervision ii) a weak procurement supply management system leading to repeated stock outs of test kits and drugs iii) a weak recording and reporting leading to inadequate capture of data, non evaluated cases iv) Poor access especially to ARVs both in terms of distance (there are fewer ART sites than DTUs) and old policy of using CD4 levels for determining eligibility to ARVs As opposed to the current WHO recommendation that all HIV + TB patients irrespective of CD4 status are eligible for ARVs 96 75

100 v) Inadequate support supervision and therefore inadequate guidance to peripheral health workers implementing TB and TB/HIV activities vi) Policy: use of CD4 to determine eligibility for ART (note this was before the country adopted the WHO recommendation that all HIV + TB patients irrespective of CD4 level are eligible for ARVs vii)lastly, the true magnitude of TB in the country is not known; CDR is based on estimates Health Provider Challenges: i) Inappropriate implementation of DOTS strategy: non adherence to sputum smear to diagnose and monitor treatment leading to low sputum conversion rates and to extremely low cure rates; non adherence to DOT - only 38% of the 2008/09 cohort treated under direct observation; poor R&R; evaluation rates (91% among 2008 cohort), ii) Poor interpersonal communication skills leading to inappropriate education of patients iii) Staff attitude Health user Challenges: i) Weak community support system - VHTs trained and functional in less than 25% of the districts in the country. ii) Low community awareness leading to late health seeking behavior, high mortality rates, poor adherence, unfavorable treatment outcomes (defaults, transfers) etc. iii) Poor community participation Recommendations i) Government should increase the level of funding to TB control including establish a dedicated TB drug budget line ii) MOH/NTLP/NACP should ensure a strong referral system to increase coverage of ART and work towards integrating TB and HIV services in the same units. iii) NTLP should as first priority prevent the production and transmission of MDR-TB, through continued strengthening of the general TB program to reduce risk factors for MDR-TB to an acceptable level, such as adequate DOT, regular drug supply and infection control; then establish and sustain PMDT iv) The monitoring visits by SCHWs would support communities implement CB-DOTS thus enhance treatment completion and monitoring. v) Increased awareness would also lead to reduced stigma associated with TB and TB/HIV. 76

101 3.3.3 Prevention and control of malaria The control of Malaria was critical in HSSP II as one of the leading causes of morbidity and mortality in Uganda. At the outset, Malaria accounted for 25-40% of outpatient visits, 20% of inpatient admissions and 9-14% of inpatient deaths in public and private-not-for-profit health facilities. Malaria and malaria-related illnesses contribute 20-23% of deaths among children aged less than five years. Some of the reasons for this poor state included: limited access to adequate treatment of malaria/fever; increasing resistance of malaria parasites to medicines; and incorrect and/or inadequate malaria treatment at home or within communities. Due to improved reporting, many cases are now being reported which may account for the increased number of cases in this FY 2009/10. Figure 3.8: Malaria cases seen in OPD from 2000/01 to 2009/10 Source: HMIS/Resource Centre, Ministry of Health The mainstay of intervention strategies for malaria included prompt and effective case management at facility and community levels using Artemisinin-Based Combination Therapy (ACTs); use of insecticide treated mosquito nets; indoor residual spraying with efficacious insecticides; intermittent preventive treatment in pregnant women; epidemic preparedness and response; and IEC/BCC, Monitoring & Evaluation & Research and Health Systems Strengthening which cut across all the interventions. 77

102 Table 3.17: The performance of the Malaria specific HSSP II indicators over the past five years Target outputs 2004/05 Baseline 2005/ / / / /10 HSSP II target Proportion of pregnant women who have completed IPT2 (%) 34 (HMIS) 37 (HMIS) 42 (HMIS) 42 (HMIS) 44 (HMIS) 39.6 (HMIS) 31.7UMIS) 80 Proportion of households having at least one insecticide treated net (%) (UDHS) 16 (UDHS) 42 (NMCP) 46.7 (UMIS) 54 (NMCP) 70 Proportion of households in 6 targeted District sprayed with IRS sprayed (%) (NMCP) 95 (NMCP) 97 (NMCP) 99 (NMCP) 80 Proportion of children under five getting correct treatment within 24 hours of onset of symptoms (%) (NMCP) 71 (NMCP) No data 13.7 (UMIS) 80 Percentage of uncomplicated fever/ malaria cases (all ages) correctly managed at health facility (%) (NMCP) 71 (NMCP) No data 13.7 (UMIS) 85 Case fatality Rate (%) 4 4 No data 3 (HMIS) 2 Percentage of health facilities without any stock-outs of first line anti-malaria medicines (%) (NMCP) 35 (NMCP) 35 (NMCP) (HMIS) 50 (NMCP) 1.4 (HMIS) No nationally representative data 2 80 Progress on targeted outputs for 2010: 1. Proportion of pregnant women who have completed IPT2 (%) In order to reduce maternal morbidity and mortality as well as improve the newborn s chances of survival malaria in pregnancy remained an essential part of the malaria control strategy in Uganda with the three elements of i) Intermittent preventive treatment (IPT) using the Directly Observed Treatment (DOT) strategy ii) Prevention with ITNs distributed through ANC services iii) Prompt treatment of clinical malaria episodes with drugs or drug combinations appropriate for the stage of pregnancy. Achievements to date include: i) Scaling up of IPT to all antenatal clinics in Uganda ii) Introduction of the pre-ruled integrated antenatal register which enabled facility recording and monitoring of IPTp uptake at health facilities. iii) New Policy and Guidelines: In order to minimize missed opportunities, the IPTp policy was revised to widen the period when an expectant mother can take SP for IPTp. It was recommended that SP could be taken between 16 weeks of gestation and term (when woman delivers: weeks). The guidelines also removed the old contraindication of the concomitant use of SP and folic acid. Furthermore, guidelines offered flexibility in methods of ensuring the directly observed therapy (DOT) of SP- IPTp where a client can now use any safe drink (e.g. milk, soft drinks, sachet water, 78

103 tea etc) to uptake the drug. Because of these changes, more women are now taking SP-IPTp under supervision in the country. iv) Some of the Partners working in this area and making contributions to the national achievements include the Uganda Health Partnerships communities partnership (UMCP) which provided advocacy and communication package in the West Nile region; NUMAT which distributed a total of 150,000 LLINs and achieved an IPT 2 coverage of 48% in the Acholi and Lango regions; AMREF in Nakasongola District and the Stop Malaria Project in 15 of the Central Uganda Region, Mid Western and Teso region Districts. The Proportion of pregnant women who completed IPT2 increased slightly and stayed at 42% between 2007/8 and 2008/9 and later dropped slightly to IPT2 coverage was found to be at 31.7 countrywide by the Uganda Malaria Indicator Survey (UMIS) of 2009/ Proportion of households having at least one insecticide treated net (%) The proportion of households having at least one insecticide treated net (%) increased steadily over the years, from 16% in 2006/7 to 46.7% by the end of 2009 (UMIS) and achieving an operational coverage of 53.1% for the proportion of House Holds having at least one net by the time of reporting in This compares well with the Operational achievement for Universal coverage at 51% (8.24M nets distributed over the past three years divided by the current population). Also from the UMIS, the proportion of under fives who slept under an ITN the previous night was 33% while that of pregnant women was 44%. Table3.18: The implementing partners and funding sources for nets. Implementing Partner AFFORD July-October 2009 Malaria Consortium Uganda(UMCP), July Malaria Consortium Uganda(UMCP) No. LLINs distributed Funding source Method of distribution 282,236 PMI Campaign targeting sleeping rooms 66,342 PMI Campaign targeting one per sleeping space 17,525 PMI campaign targeting one net per sleeping place Districts served 35,137 LLINs were distributed Kaberamaido, 15,350 in Kumi, 116,610 in Manafwa and 8,319 in Soroti and 175,416 in Mbale. Moyo (Moyo 14,948; Itula 8,018 total 22,976) Yumbe Lomogi SC 20,400 Nets Nebbi district as the last district in the project area Adjumani Cipholo S/C No. of S/C covered Only Panyimur sub county in Nebbi received LLINs in October ,000 Malaria Consortium Uganda Hoima- (311,065) Comic Relief Of UK Campaign Hoima (one net per sleeping place 3 districts, Hoima(November 2009), Bullisa (December 2009) and Kiboga (March 2010) All sub- counties in the two districts attaining universal coverage 79

104 Implementing Partner No. LLINs distributed Funding source Method of distribution Districts served No. of S/C covered Bullisa- (92,0000) 87,986 and one net per two persons in Bulisa & Kiboga) Kiboga- (201,290) Global Fund Sub Recipient CSOs/Stop Malaria Project/PACE 1,481,050 GFATM/PMI Targeted campaigns to PW & U5s Commercial sales 12,540 Nets Central and Eastern Uganda Global Fund Sub Recipient CSOs/Stop Malaria Project/PACE 2,844,950; Kampala, Wakiso GFATM Western Kampala (ADRA) Wakiso (CHS) 13 Central region districts (less Kiboga, Kampala and Wakiso) 1,854, , ,350 GAFTM nets distributed to all sub counties using the PMI funding TOTAL 2009/10 5,316,983 Total per Capita increase 7.3% The current National Operational Coverage of House Holds with at least one ITN (LLIN) stands at 54% (NMCP). 3. Proportion of targeted households with IRS sprayed (%) Objectives & targets: i) To attain at least 85% coverage of the targeted households with IRS. ii) To develop capacity at national and district levels to implement effective IRS. Implementation strategies/approaches: i) IRS has been applied in both endemic and epidemic prone areas in a systematically phased manner using WHOPES approved insecticides and involved: ii) Macro-planning, budgeting and procurement of IRS logistics at national level iii) Micro-planning and resource allocation for IRS implementation at district level iv) Advocacy, Social Mobilization and Community mobilization and sensitization at various levels (IEC/BCC activities) v) Baseline entomological, epidemiological and environmental studies vi) Training of spray personnel vii)implementation of spraying including supervision and monitoring quality of spraying viii) Post-IRS activities including post-irs evaluation activities, report writing and feedback to local district leaders Achievements: i) High community compliance and acceptance of IRS ii) High spray coverage rates of >85% of targeted houses in all 10 districts so far sprayed iii) >3.1 million people protected in past 1 year (July 2009-June 2010). 80

105 Indicator Houses Found iv) A rapid decline of malaria cases (OPD Attendance); parasitaemia, and health facility admissions v) Trained and re-trained 5,792 spray personnel in 2009/2010 FY (DHT members, Subcounty supervisors, Team leaders, spray operators, storekeepers and wash persons) Houses fully & partially sprayed % House Coverage Targeted Total Population Population Protected % Population Protected Kitgum Round 4 (Nov-Dec 2009) Pader Round 4 (Nov-Dec 2009) Table 3.19: Performance of IRS Apac Round 2 (Mar-Apr 2010) Oyam Round 2 (Feb-Mar 2010) Amuru Round 2 (Mar-Apr 2010) Gulu Round 2 (Apr-May 2010 Kumi Round 1 (Jul-Sep 2009) TOTAL 162, , , , , , , , , , , , , , , , , , , , , , ,900 3,121, ,666? 664, , , , , ,670 3,109, NB: Original Government plan targeting 24 epidemic, border/post conflict districts and periurban centres in 5 major towns with funds from Government, PMI and Global fund round 9 did not materialize. This was because the Global Fund application for funding did not succeed, and yet there were no immediate mechanisms for Government to pick up the whole bill. Type Kitgum (Oct 2009) Table 3.20: IRS Personnel Trained in 2009/10 Pader (Oct 2009) Amuru (Feb 2010) Gulu (Feb 2010) Oyam (Jan 2010 ) Apac (Jan 2010) Kumi Jul-Sep 2009 Supervisors Team Leaders Wash Persons Spray Operators ,422 Storekeepers DHT Total 937 1, , Total In addition to the above districts, boarding institutions, Army and Police Barracks were also sprayed using Lambdacyhalothrin 10% WP. The numbers of Police Barracks sprayed in 2009 were 30 as indicated here-below. 81

106 Table 3.21: Uganda Police Barracks Sprayed from June to August 2009 No. Region No of Barracks Barracks Name 1 Central 03 Nakasongola, Mityana, Mubende 2 South eastern 02 Jinja, Iganga 3 Eastern 01 Mbale 4 Mid Eastern 01 Soroti 5 North Western 01 Arua 6 Western 02 Kabarole, Kasese 7 South Western 01 Mbarara 8 Mid western 03 Kabalye PTS, Masindi PTS, Masindi barracks 9 Southern 01 Masaka 10 Kampala Metropolitan Total Naguru, Ntinda, Kireka, Nsambya, Katwe, Old Kampala, Kira Road, Wandegeya, Jinja Road, PTS Kibuli, Lugazi, Mukono, Entebbe, Bombo, Luwero African Field Epidemiology Network (AFENET) under the auspices of the Avian Influenza and other Zoonotic Infections Project (AIZIP) worked together with MOH and Districts DHT members to conduct IRS in order to prevent and avert Plague outbreak as well as control malaria in Arua and Nebbi districts in NW Uganda. IRS was carried out in 25 worst hit and susceptible villages to plague outbreaks in the last back to back outbreaks in the five sub counties in Nebbi and Arua districts. The sub counties so selected were: Kango, Jangokoro and Zeu in Okoro County, Nebbi district; Logiri and Vurra Sub counties in Vurra County, Arua district. Results: A total of 625 homesteads in Arua and 549 in Nebbi district were sprayed by the team giving a total of 1174 households sprayed. All the five sub counties in the two districts benefited from this exercise. 22 or 88% of the 25 villages were sprayed between 23rd September and 20th October Proportion of children under five getting correct treatment within 24 hours of onset of symptoms (%) Performance on this indicator which was doing well at 71% using HOMAPAK, a combination of Chloroquine and Fansidar (SP) suffered after the change of policy to ACTs, in But the effects were most pronounced in 2007/9, when, because of suspension of the major source of funding (Global Fund Round 4 Phase II) the planned roll out of ACTs to the community level to replace HOMAPAK did not happen as planned. However, pockets of partner funding continued to sustain these efforts in the Districts of Kiboga (Malaria Consortium) and the Acholi region (UNICEF). The numbers of children involved were so minimal compared to the previous performance. The projects finally wound down in 2008 because of late release of the GF Round 4 Phase II grant which had been envisaged to sustain these efforts towards the end of the projects. Following the recent release of this grant, the roll out of ACTs to community level will finally occur early in the FY 2010/11. 82

107 The proportion of children under five getting correct treatment within 24 hours of onset of symptoms (%) leaped from 25% to 60% in first year and then increased and stayed at 71% for the next two years (2006/7 and 2007/8). In 2008/9 there was no data as the planned ACT roll out to the communities did not happen. In a related event the recently concluded UMIS found that 36% of children aged less than five years took antimalarials on the same day they developed symptoms while only 13.7% accessed ACTs the same day. 5. Case fatality Rate (%) The Case Fatality rate is an impact indicator whose performance is not completely within the control of the NMCP but can be largely influenced by an interaction of all Malaria Control and Prevention interventions in scope and scale. This includes the health systems response to uncomplicated and severe malaria cases as well as availability, access, equity of services. On the other hand community awareness and use of these services also have a lot to do with the case fatality rate. The HMIS has consistently shown achievements toward the target of 2, and by mid 2010 the case fatality rate is 1.4. However, this data should be taken with caution as only 44% of the population seeks care from the Public and Private not for profit health facilities from which HMIS is compiled. The rest of the deaths occur in the community and are not captured. In addition, the accuracy and validity of figures reported has been weakened over the years by challenges of poor in-patient and incomplete reporting from hospitals and Districts respectively. 6. Percentage of health facilities without any stock-outs of first line anti-malaria medicines The proportion of health facilities without any stock-out of first line anti-malarials (ACTs) has been unstable, first showing a decline from 50% to 35% in the first two years, then back to the baseline value in 2008/9. This financial year there has been no nationally representative data on this indicator. In the absence of routine funding for nationwide supervision, data on this indicator has been largely dependent on PMI partner efforts, especially the Stop Malaria Project in Central Uganda as well as NUMAT in the Acholi and Lango regions. There is therefore no nationally representative data on this indicator. 7. Additional Efforts Case Management i) SMP conducted training of health workers in the case management of severe malaria in four districts in the Teso region, namely Kumi, Amuria, Kaberamaido and Soroti. A final report including the final numbers trained will soon be available. The training utilised trainers based in that region. Job aides on severe malaria were distributed during the trainings. ii) District health team meetings were conducted in the same districts in the Teso region, where policy changes in the management of complicated and uncomplicated malaria cases both in adults and children were discussed. iii) Pre-referral training for severe malaria case management in Nakasongola, Mukono, Kiboga and Wakiso districts were conducted. Health workers targeted were from HCIIs and HCIIIs, with the cadres trained including clinical officers, registered nurses and midwives. A final report will soon be available. 83

108 iv) Twelve central level trainers were trained in the management and clinical audit of severe malaria, who then trained district trainers in five districts trained in the management and clinical audit of severe malaria. Clinical audits on the management of severe malaria for the health workers at hospitals and health centre IVs in 4 project districts (Mukono, Wakiso, Luweero, and Nakaseke) were conducted. v) Severe malaria clinical audits conducted at 29 referral level (hospitals and HCIVs) in 5 districts. vi) In total, 320 severe malaria management posters were produced and disseminated in 4 districts. vii)technical support was provided in order to review the HMIS in line with NMCP monitoring needs. Weekly malaria monitoring indicator tools were developed and incorporated into the HMIS. The reviewed HMIS final documents are expected to be out in the next quarter. Malaria Diagnostics (i) Malaria Microscopy Training: The Ministry of Health, Malaria Control Program with support from PMI and SMP/Jump is strengthening capacity for malaria microcopy in 14 districts of Soroti, Bukedea, Kayunga, Mukono,Wakiso,Rakai, Sembabule, Mityana, Mpigi, Luwero, Nakasongola, Nakaseke, Kiboga, Kibaale, Buliisa and Masindi districts. The training approach used includes building capacity at district level developing a pool of district trainers who are full time Government employees. These are charged with responsibilities of training laboratory workers in lower level health units. (ii) Microscopy External Quality Assurance Program: The Ministry of Health, Malaria Control Program worked with the Central Public Health Laboratories with funding from Malaria Consortium to pilot malaria slide re-checking scheme in 5 districts of Hoima, Masindi, Buliisa, Kibaale and Kiboga. The Estimated population in this region is 2.2m and Malaria accounts for > 40% of outpatient cases. A total of 5 Labs (4 Hosp, 9 HCIV, 37 HCIII) was enrolled to participate in this program. (iii) WHO supported Regional Quality Assurance Scheme (RE-QAS): The World health Organisation through ARMREF supports Malaria Microscopy Quality Assurance through panel testing program. Under this scheme, standard known malaria slides prepared centrally are distributed to participating laboratories for reading. Results are processed, analyzed and feed back sent, sometimes with a call for corrective action. Selected Laboratories from all the five East African Countries including Zanzibar participate in this program. (iv) Global fund Round 4 RDT implementation: The Ministry of health received Funding from the GFATM of about 2 million USD to fund the procurement of 1.4 million RDT tests and train 5000 health workers in 17 districts across the country. Significant progress has been made towards the implementation of this grant with the major activities accomplished being Training of National RDT TOT team, as well as Printing of RDT manuals, guidelines and job aids. There are still challenges with procurements of tests which is a major source of delay in implementation. 84

109 IEC/BCC activities i) Successfully held World Malaria Day events which included a Prayer breakfast with parliamentarians, and Grand rounds in Makerere, Mbarara, Kampala International and Gulu Medical Schools. Among the other activities was the scientific symposium which attracted a wide range of papers presented and discussed among research, public health and Clinical specialists and practitioners for the first time in the history on NMCP. The other was the World Malaria day event, attended by many dignitaries and at which Round 7 Phase 1 Net distribution was officially flagged off by the Minister of Health who stood in for the Vice President of the Republic of Uganda. ii) Completed, printed and distributed Leaflets on ACTs (250 pieces in English and Local languages each), one communication strategy for Malaria Control , one Social Mobilization guide for HBMF, 20 posters on Malaria treatment using ACTs (for health facilities), 20 flow chart for Malaria in pregnancy, 20 World Malaria day Posters, 30 Community Health Promotion handbooks and 30 Posters on malaria in pregnancy in the local language in 60 of the Districts in Uganda this year. iii) Supported advocacy, communication and social mobilization including 30 Radio spots and radio talk shows per district for LLIN distribution in Central, Western Regions as well as Kampala and Wakiso Districts. In the same way supported IRS activities in Abt districts of Western Uganda. Some of this work was done in conjunction with MACIS, UHCP and other partners. M&E & Health Systems Strengthening The NMCP is in the final stages of releasing the report for the first Uganda Malaria Indicator Survey which has provided authentic statistics to use as baselines and future benchmarking of Malaria Control and Prevention performance in Uganda. National and District M&E efforts have also been boosted through the works of the CLOVER project at the Resource Centre, NMCP M&E Unit and in the districts of the South Western/Hoima and Teso regions. Amongst other activities they supported training of staff, computerization, communication with lower health facilities and installation of data management soft ware. NMCP Programme Management i) Convened three out of four Quarterly Roll Back Malaria Partnership meetings inclusive of a Five day re-treat in an attempt to forge a new strategic direction for Malaria Control and Prevention in Uganda. An Aide Memoir was reviewed, agreed upon and is in the process of being signed by all partners and officially endorsed by the Ministry of Health authorities. ii) Successfully hosted a five day Eastern and Southern African Regional Network for Roll Back Malaria meeting in Imperial Resort Hotel, Entebbe. iii) There is a new Programme Manager in the names of Dr. Seraphine Adibaku who started work in May Dr. Peter Okui is the new National Coordinator for Case Management within NMCP and beyond. 85

110 Major challenges (i) Human resources a. There was only skeleton staff in most of the health facilities where severe malaria and pre-referral training was planned thus fewer health workers were trained than initially hoped. (ii) (iii) b. Several staffing gaps exist at all levels; health facility, district and zonal/regional office therefore there is limited human resource capacity at the district and regional levels for direct services delivery and overall coordination of NMCP strategic work plan c. The weak capacity to deliver the services at the facility level and the clinicians malaria diagnosis and treatment approaches that largely hinge on clinical presentation, as a basis for diagnosis & treatment (presumptive case management). d. Changes in NMCP top staff have at times delayed decisions and activities to be implemented. There are also significant human resource constraints in terms of staff numbers at many of the facilities Medicines and diagnostic supplies a. There remains a lack of ACTs, SP and other supplies in many health facilities. Chronic shortage of malaria medicines, especially the approved 1 st line medicines - arteminisine based combination therapies (ACT). Available supplies have not been able to adequately meet the health facility level needs. The HBMF services have remained stagnant, as a result. Selected village health team members (VHT) volunteers, two per village, have been trained as community medicine distributors. However, not much has been accomplished beyond the trainings. b. Limited access to adequate treatment of malaria/fever; increasing resistance of malaria parasites to medicines; and incorrect and/or inadequate malaria treatment at home or within communities. Diagnosis of malaria a. Malaria diagnostics is currently only funded by Partners which may not be sustainable b. Low quality slide reading were observed in some districts due to poor quality microscopes and lack of effective laboratory external quality assurance system. c. The major challenge now is the delay in procurement of the 1.4 Million RDT tests for implementation in 22 districts. d. Delayed release of funds for Round 4 Phase II implementation of roll out activities for HBMF and training of RDT implementation in the targeted Districts. This is putting the grant which is already in class C at risk of being cancelled. Procurement of vital commodities for implementation of this grant have also been delayed by internal bureaucracy and slow procession of requisition within the Ministry of Health. (iv) LLIN Distribution a) Preventing data corruption in served areas (village registers often miss out/over register residents); stepping up BCC could be of help but usually not 86

111 given sufficient resources (funds &time). Focus should be towards promoting universal coverage distributions to minimize data inflation. b) Sustaining a vibrant commercial market as the main stay of LLINs program for sustainability; support in form of commercial subsidies extended to major importers and distributor helped to strengthen this sector but this stopped with the closure of NetMark and AFFORD. There is need for partner support towards the commercial sector as the main stay of LLINs beyond free distributions. c) Increasing correct use of LLINs proportionally with the apparent increasing ownership; the UMIS conducted November 2009 still shows almost 50% gap from the targeted 80% usage. There should be deliberate effort to narrow this gap in order to realize the full net gains. (v) Indoor Residual Spraying a. Sustainability of IRS: Currently, IRS is largely donor dependent b. Development and spread of insecticide resistance to public health insecticides in Uganda c. Wide distribution of LLINs without knowledge of Pyrethroid resistance patterns in the country because of absence of sustainable M & E due to inadequate funds d. Implementing IRS in diverse cultures, political orientation and social beliefs e. High cost of transportation of spray operators (SOs) (vi) Finances a. Lack of funding for support supervision country wide which has also contributed to the non-functionality of Zonal Malaria Coordinators (vii) Reporting a. Late and incomplete services data submission through HMIS system. b. The delays in the release of HSSP III and HMIS reviewed documents have led implementation of HMIS strengthening activities to be postponed. Recommendations i) Human Resource: The Ministry of Health should work closely with the Ministry of Public service to accelerate release of the revised staffing norms so that adequate staff can be recruited. There is also need to review working conditions within districts so that staff can be attracted to stay and work within the Districts. The staffing levels within the NMCP also need to be reviewed in line with the current workload and importance of the burden of Malaria ii) Medicines and diagnostic supplies: There is need to improve effectiveness of NMS and NMCP in communicating and coordinating procurement and distribution of ACTs and other supplies to districts and health facilities as well as improve the strength of the linkages between the two organizations to improve systems for ensuring a reliable supply of ACTs to the health facilities country wide. Regular supply of drugs (Fansidar) will improve the uptake of IPT1 and IPT2 since since more pregnant women will be able to access the drugs. 87

112 iii) Global Fund Round 7 LLIN distribution through CSOs a) More time should be allocated to training the CSOs on logistics and finance management (a full day in the training should be dedicated to this) b) To address the variances often seen between UBOS population estimates and actual population data, where funds and time allow, the registration exercise should take place several weeks ahead of the distribution in order for micro-planning activities to be based on actual population numbers. There should be ample time allowed from the end of the registration exercise to the onset of the actual distribution to allow for actual planning and preparation based on reliable information. c) Ample time should given be given (not less than 3 weeks) to have all materials procured, packed and labelled before distribution. d) The training should be split into two phases; one to focus on the registration just before the registration exercise and the second on distribution process. e) The hang up form should be simplified to be better understood by the VHTs. The purpose of the exercise also needs to be clarified in the Training Manual. f) An evaluation of the social and mobilization activities, pre, during the post distribution, is recommended. g) During the CSO training, the different parts of the report and the information required in each should receive additional emphasis in order to have timely and completion of reports. iv) For Round 4 Phase 2 implementation to improve to a level that can redeem the grant, there is need to improve on the bureaucratic procedures within the Ministry of Health and those concerning procurement of the necessary supplies and services. v) Regular provision funding for country wide support supervision as well as analysis, dissemination, feedback and use of data collected from this exercise will go a long way in proving delivery of Malaria Control and Prevention services. vi) GOU and partners should increase funding for IRS in order to expand IRS coverage in the country especially in the highly malaria endemic areas in order to drastically cut down malaria transmission thereby contributing to its elimination the country. vii)the country should consider Implementing Integrated Vector Management (IVM) approach (i.e. use of IRS, LLINs, Larviciding, Environmental Management Control Measures). viii) There is need for efforts to strengthen systems for reporting through dissemination of the revised HMIS, and cascade countrywide training on supervision, monitoring and evaluation while taking into account the mechanisms to address weaknesses afflicting the reporting systems currently. 88

113 3.3.4 Veterinary Public Health The mission of the Veterinary Public Health (VPH) unit is to reduce the burden of zoonotic diseases and animal related food borne infections to a level where they are no longer of significant public health importance in the country. A number of diseases that have emerged and/or re-emerged globally in the last 15 years have been zoonotic (i.e. of animal origin ); for example; Avian influenza/ Bird flu, Rift Valley fever, Severe Acute Respiratory Syndrome (SARS), Mad Cow Disease /Bovine Spongiform Encephalopathy), Viral heamorrhagic fevers, (Ebola and Marburg fever). The country is also burdened by new pandemic threats such as Influenza HINI as well as long established zoonotic diseases like rabies, bovine tuberculosis, plague, brucellosis, anthrax, meat borne parasitic diseases (cysticercosis and hydatidosis). All these zoonotic and emerging diseases cause significant morbidity and mortality and are therefore of major public health concern in Uganda. The VPH Unit contributes to the overall mission of the health sector through prevention and mitigation of the impact of these zoonotic diseases thereby improving the health and well being of the Ugandan population. 2. Progress on implementation of interventions Planned in HSSP II In FY 2009/10 Ug.shs. 175 million were secured for procurement of human rabies vaccine through the National Medical Stores for post-exposure prophylaxis to rabies suspects in the country. Reduction of the burden of emerging and zoonotic diseases was undertaken through a number of strategies, such as developing guidelines, training, public awareness and implementation of prevention and control for a number of zoonotic diseases such as: Rabies: This was achieved through the Urban Rabies Control Initiatives (URCI) conducted in two Kampala City Council divisions and organizing activities for the World Rabies Day globally commemorated on 28 th September annually. Pandemic influenza type A H1N1: Public awareness campaigns were coordinated and implemented throughout the outbreak of the disease in the country (July 2009 to January 2010). Brucellosis: The VPH unit in collaboration with Central Public Health laboratory (CPHL) conducted assessment of laboratory diagnostic protocols for brucellosis in Masaka Regional Referral Hospital, Kitovu Hospital and Villa Maria Hospital in Masaka district. 89

114 Table 3.22: Veterinary Public Health key outputs FY 2009/10 HSSP 11 target/ indicators 2004/ / / / / /10 Data Source Number of human rabies vaccine vials procured 11,846 13,000 9,600 1,500 4,048 8,750 VPH reports Number of suspected cases given rabies post-exposure treatment 2,962 3,750 2, ,012 1,325 Rabies postexposure treatment reports Reporting of cases of zoonotic diseases Weekly IDSR reporting. Quarterly performance reports VPH Unit Technical Support supervision to districts VPH reports Major challenges There is gross understaffing within the department and there is urgent need to recruit of more professionals. There is a twofold under funding for the purchase of human rabies vaccine. Recommendations Increase staffing of the VPH Unit during the process of restructuring the Ministry. The National Medical Store should allocate more funds for human rabies vaccine Diseases targeted for elimination Uganda Guinea worm eradication programme Dracunculiasis is one of the diseases targeted for eradication nationally and globally. Uganda achieved this goal and the country was certified free of dracunculiasis in 2009 by the World Health Organization. However, the country still faces a challenge of cross-border importation of guinea worm cases from Southern Sudan, the only neighboring country still endemic for the disease. 90

115 Achievements The following were the main achievements of the programme during the FY 2009/10. i) No cases of guinea worm (indigenous or imported) reported during the financial year. ii) Guinea worm surveillance was fully integrated into HMIS and IDSR. Active surveillance conducted in 74 at risk villages in the 15 districts bordering Sudan iii) Technical support supervision conducted in all formerly endemic districts. iv) NCC had all scheduled meetings and field visits to the formerly endemic districts. v) All reported rumors of suspected cases were investigated and all proved to be false cases. vi) Inter-district coordination meeting held in Lira. vii)mapping of populations at risk of importation of the disease from S.Sudan achieved. viii) Printing of reward posters and post cards to assist in advocacy and social mobilization of communities about the disease. The specific indicators set during the HSSP II were all achieved as shown in the table below. Table 3.23 : Achievements of the Guinea worm eradication programme Indicator 2004/05 baseline 2005/ / / / /10 No transmission Achieved Achieved Achieved Achieved Achieved Achieved 100% containment of imported cases Achieved Achieved Achieved Achieved Achieved Achieved Challenges The following challenges have continued to affect the operations of the programme:- Way forward. (i) Threat of cross-border importation from the Southern Sudan (ii) Dwindling resources to UGWEP at this stage of post certification. (iii) Lack of maintenance of boreholes in some of the formerly endemic villages. During the FY 2010/11, the programme will consolidate post certification interventions to check potential threat of imported cases from Southern Sudan. The main focus will be on the crossborder collaboration with S.Sudan; rumour registry and investigation; strengthen the capacity of village health teams for community based surveillance and case search for any rumours in all formerly endemic districts; support supervision & monitoring at all levels; advocacy & community mobilization; maintain cash reward system to ensure vigilance and lobbying for more safe sources of drinking water supply. Conclusion The programme will continue to submit the monthly data on guinea worm to the World Health Organization as required until global eradication of the disease has been achieved. 91

116 Leprosy control programme The objective of the programme during the HSSP II was to further reduce the leprosy elimination status to less than 1 case for every 10,000 population and to reduce the rate of grade 2 disability among the newly diagnosed cases to less than five (5%). During the HSSP II period, prevalence rate was further reduced from 0.16 in 2006/07 to 0.13/10,000 populations in 2009/10. It would have been even lower if all patients who completed the treatment schedules had been released from treatment and removed from treatment registers. The proportion of new cases with grade 2 disabilities has almost doubled when compared to 2005/06, which is reflection of a delay in case detection. This may be attributed to lack of awareness among the population and lack of knowledge as well as appropriate skills among health workers to recognize and manage leprosy cases. Figure 3.9:The distribution of new Leprosy cases and highlighting the Leprosy hot spots in red Yumbe 17 Moyo 8 Sudan Kitgum 21 NTLP UGANDA New leprosy cases detected during 2009 Total number = 346 Democratic Republic of Congo Lake Edward Rukungiri 2 Kanungu 1 Kisoro Rwanda Bundibugyo 4 Kabarole 1 Kasese 5 Bushenyi 0 Ntungamo 0 Kabale 0 Lake Albert Kyenjojo 0 Kamwenge 0 Mbarara 1 Arua 35 Nebbi 2 Hoima 6 Kibaale 0 Sembabule 0 Rakai 1 Adjumani 4 Masindi 11 Kiboga 0 Mubende 1 Masaka 0 Gulu Moroto 12 Mpigi 2 Tanzania Apac 34 Nakasongola 4 Luwero 2 Wakiso 0 Kampala 11 Pader Lira 40 Kaberamaido 2 Soroti 5 Kalangala 2 Lake Victoria Katakwi 0 Kotido 4 Kumi 20 Kamuli 2 Pallisa 4 2 Mbale Iganga Kayunga Tororo Jinja 0 Bugiri Mukono Mayuge 1 Busia Source: NTLP/GLRA Ministry of Health May 2010 Nakapiripirit 0 Kapchorwa 0 Sironko Kenya n = number of new leprosy cases No new cases 1 to 9 10 to and above Some districts have cases attributed to new (smaller) districts curved out of them 92

117 Table 3.24: Progress of Leprosy case notification over the HSSP II period YEAR Pauci Bacillary (PB) Multi Bacillary (MB) ALL New Cases Case detection Rate 2004/ / / / / / Source: NTLP Quarterly Leprosy Surveillance reports 2004 / /10. The absolute numbers of newly notified leprosy cases decreased from 552 in 2005/06 to 346 in 2009/10. Case detection rate was reduced to almost a half, from 2.1 to 1.15/100,000 population over the same period. Given the concurrent upward trend of disabilities among new cases, this may be more a reflection of actual failure to detect cases than an indicator of diminishing leprosy incidence. This is reflection of a delay in case detection which may be attributed to lack of awareness among the population and lack of knowledge as well as appropriate skills among health workers to recognize leprosy cases. Progress Following attainment of the Leprosy Elimination target in 2004, there was no more need to conduct leprosy elimination campaigns. Instead World Leprosy Day was commemorated at 4 different sites in the country for purposes of sensitizing the general population on the continuing existence of yet untreated leprosy cases and the availability of free effective anti-leprosy treatment. The occasions also served to lobby civic leaders to allocate resources to leprosy control. Activities for intensified case finding were planned for 6 but implemented in only 2 districts. The yield of new cases was extremely low but during the exercise the health facility staff in the selected sites was re-trained in suspecting, diagnosis and management of leprosy cases. Greater emphasis was shifted to Contact surveillance over the HSSP II period. The emphasis on contact tracing has been sustained, by issuing guidelines and modified reporting forms to emphasize the importance of this activity. Implementation has been done mostly by requesting patients and those accompanying them to screen their own families and to encourage those with suspect symptoms to attend the nearest health facility for screening. Between 2007/08 to 2009/10, about 2% of contacts screened turned out to be leprosy cases, representing about 9% of all new cases notified in the same period. Contact tracing is only next to examination of general suspects as an approach for case finding. Systematic examination of school children is no longer recommended as a case finding strategy except in a relatively high burden situation. However, leprosy should remain an integral part of school health services. 93

118 In 2009/10, School surveys were conducted in the seven districts of Sironko, Kaabong, Kotido, Adjumani, Amuru, Kitgum and Oyam covering a total of 4778 children. There were seven(7) leprosy cases were identified, 6 of them from Kitgum and Oyam. A higher number of cases (18) were identified when the surveys covered more children in 2008/09 (11, 417). Overall less than 1% of screened children had leprosy. In the final year of HSSP II, training of health workers in diagnosis, referral and treatment of leprosy cases was as follows: 1 Zonal Supervisor attended an international leprosy course in Addis Ababa, Ethiopia. 23 newly designated District Supervisors attended the basic 4 weeks course for District TB/Leprosy Supervisors (DTLSs). 118 general health workers attended inservice training programmes on different aspects of leprosy control. 837 pre-service trainees (528 nursing students) attended short orientation courses in leprosy. The coverage was higher than planned for the year. The referral system used for leprosy control currently is not yet well integrated into the general health services referral system. Case finding activities are integrated into the PHC system, supported with dedicated focal persons at District and Zonal levels. Leprosy suspects from most health units are referred to the District Supervisor (DTLS) to ascertain the diagnosis and start treatment. Difficult cases are referred to the Zonal Supervisor or to one of the leprosy referral facilities. All Leprosy referral facilities are Faith Based NGO except Lira Regional Referral Hospital. Monitoring is done through data collection using Health Unit Leprosy Registers, and District Registers as well as Quarterly Reports on Leprosy Control compiled by all districts and used at NTLP Central Unit to compile national data. Treatment (MDT) was provided to 775 patients (346 of whom were diagnosed during 2009/10). There are reports of 392 admissions for management of leprosy related complications (18% for leprosy reactions, and 36% for management of ulcers) About 1,400 pairs of protective footwear were manufactured and distributed to people living with insensitive feet due to leprosy; this covered about 50% of the estimated needs. A format for collecting information about people with rehabilitation needs after leprosy treatment has been further disseminated to cover all districts in the country. Ministry of Gender Labour and Social Development has already developed and is implementing Community Based Rehabilitation (CBR) programmes at Sub-County level for Persons with Disabilities (PWDs). The NTLP Rehabilitation Advisory Committee (RAC) is developing a strategy for linking the people with disabilities due to leprosy to the existing and functional CBR programmes in the various districts. Major challenges i) There is evidence pointing to an increase in the proportion of newly detected leprosy cases found with already established visible (grade 2) disabilities at the time of detection. This is related to late detection as a consequence of lack of awareness in the general population and of knowledge and relevant skills among health workers. ii) Anecdotal evidence suggests that there is a large number of leprosy patients that develop new grade 2 disabilities in the course of treatment; this is a reflection of poor quality care in terms of identifying and providing appropriate management for high risk sub-groups of known leprosy patients e.g. Only 50% of the needs for protective footwear for people 94

119 with insensitive feet were addressed during the final year of this period. Such patients have a high risk of developing foot ulcers. iii) Inadequate funding for advocacy, communication and social mobilization activities as well as other of interventions for prevention and management of leprosy related disabilities. iv) Diminishing skills and capacity for leprosy case management among general health workers v) A special referral system for leprosy seems to operate alongside the normal health services referral system in the country. Such a parallel system is bound to have limited coverage and is not sustainable. vi) Very few Sub-Counties have functional CBR programmes that have integrated persons with disability due to leprosy. Recommendations i) Mobilization for more resources to operationalise the proposed and planned activities detailed below. ii) Provide for measures for advocacy and social mobilization to improve public awareness of the signs and symptoms of leprosy iii) Provide for measures to improve the knowledge and skills of staff in the general health facilities as well as those providing referral services iv) All districts should include contact surveillance as a core case finding activity. This is particularly important in more low prevalence situations where other methods are less likely to lead to early detection of new cases Onchocerchiasis Onchocerciasis is endemic in 37 districts where an estimated 3 million people are at risk of contracting it and over 2 million people are on treatment with ivermectin. The disease which is transmitted from one person to the next through the bite of a female black fly, causes chronic skin lesions, troublesome itching and sometimes blindness.. Onchocerciasis Control Programme is mandated to reduce the burden of onchocerciasis in the country to levels where it is no longer a disease of public health importance. The major strategy of reducing the burden of onchocerciasis is annual or biannual mass administration of ivermectin and vector elimination in isolated foci. In some districts the programme aims at eradicating the disease. In these districts ivermectin is given twice a year. Vector elimination interventions are also implemented in foci where the transmitting vectors breed. The specific targets as set in HSSP 11 (2006/2006) (2009/2010) were therapeutic coverage (over 70%), geographic coverage (100%) and integrated work plan in 90% of the districts endemic with onchocerciasis 95

120 Table 3.25: Achievements of the Onchocerciasis control programme from 2005 to 2010 Indicator Geographic coverage 100% 100% 100% 100% 100% * Therapeutic coverage 78% 80% 79% 81% 78% * Integrated plans 10% 30% 60% 80% 90% * NB * Treatment for this year is ongoing in some districts and the data provided for therapeutic coverage and integrated plans is an estimation since no comprehensive study has been done. The data on integrated is based on the old districts such as Bushenyi or Yumbe and excludes Kitgum and Pader. The decline in coverage is attributed to the low coverage in Koboko and Yumbe districts which registered 56% and 55% respectively which skewed the national coverage. Challenges i) Lack of district/government financial contribution. The programme is whole dependent on donors which makes sustainability difficult ii) Limited experienced manpower especially in the area of vector elimination. The few experienced staff are overworked. iii) Health workers are few and already burdened by clinical work which makes their participation in the community health interventions difficult iv) Gross understaffing at Onchocerciasis Control secretariat. Only two officers are on government payroll. All support staff and drivers are dependent on donors. Way forward The Ministry should expedite the process of recruiting staff for the secretariat Neglected Tropical Diseases Division The main role of the Division of Neglected Tropical Diseases (NTDs) during the period under review continued to be the prevention, control and /or elimination of the diseases which belong to the category of neglected tropical diseases. To ensure this, the Division deployed two major strategies, using the integrated approach, namely: i) Implementation of mass medicine administration (MMA) for the elimination of Lymphatic filariasis, control of schistosomiasis or bilharzia and soil transmitted helminths or Intestinal parasites. ii) Implementation of Intensified disease management for the control of sleeping sickness and Kala-azar. Generally, these diseases are parasitic and bacterial ancient infections that have been endemic in the country for centuries with hardly any attention paid to them as far as control is concerned. 96

121 The leading neglected tropical diseases in the country include: i) Lymphatic filariasis or elephantiasis which puts up to 15 million Ugandans at risk of infection. ii) Schistosomiasis (Bilharzia) which puts up to 16.7 million Ugandans at risk of infection. iii) Soil- transmitted helminths or intestinal parasites which put up to 22 million Ugandans at risk of infection. iv) Onchocerciasis or river blindness which puts up to 2.6 million Ugandans at risk of infection. v) Sleeping sickness or Human African Trypanosomiasis (HAT) which puts up to 10 million Ugandans at risk of Infection. vi) Trachoma which puts up to 7 million Ugandans at risk of infection vii) Leishmaniasis or Kala-azar which puts up to 0.5 million Ugandans at risk of infection. viii) Plague which puts up to 1 million Ugandans at risk of infection. ix) Buruli ulcer for which only one district, so far, is known to be endemic. However, this report covers only Lymphatic filariasis, Schistosomiasis and soil transmitted helminths and sleeping sickness. Onchocerciasis is covered under the Department of National Disease Control while trachoma is covered under the Disability and Rehabilitation section. On the other hand, this report does not cover plague, Leishmaniasis or Kala azar and Buruli ulcer because not much is being done about these diseases under the Ministry of Health currently. What is happening in the field of plague is mainly research based at the Uganda Virus Research Institute (UVRI). The same applies to Buruli ulcer whose research is based in the Pathology Department of the Makerere school of Medicine. Similarly, the main thing going on in the field of Kala-azar is research based at Amudat hospital under the funding of the Drugs for Neglected Disease Initiative (DNDi). However, the patients who are not included in the research studies receive routine treatment using drugs provided by DNDi. The drive to prevent, control and/or eliminate these diseases is a new realization arising from the far-reaching consequences that some of these diseases cause, e.g. i) Trachoma & river blindness are known for causing blindness. ii) Leprosy, Kala-azar, River blindness & Buruli ulcer are known for causing considerable disfigurement. iii) Lymphatic filariasis is known for causing a high degree of disability. iv) Sleeping sickness is known for causing a high degree of debilitation and eventual death if untreated. Furthermore, these diseases are associated with extreme poverty and illiteracy and the heat and humidity of our tropical setting. They affect, almost exclusively, poor and powerless people living in rural communities and are given little attention; hence, the term Neglected. The price of neglect, however, is very high because these diseases contribute, substantially, to disabilities, stigmatization and malnutrition in many communities. 97

122 In addition, they affect the physical and intellectual development and educational outcomes of children, fix intergenerational cycles of poverty, challenge food security and, above all, limit national economic growth. Fortunately, for five (Lymphatic filariasis, Schistosomiasis, Soil-transmitted helminths, trachoma and river blindness) of these diseases, there are now simple, effective and low- cost interventions available for their control and /or elimination. These interventions are largely based on what is referred to as preventive chemotherapy (PCT) using medicines which are donated, free of charge, through various initiatives and partnerships. Thus, this group of NTDs is said to be tool ready diseases as opposed to the tool deficient diseases which consist of sleeping sickness, buruli ulcer, Kala azar and plague. For this group of diseases, there is great need to improve the existing interventions and strategies and /or to develop new ones for their control. This report covers mainly the tool ready diseases whose interventions are provided as free donations through international initiatives and partnerships as already alluded to. Interventions against neglected tropical diseases are based on the following key principles: i) The right to health by everyone. ii) Existing health system as a setting for them. iii) A coordinated response by the health system. iv) Integration and equity v) Intensified control of diseases alongside pro-poor policies. Disease specific Progress Report Disease specific Progress Reports: Lymphatic filariasis, (LF) Lymphatic filariasis, also known as Elephantiasis, is transmitted by mosquitoes that bite infected humans and pick up the microfilarial that develop, inside the mosquito, into the infective stage in a process that usually takes 7-21 days. In its most obvious manifestations, the disease causes enlargement of the entire leg or arm, the genitals, vulva and breasts. The psychological and social stigma associated with these aspects of the disease are immense. The disease is associated with extreme poverty. According to the mapping that has been carried out, so far, the disease is endemic in 44 districts where a population of more than 15 million people are at risk of infection. During the period under review, two core interventions were supposed to be deployed, namely: i) Mass medicine administration using ivertmectin and albendazole for interruption of transmission of the disease. ii) Management morbidity and disability associated with the disease, namely hydrocoeles and lymphoedema or elephantiasis. 98

123 Progress Specific targets as stipulated in HSSPII: i) To achieve 90% therapeutic coverage of the affected people with single annual dose of ivermectin and albendazole. ii) Reduce morbidity and disability associated with the disease by 25%. Table 3.26: Therapeutic coverage for people affected by lymphatic filariasis HSSP II target/indicators 2004/ / / / / /10 Data Source No of IUs Comments Therapeutic coverage Management of morbidity and disability associated with LF % % 92.40% 93.40% 92.86% PELF data Bank No comprehensive programme has been initiated yet Coverage calculated using the eligible population as the denominator Indicator Progress Core interventions i) Mass medicine administration in all the endemic areas ii) Intensive public education and social mobilization Table 3.27: Performance according to set targets for elimination of lymphatic filariasis A: Coverage s HSSP II baseline FY 2004/ / / / /9 2009/10 Data Source 1. Target IUs Total population Eligible population 4. Treated population 5. Chemotherapeutic coverage (Total) 6. Chemotherapeutic % &0.9% 84.0% 74.2% % 88.6% % 92.8% 93.4% PELF Data Bank Comments 99

124 Indicator HSSP II baseline FY 2004/ / / / /9 2009/10 Data Source Comments coverage (Eligible) B: Adverse events Not Assessed: No results therefore C: Microfilaremia level 1. Obalanga 22.4% - 0.4% 2. Akumangor 1.7% 0.6% - 3. Alebtong 25.5% - 0.6% 4. Barr (a) Hydrocele D: Chronic manifestation rate 1. Obalanga 17.3% - 6.3% 2. Akumangor 8.2% 2.1% - 3. Alebtongor 28.7% - 4.7% 4. Barr (b) Limb Elephantiasis 1. Obalanga 3.7% - 0.3% PELF Data Bank PELF Data Bank Hydrocelectom y support receive from DANIDA 2. Akumangor 3.2% 0.2% - OHHRCA active 3. Alebtong 9.7% - 6.1% 4. Barr 1.7% 0.4% - E: Transmission No follow up Rate OHHRCA: Obalanga Health and Human rights Care Association, a voluntary group of people who have suffered from the disease before. Challenges: i) Operations of the programme are entirely dependent on donor funding. ii) Morbidity and disability management are yet to commence. Recommendation: The Government of Uganda in general and the Ministry of Health in particular should demonstrate ownership of this programme by making financial contribution towards it. Sleeping sickness: Sleeping sickness is caused by protozoan parasites, trypanosomes, which are transmitted by tsetse flies. The disease occurs in two forms: a chronic form caused by T.b gambiense which occurs in the North and North Western Uganda; and an acute form caused by T.b. rhodesiense 100

125 which occurs in south Eastern Uganda. The chronic infection lasts for years, whilst the acute disease may last for only week before deaths occurs if not treated. Currently, there are strong fears about a geographical overlap of these two forms of the diseases in the Teso/Lango regions. If this occurs, it is likely to cause problems of diagnosis, treatment and control of the disease. Under HSSPII the core interventions planned for implementation were as follows: i) Social mobilisation ii) Case detection and management including regular screening of communities iii) Drug distribution iv) Integrated vector management(ivm) v) Sleeping sickness surveillance and monitoring All these interventions were implemented except IVM. Specific targets i) Improving access to quality diagnostic facilities by 80%. ii) Improving access to quality treatment facilities by 80% iii) Community empowerment for sleeping sickness control increased to 100% of the communities in endemic districts. Improving access to quality diagnostic and treatment facilities has been met up to 80% and community empowerment for ownership of sleeping sickness control currently stands at 60%. Table 3.28: Performance to set targets for elimination of sleeping sickness HSSP II Target/Indicators Proportion of HAT patients detected in the early stage of infection. Proportion of HAT patients developing treatment related complications 2004/ / / / / /10 Comments Not done Not done 33% 28% 39% 35% 45% This proportion is slightly lower in the T,B gambiense focus Not available Not available Not available Not available Proportion of HAT patients relapsing after treatment Not done %0 4.3% 4.5% 1.5% 1.4% Proportion of HAT patients followed up after treatment Data source: Treatment centers Not done 42% 38% 40% 48% 52% Not available This was assessed for patients who received DFMO Follow up was assessed at least once 101

126 Major challenges i) Lack of ownership of the programme by the district local governments where the disease is endemic. ii) The likely overlap of the chronic and acute forms of the disease at some geographical point in the Lango/Teso regions. iii) Very high drug (melarsoprol) failure rates, particularly in the Omugo area, Arua district. iv) Human border (SouthernSudan, DRC Congo & Kenya) traffic v) Cattle movement & market promoting disease transmission vi) Inadequate operational funds vii)shortage of appropriately skilled manpower Recommendations i) Districts should be supported to own the programme ii) Efforts should be made to halt the overlap of the two forms of the disease. iii) More resources (Human and Financial) should be committed towards the programme. Schistosomiasis and soil- transmitted helminths control During HSSP II, the focus was on scaling up the interventions to reach the new populations at risk in addition to the re-treatment of previously treated populations both in the communities and schools. Targets: i) Expand preventive chemotherapy in all the endemic districts up to 100%. ii) Get all endemic districts to integrate the prevention and control of schistosomiasis and soil transmitted helminths within their district work plans. Mechanisms for scaling up; i) Develop district capacity and provide technical support for the management of the programme. ii) Ensure the availability of medicines and improve the efficiency of their distribution. iii) Promote the integrated approach for the distribution of medicines. iv) Involve the private sector. Core Interventions i) Social mobilization ii) Mass Medicine distribution both community and school based. iii) Advocacy for improved water supply and sanitation. iv) Empower communities and schools for the control of Schistosomiasis and soil transmitted helminths. 102

127 Progress i) 11.5 million School children and 3.5 million adults treated. ii) Reduced prevalence of schistosomiasis to less than 20% in 80 % of the endemic districts. Table 3.29: Performance according to selected indicators for Schisto/STH Control Indicators 2004/ / / / / /10 Comments District targeted for chemotherapy (schisto/sth) Percentage of schools in the programme % 29.4 Schisto is only in a few sub counties in endemic districts Drug coverage after chemotherapy Proportion of high prevalence of schisto/ STH infections Proportion of visible haematuria in the case of S. haematobium 88.00% 87.60% 84.80% Missing data % 43% 17% 12% Not yet computed N/A N/A N/A N/A N/A FY 07/08 has incomplete data set Treatment for FY 2008/09 is still under way Baseline surveys for mapping S. haematobium have not yet been done Overall proportion of children with any of the soil transmitted helminthes 78% 44.20% 21.70% 19.30% Not yet computed Evaluation for FY 2008/09 has not yet been done Schisto/STH, Prog/NTD records Challenges: i) Improvement of water supply and sanitation ii) Incentives for community medicine distributors iii) local funding Recommendations i) The Ministry of Health should liaise with the relevant sectors to improve water supply and sanitation in addition to Mass Medicine Administration (MMA). ii) Vector (snail) control should be deployed alongside MMA. iii) The Government of Uganda should start contributing funds towards the programme. 103

128 3.4 Non-communicable diseases/conditions cluster Uganda is experiencing dual epidemics of communicable and non communicable epidemics. Non communicable diseases such as diabetes mellitus, cardiovascular diseases, cancer and chronic respiratory diseases are on the increase in the developing countries and Uganda is no exception. This cluster includes challenges and achievements in following: Injuries, Disabilities and Rehabilitative health; Gender based Violence; Mental Health and Control of Substance Abuse; Integrated Essential Clinical Care; Oral Health and Palliative Care Prevention and control of non-communicable diseases Non communicable diseases (NCDs) particularly; cardiovascular diseases, diabetes, cancers, as well as chronic obstructive pulmonary diseases are becoming increasingly important as causes of morbidity and mortality in the Ugandan population. The Uganda Heart Institute records have demonstrated a 500% increase in outpatient attendance due to heart related conditions over the past 7 years ( ). The Uganda Cancer Institute has also reported an upward trend in cancer incidence over the past four years ( ), particularly among HIV infection related cancers. Regional referral hospitals have reported an increasing number of diabetes and chronic obstructive pulmonary disease patients either admitted in their medical wards or seen at their outpatients clinics. The increase in the incidence of chronic non communicable diseases is predicted to continue over the years fueled by the increasing exposure of our population to unhealthy lifestyles associated with urbanization. The WHO predicts that NCDs will reach epidemic proportions by the year 2025 if NCD preventive, control and surveillance measures are not undertaken immediately. The Non communicable disease programme was established during the 2006/07 Financial Year to the plan, implement and coordinate actions aimed at prevention and control of NCDs in Uganda. The mandate of the NCD prevention and control programme is to reduce the morbidity and mortality attributable to non-communicable diseases through appropriate health interventions targeting the entire population of Uganda. Achievements of the NCD programme over the HSSP II period are summarized in table Major Challenges i) There is no baseline data and information on NCDs and their risk factors in Uganda. This data and information is critical to the formulation of an evidence based National NCD policy and the development of comprehensive and integrated NCD interventions. The delay in completing the NCD survey due to insufficient funds is consequently delaying the formulation of an NCD policy and development of other NCD prevention and control interventions. 104

129 Table 3.30: Progress on implementation of interventions planned in HSSP II HSSP II Target Indicator HSSP II Baseline 2006/ / /10 FY 2004/5 Comments Obtain national baseline data No NCD Programme NCD Programme NCD Survey plan Listing of Enumeration Survey pre-test and data collection on NCD risk factors in the Uganda population established completed Areas completed delayed by lack of funds No baseline Planning for NCD Survey started NCD Stakeholders Plan for pretesting of Data collection planned for FY meetings held Survey tools and 2010/11 subject to release of funds. Equipment completed Resource started mobilization Survey tools produced. National NCD Policy, No baseline Technical team to NCD Survey results to guide policy standards and Guidelines formulate NCD policy formulation produced identified National Programme for NCD prevention and control in place No baseline Draft 0 produced Programme interventions to be guided by survey results Percentage of HC IVs with No baseline functional integrated NCD clinics increased by 30% Health facility audit plan Audit to be carried out as part of the completed NCD survey ii) Existing efforts against NCDs are facility based, poorly coordinated and supported iii) Insufficient drugs and high cost of medicines for NCD conditions at health facilities, particularly those at lower health care levels iv) Understaffed and under resourced NCD Prevention and Control Programme Recommendations i) Facilitate the NCD Programme to complete the planned National NCD Survey. ii) Conduct a rapid assessment of Health facilities at HC IV and above to establish the actual capacity to prevent and control NCDs. That will be the benchmark for setting realistic targets in improving the quality of NCD care. iii) Facilitate the completion of the Ministry of Health restructuring and support the NCD programme with adequate human and financial resources to enable it to carry out its mandate 105

130 3.4.2 Injuries disabilities and rehabilitative health Prevention of injuries, disabilities and rehabilitative health encompasses conditions that result in an individual s deprivation or loss of the needed competency The HSSP II period focused on integrating injury and disability prevention interventions with other programmes. The programme is coordinated by a section at the Ministry of Health in conjunction with an Injury control Unit in Mulago National Referral Hospital. The strategic objectives were to: i) strengthen and increase accessibility to rehabilitative health care services of PWDs in the districts for a better quality of life and ii) provide standards and guidelines to the districts for development and provision of quality rehabilitative services The progress towards attainment of the specific HSSP II targets is shown in table Table 3.31: Progress on implementation of intervention planned in HSSP II Indicator 2004/ / / / / /10 HSSP II Target Mass Distribution of Azithromycin and Tetracyclin to all Trachoma endemic districts (25 districts). * * * 7 (28%) 11 (44%) 12 (48%) 100% Integration of trachoma prevention and control measures in work-plans of endemic districts Increase by 30% access to and provision of surgical services to patients with trichiasis * * * * * * 25 * * * * * * 30% In order to chart progress toward the control and elimination of trachoma, prevalence studies were carried out in all 25 endemic districts. Data has been compiled and disseminated to the relevant districts and Development Partners who support Prevention of Blindness programme in the country. The Lions Club International supported a rehabilitative project of lid rotation in Busoga region that has one of the highest prevalence of trachoma. Reduction of visual and hearing impairment: i) ENT and Eye care Units were established in the districts of Kabale, Mbarara, Moroto, Soroti, Kitgum, Arua, Nebbi, Gulu and Lira so as to scale up the early detection and proper treatment of disorders of sight and hearing in order to minimize complications. This was in collaboration with LAN and SSI. ii) A communication strategy on hearing impairment has been developed and is in final stages. iii) Guidelines on prevention and management of Low Vision have been developed and are ready for dissemination. 106

131 Table 3.32: Summarizes the progress of other important milestones. Indicator 2004/ / / / / /10 HSSP II Target To reduce prevalence of hearing impairment - 10% 9.80% 9% 9% 8% 8% To reduce prevalence of visual impairment - 1% 0.90% 0.90% 0.80% 0.80% 0.80% Provision of assistive devices to PWDs who need them % 2% 3% 5% ICRC rehabilitation Fort Portal and Mbale orthopaedic workshops. To reach 80% of the population with messages on disability and rehabilitation. Conduct prevalence Trachoma prevalence studies in all endemic districts (25 districts) % 31% 51% NTDs promotes disability prevention in 57 districts. - 28% 44% 64% 80% 20 districts surveyed. 199% 7 districts 11 districts surveyed. 16 districts surveyed. all 25 districts have been surveyed. Strengthening of Regional orthopaedic workshop for production of assistive devices ( surveyed out of 6 (Arua, Gulu) 2 out of 6 3 out of 6 (ICRC (Arua, Gulu) rehabilitated Fort Portal in addition 4 out of 6 (ICRC rehabilitation Mbale workshop in addition) Early detection and proper treatment of disorders of sight and hearing in order to prevent complication in all Regional Referral Hospitals (11) 81% Nine Regional Referral Hospital have functional Eye and ENT Units. 81% Data collection on injuries and disabilities i) In collaboration with UBOS suggestions to have more specific items in the U.D.H.S field tools focusing on disability have been made. ii) The Section has developed a data collection/surveillance tool on Landmine survivors. iii) The Cataract Prevalence Survey conducted in Masaka district in 2008, provides highlights on the burden of the condition. Prevention of accidents and access to assistive devices i) In 2006, sensitization of the general population and school children about road traffic accidents was undertaken. This was during the United Nations Global Road Safety Campaign whose theme was Young Road Users. Black spots on some major highways were identified and marked. 107

132 ii) Four regional orthopaedic workshops were strengthened for production of assistive devices. Six orthopaedic technicians were trained in wheelchair technology at TATCOT in Tanzania and have been deployed in regional Referral Hospitals. A wheelchair provision project supported by MOTIVATION was inaugurated. In collaboration with UNDP Land Mine survivors in Oyam, Amuru, Pader and Lira districts have been provided with assistive devices. In partnership with ICRC orthopaedic workshops at Fort Portal and Mbale Regional Hospitals have been renovated and are in full production capacity. iii) Enhanced collaboration with the Social development Sector in respect to the Community Based rehabilitation (CBR) initiative mainly in support of Land Mine Survivors was carried out. iv) Dissemination of guidelines of handling of trauma, disabilities and rehabilitative care. In collaboration with WHO injury prevention and control policy has been developed and is in final stage. Rehabilitation and health care policy on disability was cleared by MOH top management meeting and is ready for forwarding to Cabinet. Challenges Provide the main challenges specifically related to why the set targets were not attained or the lack of progress during the HSSP II period. i) Understaffing at all levels. For example 3 of the Regional Referral Hospitals (Masaka, Lira and Fort Portal) cannot provide specialist eye care services because they don t have ophthalmologists. ii) Inadequate support to orthopaedic workshops. Although technicians are available at all the 6 orthopaedic workshops, raw materials for production of assistive devices are visually inadequate or not available at all. iii) Low priority accorded to disability at all levels. For example disability programmes are usually allocated the smallest budget support. iv) The challenge of coordinating many different stakeholders with varying interests still exists. Recommendations Increase budget allocation to activities targeting prevention of disabilities and rehabilitation services, e.g. if possible create a sub-programme for orthopedic workshop so that they have a separate budget from that of the hospitals where they are located Gender mainstreaming Gender mainstreaming in health is aimed at advocating against all forms of discriminations, such as sex, age, race etc. This includes physical, psychological injuries due to domestic violence, assault, rape, defilement, conflict situations as well as cultural practices including Female genital mutilation (FGM) Progress i) Sensitization of all regional Hospital and general district hospitals in GM ii) Manuals on GM where distributed in all Regional and general Hospitals 108

133 iii) Built up sectoral corroborations ( WHO, DANIDA, Law societies, Police ) e.t.c iv) Process for planning together is on-going. Challenges i) Gender is still considered to be all about sex, in terms of empowering women. ii) The few trained hospital staff can not cause the desired change in attitude and practice. iii) Weak GM Monitoring & Evaluation systems iv) The concept of gender was not universally understood and conceivable by health managers Recommendations i) Scale up GMs in all PNFPs and PFP health facilities ii) Sensitize CDOs on Health Gender Mainstreaming in all Hospitals iii) Setup a Database on GMS in all District iv) Plan to engender all National Health Indicators and vital documents v) HMIS to be reviewed to address Gender vi) Need to sensitize Parliamentarians on GM for advocacy vii)cpds on GMS to be conducted in all Hospitals viii) Most managers wish to have gender as a health indicator Mental Health, Management of Neurological Disorders and Control of Substance Abuse The programme has the mandate to implement interventions to address the high burden of mental health problems which contribute about 13% of the burden of disease. Uganda is experiencing a major challenge in addressing the high prevalence of epilepsy and other neurological disorders. Supervision reports indicate that about 75% of attendances at Mental health clinics have some form of neurological problem commonly Epilepsy, with cases of dementia on the increase especially among persons living with HIV/AIDS. The programme is scaling up interventions to prevent and manage substance abuse problems which have increased in all age groups resulting not only in addiction and increased crime but also deaths due consumption of unsafe and adulterated alcohol. Progress i) The Six Regional Mental Health units constructed in Masaka, Mbale, Lira, Mubende, Jinja and Moroto are now functional, although only one has resident Psychiatrist. ii) The Draft Mental Health Bill is ready for presentation to parliament. iii) The National Alcohol policy is ready for presentation to cabinet. iv) The draft Mental Health policy has been presented to the senior management committee of the MOH and is being reviewed. v) Drafting of Tobacco control policy, Tobacco Control Bill, Drug control master plan is on going. vi) Several Media programmes were held for educating the public on Mental Health, Epilepsy and substance abuse control. IEC materials were developed and disseminated on World Mental Health Day, World No Tobacco Day, National Epilepsy Advocacy Day and the UN Day against substance abuse and illicit trafficking. 109

134 vii)to build capacity for management of mental health, neurological and substance abuse problems, sensitization of District political leaders, District Health Management Teams and other relevant sectors was conducted and PHC workers trained in community Mental Health to cover all Districts in the Regional referral areas of Arua, Lira, Mubende, Mbarara, Gulu, Mbale, Masaka, Moroto, and Kampala. Training of Psychiatrists, Psychiatric Social workers and Psychiatric Clinical officers was supported by SHSSPP II. Most Districts have recruited Mental Health professionals for integration of Mental Health into PHC. Table 3.33 Progress on implementations planned in the HSSPII Indicator 2004/ / / / / /10 Comment Functional Mental Health units at regional referral hospitals Community Access to MH services Proportion of HCiv with Psychiatric Nurses or other MH staff Proportion of HCIV with MH plans Proportion of HCIVwith at least one antipsychotic, one antidepressant, and one antiepileptic medicine No baseline No baseline No baseline No baseline 50% 10% 100% 100% 100% 4 out of the 13 have resident Psychiatrists. There is need to provide posts for Clinical Psychologists, Social Workers and more nurses for full functionality 20% 50% 60% 65% 75% Access to H services has extended to most health center IVs and some HC III and II following in service training by the program 30 No data 70% 60% 75% Most HCIV recruited MH nurses but some deployed to do other duties All HCIV have plans but MH generally under funded 10% 30% 30% 50% 800% MH medicines are not adequate to meet the demand created by the program. NMS not providing a full range of medicines on the EML 110

135 Major Challenges i) Inadequate staffing at Regional Mental Health units ii) Inadequate resource allocation to address mandates of Mental Health, Neurological Disorders and Alcohol and drug abuse at central programme level and District level iii) Inadequate supply of MH medicines by NMS. iv) No budget for food for unaccompanied patients admitted at Regional referral MH units who are brought by police. v) The basic medicines kit for HCIII and HCII does not have MH and anti epilepsy medicines thus disrupting the service already established at those levels. Recommendations i) Restructuring should address the staffing needs for MH at the central and Health facility level especially Regional MH units to provide adequate staff and multidisciplinary teams. ii) Increase funds allocated to the programme address the mandates. iii) The Ministry should put in place a mechanism for bulk purchase of MH and Anti epilepsy medicines by NMS. iv) Hospitals need to budget for food for MH patients with no attendants. v) Ensure that all regional referral hospitals have Psychiatrists. vi) Review the basic medicine kit to include the MH and anti epilepsy medicines according the EML 111

136 3.4.5 Integrated Essential Clinical Care Hospital Services Essential clinical care is one of the key elements of the minimum package and indeed a major purpose of any health system. Hospitals remain to be the main contributors of essential clinical care. In the public eyes, hospitals provide the face of the health system for which a rough assessment of the health system is made. The number of hospitals providing essential clinical care in Uganda has continued to grow in the recent years. The recent growth has been mainly from the private sector and institutional hospitals. It is noteworthy that the definition of a hospital as in the Hospital Policy is not yet adhered to in accepting or classifying health units as hospitals. According to this policy, a hospital is A registered health care facility, public or private organization for profit or not, devoted to providing curative, preventive, promotive and rehabilitative care, through outpatient, inpatient, and community health services. It should have at least 60 beds, a high level of skilled medical personnel including doctors, and be able to carry out major surgery and advanced investigative procedures including X-ray. The table below shows the distribution of these hospitals. Table 3.34: Hospitals in Uganda 2009/2010 National Referral Beds Regional Referral Beds General Beds Total Beds Public 2 2, , , ,288 PNFP 51 8, ,013 PHP Institutional 9 1, ,005 Total 2 2, , , ,151 The number of PHP beds worked out from the average 13 of the 15 hospitals the number of Institutional beds worked out from the average of 7 of the 9 hospitals Hospitals continue to be major contributors to the outputs of inpatient, outpatient and preventive care. In this report we capture this contribution and analyze the performance of hospitals in that context. The specific contribution of Private Not for Profit (UCMB, UPMB, and UMMB) hospitals will also be highlighted. Reports for the year 2009/2010 have been received from 69 general hospitals, 12 regional referral hospitals and from 3 large Private Not for Profit hospitals (PNFP) that will be analyzed in the regional referral hospitals set. The information requested was what is routinely reported in the HMIS forms especially HMIS form 107 in order to reinforce proper reporting and use of HMIS information at hospital level. This is the sixth annual report where there has been effort to analyze the functioning of hospitals. This analysis largely looks at outputs of hospitals and relates to inputs and to outcomes including quality. In order to have uniform comparison of outputs of hospitals we will continue to use the 112

137 Standard Unit of Output (SUO). 24 The SUO is a composite measure of outputs that can allow fair comparison of volumes of output of hospitals that have varying capacities in providing the different types of patient care services. Basic efficiency indicators for resource use will be generated and tables comparing hospitals will be generated. I). General Hospitals According to the records there are 113 General hospitals, however only 69 general hospital reports were received for this annual report exercise a number of which were incomplete. 1) Inputs a) Finance Of the 69 general hospitals whose reports were received, only 54 had financial reporting. The absence of expenditure on human resource for health for public general hospitals continues to make meaningful interpretation of these results difficult when we know that 50-70% of the total cost of running hospitals is human resource cost. The 54 hospitals received a total of Ush. 29,175,186,304 and spent 97% of that amount to provide the service. There is a very wide dispersion in expenditure about the mean of million shillings ranging from 12 million to 3 billion. b) Human resource A big shortage of health personnel still exists. Overall only 62% of the positions in the 42 general hospitals were filled compared to 61% in 2007/08, for medical staff positions (medical officer, dental, pharmacy, qualified nursing and allied health staff) only 55% are filled. Of all the cadres nursing staff have the largest gap in absolute numbers (-3,380) while pharmacy staff have the lowest percentage of positions filled at 44%. Too many nursing positions are filled by nursing aides especially in private hospitals as a coping mechanism to cut costs while keeping the service going. The effect of this on quality of care is not proven but is expected. c) Drugs and medical supplies Availability of medicines and supplies are a key aspect of hospital quality of care. This item is the second highest expenditure after human resource. The analysis of this is made and reported in the medicines section of this report. 2) Outputs Although hospitals are multiproduct firms, only some (considered important) of the outputs were collected and analyzed. Table 3.35 below shows selected outputs from General Hospitals. 24 SUO stands for standard unit of output an output measure converting all outputs in to outpatient equivalents. SUO total = Σ(IP*15 + OP*1 + Del.*5 + Imm.*0.2 + ANC/MCH/FP*0.5) based on earlier work of cost comparisons. 113

138 Table 3.35:. Staffing positions in general hospitals Med. Doctor Dental Pharmacy Nursing Allied Health Admin staff Support Medical Staff Total staff LG Staffing Norms Total in Post 63 hospitals Average per hospital Min Maximum Expected total Staff Gap for 63 hospitals % in post 2009/10 59% 48% 46% 54% 59% 68% 152% 55% 62% % in post 2008/09 % in post 2007/08 58% 52% 44% 59% 61% 52% 61% % in post 2006/07 83% 63% 58% 67% 86% 67% Medical staff only excludes nursing assistants, admin staff and support staff Table 3.36: Outputs from the General Hospitals FY 2009/10 Beds In patients Inpatient days Out patients Deliveries Major operations ANC Cesarean Section Immunizat ion SUO Total 9, ,074 2,555,647 2,929,399 96,517 37, ,608 20, ,358 12,335,613 Average 2009/ ,472 38,722 42,455 1, , , ,777 Minimum ,600 2, ,140 Maximum , , ,907 4,238 2,056 13,532 1,116 42, ,980 Average 2008/09 Average 2007/ ,271 32,197 1, ,197 1,063 13, , ,194 33,185 1, , , ,348 Data from 69 hospitals Source: Hospital submissions for AHSPR 2009/10. Note that figures for previous years are from Resource centre As indicated in table 3.36 hospital outputs have been measured in composite units the SUO. With this measure we can compare the volume of output or activity basing on 5 main indicators outpatients, inpatients, deliveries, immunizations and Antenatal/Family planning/mch. The top ten hospitals with the highest outputs are: Iganga, Busolwe, Mityana, St. Joseph Kitgum, Dr. Ambrosoli Kalongo, Kitgum Government, Kitovu, Kawolo, Kagadi and Tororo government. 114

139 Eight of these (underlined) have kept this group since last year 2008/09. Details can be seen in Annex II. Although the core hospital outputs like admissions, outpatients and deliveries have increased compared to last year, there has been a reduction in average Standard Units of Outputs due to a very high reduction in antenatal and immunization outputs which may be an indicator of improving utilization of these services in the lower level units. Some hospitals are still not able to major operations including cesarean section!! The clinical department should work with the relevant districts to address the causes of this. a) Efficiency of use of services Compared to last year (2008/09) there has been some improvement in hospital efficiency indicators however the dispersion is great, most of the indicators being propped up by extra busy hospitals. It has not been possible to analyze efficiency for use of funds because of lack complete or reliable financial reports. This year, the average hospital had the following indicators compared to the previous year in brackets: Average length of stay of 4.6 (4.9) days; bed occupancy rate of 80% (66%); one staff on average was producing 1,487 (1,260) units of output. This year the average hospital had 142 beds, 8,472 admissions and had 120 staff. We can infer that for 2009/10 there was improvement of efficiency with hospital admitting more, reducing the average length of stay getting higher bed occupancy rate and SUO per staff compared to the year before. The table 3.37 elaborates this. Table 3.37: Selected Efficiency Parameters 2009/10 Total Number of Beds Total Admissions Average Length Of Stay Bed Occupancy Rate Total Staff SUO/Staff Total 9, ,074 8,056 Average 2009/ , % 120 1,487 Min Max , ,829 Average 2008/ , % 120 1,260 Source: Hospital submissions for AHSPR 2009/10. Quality and overall performance Previous analysis of quality of care has been based on still birth rate, maternal death rate, qualified staff per bed and cesarean section rate. However there was not sufficient information to make a comprehensive and comparative analysis to the previous years. It is however important to 115

140 note that a very high number of maternal death continues to occur in our hospitals, 9 maternal deaths occur in each hospital on average and 648 maternal deaths were reported by the 69 hospitals. One outlier Bugiri hospital with 105 maternal deaths needs to be investigated. II) Regional Referral Hospitals There are 13 regional referral hospitals in the country, but for the annual reporting exercise 4 large PNFP hospitals (Nsambya, Rubaga, Mengo, and Lacor) with the scale and scope of regional referral hospitals are included in the group. The full set should then be 17 hospitals. Reports were received from 15 out of the 17 hospitals some of them incomplete. a) Inputs i) Finance Only 8 hospitals had complete financial reports for a good analysis. From this set a total of Ush 30,302,038,665 was received and 30,656,894,055 was spent 101% absorption capacity. The average expenditure for a regional referral hospital is 3,832,111,757. ii) Human resource The total number of staff in the 14 hospitals that provided staff information was 3,345 on average the number of staff per hospital is 239 but with a wide range from 125 to 373. Seventy two per cent of the total staff are medical staff (medical doctors, dental, pharmacy, nursing - excluding nursing aides and assistants and allied health). Table 3.38: Staff in 14 Regional Referral and large PNFP hospitals Doctors Dental Pharmacy Nursing Allied Health Admin staff Support Medical Staff Total staff Total Average 2009/ Min Maximum Source: Hospital submissions for AHSPR 2009/10. iii) Drugs and medical supplies This information is analyzed and reported under the medicines and supplies section of the annual report. b) Outputs The outputs of the 13 regional referral hospitals and 3 large PNFP hospitals have been analyzed here below. The hospitals attended to 349,698 inpatients, 1,761,150 outpatients and 68,024 deliveries among other outputs. On average each hospital attends to 21,856 inpatients, 117,410 outpatients. A comparison of volume of outputs based on the SUO has been made and is shown in figure 3.10 below. The average SUO per hospital is 468,

141 Figure 3.10: Volume of outputs for Regional Referral and large PNFP Hospitals Details of the rest of the outputs are shown in the table 3.39 below. Table 3.39: Outputs of Regional Referral and Large PNFP hospitals Hospital Name Total OPD attendances Total ANC Deliveries in Unit Total Immunization Total Family Planning No. started ART Beds Admissions Patient Days Major Operations SUO Lira 121,816 6,886 3,414 16,832 3, , , ,794 St Raphael Nsambya 159,424 25,509 7,561 48, ,785 88,111 3, ,397 Mbarara 180,450 6,246 7,459 27,724 1, , ,050 3, ,671 Soroti 90,915 11,134 4,368 31,491 1, ,955 96,902 2, ,879 Mubende 34,258 4,820 2,049 9, ,608 49,650 1, ,391 Mbale 97,947 8,858 7,036 17,343 4, , ,436 1,678 1,045,578 Hoima 98,786 9,484 3,685 21,481 1, ,416 85,678 1, ,388 Rubaga 174,938 13,032 7,420 49, ,925 69,147 2, ,674 St.Mary'sLa cor 171,288 7,501 3,387 21, , ,161 3, ,437 Gulu 125,423 6,225 3,874 9,149 1, ,755 84, ,975 Moroto 34,801 1, , ,261 49, ,945 Jinja 90,707 12,847 4,986 9,912 2, , , ,952 Arua 82,082 11,168 4,824 20,187 6,245 1, , ,978 1, ,526 Masaka , , ,115 Kabale 49,493 8,918 3,312 6,378 6, ,781 76,407 2, ,936 Fortportal 248,822 11,431 4,226 21,792 1, , ,692 1, ,377 Total 1,761, ,032 68, ,563 34,335 5,329 5, ,698 1,708,873 27,796 7,500,

142 Average Hospital for all Name Hospitals Total OPD attendances Total ANC Deliveries in Unit Total Immunization Total Family Planning Average 2009/10 117,410 9,735 4,535 21,038 2, , ,805 1, ,752 Min 34,258 1, , ,261 49, ,945 Max 248,822 25,509 7,561 49,340 6,867 1, , ,161 3,456 1,045,578 Average 2008/09 96,231 12,197 4,662 27, , ,848 Average 2007/08 136,446 14,329 4, ,559 3, ,348 Average 2006/07 121,038 12,772 4, , ,804 No. started ART Source: Hospital submissions for AHSPR 2009/10. And Resource Centre Beds Admissions Patient Days Major Operations SUO Compared to the year before, there has been improvement in the following outputs: Outpatient attendance, admissions and major operations including the overall standard units of output. c) Quality assessment Previous analysis of quality of care has been based on still birth rate, maternal death rate, qualified staff per bed and cesarean section rate. However there was not sufficient information to make a comprehensive and comparative analysis to the previous years. It is important to note that a very high number of maternal deaths continue to occur in these hospitals, 37 maternal deaths occur in each hospital on average and 559 maternal deaths were reported by 15 hospitals. Hoima hospital is an outlier contributing 285 maternal deaths in the year. There is need to investigate this and address the reasons for this high death. d) Efficiency of use of services Regarding the scale of operation the mean hospital in this group is 320 beds, admits 21,856 patients and has a staff of 239. Generally the regional referral and the PNFP hospitals analyzed here have a high rate of utilization Average bed occupancy is 91% compared to last year (2008/09) when it was 79%. In 2009/10 Staff productivity was 1,599 SUO/Staff greater than that for general hospitals (1,487). This is due to the very high utilization of regional referral hospitals. The average length of stay of 5 days is marginally higher than in the general hospitals (4.6) attributed to the case mix of patients in referral hospitals. 118

143 Table 3.40: Efficiency parameters of Regional Referral Hospitals and large PNFP hospitals Hospital Name Beds Total Admissions Average Length Of Stay Bed Occupancy Rate % SUO SUO/ Staff Lira , ,794 1,360 St Raphael Nsambya , ,397 1,299 Mbarara , ,671 Soroti , ,879 2,382 Mubende , ,391 1,521 Mbale , ,045,578 Hoima , ,388 1,253 Rubaga , ,674 1,740 St.Mary's Lacor , ,437 1,528 Gulu , ,975 1,490 Moroto 149 9, ,945 1,534 Jinja , ,952 1,198 Arua , ,526 1,303 Masaka , ,115 Kabale , , Fortportal , ,377 Total 5, ,698 7,500,036 2,133 Average 2009/ , ,752 1,599 Min 120 9, ,945 1,534 Max , ,045,578 2,034 Average 2008/ , ,848 Average 2007/ , ,348 Average 2006/ , ,804 Source: Hospital submissions for AHSPR 2009/10. And Resource Centre National Referral Hospitals Mulago Hospital The mandate of Mulago National Referral Hospital is to provide super-specialized healthcare, training and conduct research in line with the requirements of the Ministry of Health; with a vision of becoming the leading centre of healthcare delivery in Africa. In order to move towards this vision, the centre adopted the following strategic objectives: 119

144 i. To strengthen management systems and structures ii. To scale up the integrated super-specialised healthcare package iii. To formalize collaborative partnerships iv. To improve on customer care and public relations Progress Progress has been realized during 2009/10 as outlined below: 1. Strengthening of management structures and systems: i) The role of hospital administrators within the departments structure has been clarified and strengthened; ii) Staffs now have written job descriptions and there is an improvement of pay roll management; also a retention strategy for existing specialists has been developed e.g. the process of provision of housing and transport to Senior Consultants has just began with a plan to increase the number provided with housing and transport. iii) Harmonization of the procurement systems across departments as well as streamlining and strengthening of the supply chain management process. iv) Strengthening of the Hospital security system; 2. Efforts were made to scale up the integrated super-specialised healthcare package with a focus on increasing the human super-specialized resource capacity as illustrated in the examples below: i. Super specialists in various fields of specialization were recruited ii. Specialists were trained in Gastroenterology, Neurosurgery, Orthopaedics as well as the continued support given to those on MMed Programs. iii. Continuous Professional Development (CPD) is ongoing; iv. A platform to ensure exchange visits has been created with several universities. 3. In order to enhance infrastructural and space capacity that ensures that Mulago Hosptial can adequately provide super-specialised healthcare, a number of developments have taken place as outlined below: i) Architectural plans for Mulago III have been developed and an impact assessment study has been done. ii) Bills of quantities for women s hospital have been done and those for Uganda Heart Institute are being developed. iii) The construction of Uganda Cancer Institute has begun and maintenance of existing infrastructure is ongoing. iv) The establishment of the following units: A telemedicine centre and the installation of an ICT program which is to become operational the following FY. v) Sickle cell clinic; vi) The relocation of the labour ward and theatre; vii)construction of the PPS pharmacy; 120

145 viii) Construction of staff restaurant. 4. Progress towards achieving the objective of formalizing collaborative partnerships include the development of monitoring mechanism for collaborations; development of a framework for collaboration and review of existing MoUs using accreditation criteria with a Memorandum of Understanding (MoU) template now in place. Figure 3.11: Admissions and Outpatient visits in 2009/2010 Number of admissions and outpatients seen per quarter in the FY 2009/10 5. Admissions and Outpatient visits This FY Mulago Hospital provided services for 614,223 out patients and 120,848 in patients. The trends for both in and outpatients have been shown modest increases from 400,653 to 614,223 outpatients from 2000 to Over the past year, the numbers of patients seen in Mulago Hospital9 in and out patients) are evenly distributed over the past year (figure 3.11). Over the past 10 years, the admissions have also increased from 88,391 to 120,848 (figure 3.12). 121

146 Figure 3.12: Trends of admissions and outpatient attendances from Mulago Hospital Admissions and Outpatients for the period Butabika National Referral Hospital Butabika Hospital was established in 1955, and is still the only National Referral Mental Health Institution in the country. The Hospital provides tertiary expert management for all patients with mental and psychological problems on a referral basis with a bed capacity of 550 patients. At the same time, it is a teaching hospital for all students who come for a placement in Mental Health ranging from nursing cadre to Postgraduate students. The Hospital is also mandated to provide specialized mental health care, train health workers and carry out mental health related research. In addition, Butabika Hospital provides General Outpatient services to the people from the surrounding areas of Nakawa Division. Performance during FY 2009/2010 i) Hospital patient care: In 2009/10, the centre provided mental health inpatient care to 4,394 first time admissions and 1,752 readmissions. Figure shows that the number of first time admissions is much higher in 2009/10 compared to the previous two financial years. 95,106 patients were seen in the various clinics at the Outpatients unit. ii) Community Mental Health Services: A total of 1,225 patients were resettled in to their homes; 2,114 patients were seen at four of the mental health outreach clinics at Nansana, Kitetika, Nkonkonjeru and Maganjo-Nkonkojeru; also, 21 forensic clinics were conducted in Luzira prison; 959 patients were re-integrated with their families whilst another 475 were rehabilitated. iii) Funds from the Support to Health Sector Strategic Plan II (SHSSPP II) were used to train and conduct community sensitisation activities for both RH and Mental Health were carried out (see Table ). 122

147 Figure 3.13: Admissions in Butabika Hospital from 2007/08 to 2009/10 First Admissions for Fy 2007/08 to 2009/10 No of Patients / / /10 Financial years July Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun i) Provision of Mental Health Training:1,812 Students from various Institutions were trained; Makerere University School of Health Science, Kampala University, Kampala International University, Uganda Christian University, Aga Khan University, Paramedical Schools: School of Psychiatric Clinical Officers Butabika, Medicare Health Professional College Mengo, Health Tutors College and Nurses Training Schools of Masaka, Matany, Mengo, Mulago, Kalong, Rakai, Rubaga, Kiwoko, Kibuli, Nsambya and Butabika. ii) Technical support supervision to regional referral hospitals: Regional Hospitals of: Arua, Lira, Masaka, Gulu, Mbale, Jinja, Fortportal, Kabale, Hoima, Tororo and Soroti were supervised. iii) Research and advocacy: Research was conducted in the areas of mental health and research and 6 journal articles were published. iv) Infrastructure and development: the process of developing a master plan for the hospital has started; completed the construction of 3 semi-detached (2 in one) staff housing units; most of the hospital land was fenced off, remaining only about 500 metres which were incomplete due to inadequate funding; continuous maintenance of buildings, grounds and infrastructure. Butabika hospital benefits from the Support to Health Sector Strategic Plan II (SHSSPP II) project that runs rom Procurement during the financial year is summarized in Annex 123

148 Table3.41: Summary of Reproductive and Mental Health activities in Butabika Hospital MENTAL HEALTH Activity Target Output Comments Training Psychiatry 12 M Med 8 M Med Psychiatry Could not raise the 4 and 3 have completed Clinical psychology 3 4 Msc Social Worker 4 3 Health tutors completed Seminars Psychiatric Clinical completed officers District leaders 12 regions 10 regions covered On going Support to psychiatric unit MoH Clinicians 12 regions 10 regions Supported development of policies Facilitated Monitoring and supervision of mental health services Tobacco control policy Supervision vehicle On going Workshop held and facilitated Provided Reproductive Health Trainings Logistics management Completed Adolescent Sexual and reproductive health Completed Family planning (basic) More need to be trained FP Long term and permanent VHTs EmOC On going Some new areas for training came in. there is need for more training On going Support supervision Anesthetic officers 0 1 Still at school Support in this area is still required By region obstetricians 4 visits 2 conducted On going By the central team 4 visits 2 conducted On going Support HC IVs for Mentoring provide surgery for Emergency obstetrics 34 5 Lack of support services- Theatre, equipments, infrastructure and personnel Supply of training equipments Procured Delivered to o MoH RH division completed 124

149 v) Table 3.42 shows that the hospital received much less than was budgeted for. Also, research, advocacy and public relations were two of the outstanding underfunded priorities to the tune of six hundred and sixty million Ushs. Table 3.42: Budget Performance for the FY 2009/2010: Details: Approved Budget Actual Funds Received Percentage Performance a) Non wage 2,798,707 2,096,874 89% b) Wage 1,569,694 1,390,990 75% c) Development 7,485,141 5,327,145 71% Total 11,853,542 8,815,009 74% Challenges 6.1. Human Resource: Inadequate staffing levels across all cadres. Lack of adequate remuneration of staff leading to loss of morale, chronic absenteeism and a high attrition rate Insufficient Budget: Inadequate provision of financial resources to match with increasing number of patients, inflationary changes and high cost of medicines Disease Burden: Increased mental health disease burden all over the country leading to increased bed occupancy of 120% Supply of Drugs: Essential psychiatric medicines are not readily available in most centres Advocacy for Mental Health: Lack of community and social support for the discharged patients has continued to result into increasing number of relapses and re-admissions Delay in approval extension of contract periods by the Bank, hence leading to time loss of about one month. The bank approval of the contractors request for extension of completion dates was one month after the request. The contracts hence expired and no works were being done during the month Non availability of sound construction materials in some areas like Katunguru HCIII, Bufundi HCIII and Buhara HCIII in Lot 3 and Rukungiri sites in Lot 4. During the implementation phase (construction), material tests were carried out and many samples of especially sand failed. The materials hence had to be procured from far quarries thereby not only causing delays in progress but also increasing co0sts due to the haulm distances. 125

150 6.8. Revision of the VAT policy to exempt all Heath sector projects greatly affected the progress of works as claimed by the contractors that they continue to meet input VAT hence affecting their cash flows. This was the main reason for the extension of time given by the contractors who claim that they continue incurring input tax which is not recovered hence affecting their cash flows and profitability Oral Health Oral health encompasses the positive aspects of good oral health, all conditions including dental caries, periodontal disease and derangement of the oral-facial tissues. Oral health problems are important public health problems because of their high prevalence in the in the population. According to the National Oral Health Survey of 1987, dental caries affects 51% of the children below 6 years, 60% of the children between 6-12 years, 68% of adults between years and 82% of adults above 55 years. For Gum diseases 80% of children below 6 years have poor oral hygiene. The goal of the oral health programme, therefore is to ensure the availability of safe and appropriate oral health services for the entire population. Strategic objectives i) Develop National oral health strategies and implementation plans focusing on the nation al, districts and community levels. ii) Integrate oral health care activities into other health and related programs and institutions (e,g maternal and child health, nutrition, schools and sanitation programs). iii) Strengthen district health facilities with appropriate oral health technologies and human resources. iv) Capacity building using the locally available staff in the health sub-districts. The goal of the oral health program is to ensure the availability of safe and appropriate oral health services for the entire population. 126

151 Table 3.43: Performance against oral health programme indicators HSSP II target/indicators 2004/ /6 2006/7 2007/8 2008/9 2009/10 Comments Guidelines on oral health care developed 40% 45% 48% 60% 65% 50% Target achieved fairly HC IVs with well equipped and functional dental units Awareness of the population of the risk factors and prevention of oral disease/conditio ns increased 10% 10% 18% 18% 18% 18% No Ministry of Health project to equip HC IV.s with dental units 10% 10% 13% 20% 50% 50% Target fairly achieved Access primary health care to oral 42% 42% 50% 50% 50% 60% There is need to extend oral health care services to HC III level Develop a National Oral Health policy None None Draft oral health policy Final draft was made Final draft printed Oral health launched Target achieved 80% 90% 100% Challenges The biggest challenge is the low prioritization and public health funding of oral health services. Subsequently, the following health system gaps are observed: i) Inadequate equipment in most government hospitals and HC IV s ii) Lack of dental infrastructure in many districts especially the new ones. iii) Non- or under utilization of many of the oral health care workers in the district PHC programs. iv) Non recruitment of oral health staff in most districts. 127

152 Recommendations i) The health infrastructure division should incorporate in their annual budget a phased rehabilitation and construction of new infrastructure for oral health, especially in the new districts. ii) Due to limited funding oral health awareness activities should be integrated into other programs like school health, maternal and child health, nutrition, HIV/AIDS, Health education iii) There is need to increase funds for oral health care services in the country Nursing section The nursing profession comprises the largest category of health professionals that provide health care within the country. These professionals carry the responsibility of bringing health services to all communities through the spectrum of health care delivery mechanisms from primary health care up to tertiary levels of health care. Any shortage experienced in this professional cadre negatively impacts on access and the quality of care that is enshrined in the country s constitution and Ugandan National Health Policy. Therefore to achieve and maintain an adequate supply of nursing professionals who are appropriately educated distributed and deployed to meet the health needs of the Ugandan population; the nursing department is charged with the responsibility of offering technical support supervision, capacity development, deployment of nursing personnel in RRH and coordination nursing activities as indicated below. Technical Support Supervision The main objective was to improve standards and quality nursing care. It is also carried out to identify HRH issues affecting the provision of quality health services. Achievements The Nursing Department has stepped up the technical support supervision visits. This has enabled the nursing leadership to reach and address about 30% of the nurses in both in private and public health facilities on a number of issues affecting the provision of nursing care. The nurses especially in the public health facilities were addressed on issues concerning poor attitudes, communication skills and customer care. Areas of effective documentation and medical legal issues were also highlighted. The department has also participated in the Area Team support Supervision. Challenges Although the Uganda National Minimum Health Care package (UNMHCP) is well defined under the four clusters namely: (i) Health Promotion, Disease Prevention and Community Health Initiatives; (ii) Maternal and Child Health; (iii) Prevention and Control of Communicable Diseases; and (iv) Prevention and Control of Non-Communicable Diseases 128

153 (NCDs) emphasis during the implementation has remained very limited due to a number of factors. i) Severe shortage of nurses and midwives is affecting the quality of nursing care. ii) Constant stock out of essential medicines and supplies in a good number of heath facilities. iii) Guidelines such as blood transfusion and injection controlguidelines; protocols and manuals on practical standard procedures are either not available or not being utilized.. iv) Infection control committees are not functional in majority of the facilities. In addition infection control equipment and supplies were constantly in short supply and in most facilities nurses lacked protective gear/ uniforms. One could hardly tell the difference between the health care provider and the client. v) In most health centers especially health centre IVs and general hospitals, health services were being provided largely by nurses and where there were no nurses the nursing assistants seemed to be running the health facilities under no adequate supervision. vi) Although the training of Nursing Assistants has been rendered illegal, new institutions have continued to emerge vii)although there has been improvement in infrastructure, these are not being fully utilized e.g. a number of mental health units where there is a shortage of staff. Also a good number of staff houses have not been renovated while the majority of nurses face acute shortage of accommodation. viii) Many regional and general hospitals have no fully established casualty departments and most nurses in these health facilities have not fully acquired skills in disaster preparedness. ix) While VHTs are playing an important role in health care promotion and provision their functionality has remained very limited due to lack of support from the trained health workers in many districts due to acute shortage health care providers. Capacity building Through collaboration with UNFPA / Midwifery project about 80 midwives from Northern and Western Region were trained in current issues in reproductive health. 20 Nurse leaders at National and Regional Referral Hospitals were also trained in leadership for change Course developed by International Council of Nurses. In response to the high burden of tuberculosis in Uganda, 50 nursing staff working at various levels of care received training on new TB treatment guidelines. In addition, a good number of research papers were also presented during the Annual Scientific Conference for Nurses and Midwives. However, there is a need to establish regular meetings of researchers and policy makers to turn research findings into policy. There is also lack of a national database for research done hence rendering it difficult to access. 129

154 Coordination and collaborations of nursing activities Through the Egyptian Technical Corporation and collaboration, eight (8) nurses were able to attend fully sponsored short courses on women s health, reproductive health and MCH(safe motherhood). Also under the support of Capacity project the scheme of service has been developed to near completion. In addition the Nursing Strategic Plan has been finalized pending stakeholders input. Under the guidance of WHO and UNFPA terms of reference the consultants to review the training of comprehensive nursing has been developed. The final report is expected at the end of November Furthermore collaborative and coordination efforts between the Nursing Department, Ministry of Education and The Nurses Council have been strengthened. E-Learning training curricular and the training cadre to be trained under the support of AMREF have been identified and the E-learning Project is due to start shortly. Through the WHO support a member from the Nursing Department and other 2 officer from UBTS and Mulago Hospital attended a workshop on blood transfusion. A number of challenges associated with the effective management of Blood transfusion were highlighted and an action plan towards the improvement of these services needs to be implemented. Recommendations i) While all the planned technical support visits were carried out there is a need to scale up to ensure good quality of care and mentoring professionals at regional and primary care levels. ii) iii) iv) Lack of staff accommodation staff travel long distances to the health facilities leading to late coming, absenteeism, and leaving stations early. There is a need to quantify medicine and health supplies requirements and provide enough quantities in the health facilities to enable nurses and midwives to provide services efficiently. Develop strategies to strengthen and streamline district HRH planning, recruitment and management to improve staffing levels in districts and facilitate data driven budgeting and equity in health workforce distribution v) Although the Nursing Department continues to work closely with the Uganda Nurses and Midwives council there remains a major challenge for the Council in improving and maintaining the quality of nursing services delivered to individuals and communities in accordance with the national policies and priorities. These challenges include inadequate financial and human resources. vi) The issues associated with the nursing workforce are particularly complex and dynamic and involve multiple stakeholders, including governments, employers, professional associations, Nurses union, and educators. Therefore, addressing the long standing wrangles within the Uganda Nurses Union leadership would require the full involvement and cooperation of all of these organizations in order to maintain a productive and professional workforce. 130

155 Palliative care Palliative Care (PC) is an approach that aims to improve the quality of life of patients and their families facing life threatening illnesses and those with severe pain, such as HIV/AIDS and Cancer. Understanding Palliative Care has helped to extend appropriate care to other forms of illnesses associated with severe pain such as sickle cell anemia, severe burns and in some cases of accidents. The strategic objectives of Palliative Care under the HSSP II have been defined as 1. Increasing the number of health workers trained to provide Palliative Care 2. Increasing the number of patients accessing Palliative Care. Ministry of Health has continued to partner with different organizations for the development of human resources, provision of oral morphine and other medications, and for monitoring and supervision of Palliative Care services in the health facilities. The Ministry of Health provided free oral morphine for pain and symptom management to those who needed it, and Coordinated all Palliative Care stake holders and Development Partners involved in implementing services at the districts to ensure provision of quality Palliative Care services. Challenges i) There is still limited appreciation of Palliative Care among some health facility managers, the public and policy makers. Inadequate funding to meet the training needs for the health workers. ii) Continued stock outs of oral morphine and other required medicines, iii) There has been slow scale up of Palliative Care services to districts. iv) Lack of transport for support supervision and mentoring of trained health workers 131

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157 Chapter FOUR Integrated Health Sector Support Systems Integrated Health Sector Support Systems This chapter describes the sector s performance on the six interdependent building blocks that support the implementation of the UNMHCP. 4.1 Health Financing The goal of health financing for the sector is to raise sufficient financial resources to fund the sector programs whilst ensuring equity and efficiency in resource mobilisation, allocation and utilisation. The medium term objectives include: 1 To mobilize additional resources to fund the sector strategic/investment plans 2 To ensure effectiveness, efficiency and equity in resource allocation and utilization. 3 To ensure transparency and accountability in resource utilization Health care financing provides the resources and economic incentives for operating health systems and is a key determinant of health system performance. Equitable financing is based on: financial protection, progressive financing and cross-subsidies. Efforts to improve health financing were guided by concepts of universal coverage and social health protection. The health sector was financed through government revenue, private sources and development assistance under the SWAP arrangement. At the start of HSSP II, the per capita expenditure for health fell far short of the amount needed to finance the UNMHCP. For instance, provision of UNMHCP in all health facilities was estimated at USD 41.2 in 2008/09 and was expected to rise to USD 47.9 in FY 2011/12 (HSLP Africa Limited, 2008). Trends of the Health Sector funding 2006/ /09 One of the HSSP II financing benchmarks was working towards having a 15% proportion of the total GoU budget. A more realistic estimate for the HSSP II was put at 13.2 %. The figure 4.1 and table 4.1 below illustrates how well the sector has performed in this respect. Although funds allocated to the Health Sector have steadily increased from Ushs 236 Billion in Financial Year 2006/07 to Ushs 735 Billion in Financial Year 2009/10; they are still inadequate to fund the UNMHCP. An estimated Ushs 1.5 Trillion is required annually to deliver the UNMHCP

158 Figure 4.1: Graphical illustration of Government s allocation to the Health Sector from Whereas resources allocated to health have been increasing steadily, the public per capita expenditure has averaged at 8.9 USD over the last ten years. The percentage of government allocation to health as a proportion of the total GoU budget has not significantly increased. This trend has important implications for service delivery as it will imply the need for further priority setting. If Uganda s population grows at current rates, there will be need for Government to correspondingly increase the health budget to meet the needs of the population. The government budget for health is allocated at the Central and Local Government levels. About 52 % of the health sector budget is decentralised. Table 4.1: MTEF allocation to the Health Sector from Per capita expenditure in Ushs Per capita expenditure in USD GoU allocation to health as % of total GoU allocation Year GOU DONOR/GHI TOTAL 2000/ , / , / , / , / , / , / , / , / , / , Source: MoFPED approved estimates and Budget performance reports. 3. Analysis of health spending in FY 2009/10. An analysis of health expenditure in FY 2009/10 highlights the following issues; 134

159 1. Government funding of health services is still inadequate estimated at 11.1 USD Per capita in FY 2009/ Donor support for health is a major component of the budget though largely targeted to three disease areas namely; Malaria, HIV/Aids and TB, 3. The bulk of the Donor support to the Health Sector approximately 41% is off budget 4. A significant proportion (21%) of the Government of Uganda expenditure on health is mainly on payment of salaries. 5. The government budget for health is allocated at the Central and Local Government levels. About 52 % of the health sector budget is decentralised 6. There is high fragmentation within and between health financing mechanisms, mainly due to high reliance on out-of-pocket payments and limited prepayment mechanisms. Without compulsory health insurance and with the low coverage of private health insurance, Uganda has limited pooling of resources, and hence minimal crosssubsidization. Table 4.2 :Central government transfers FY 2009/10 budget performance ITEM Approved Budget Actual performance Percentage PHC Wages % PHC Non wage % General Hospitals % PHC Nonwage-NGO % NGO wage Subvention % PHC Development % PRDP % Total % Source: MOH- Budget and Finance Division. 4.2 Donor support billions of Ugx Donor or Development Partner (DP) funding contributes a substantial amount to the health sector budget in Uganda. This support is channeled through budget support, project funding and off budget support. The proportion of the project support in the FY 2009/10 budget was 41%. However, the Health Sector continues to receive a large share of resources (technical support, financial, medicines and equipment) through off-budget financing mechanisms. Off budget support was estimated at 59%, approximately Ushs 440 billion in FY 2009/

160 Figure 4.2: Donor support to the health sector 2007 to 2010 The major constraint is that, while these resources are targeted at health, the off budget spending priorities are not aligned to existing Government plans; there has been duplication of interventions and excessive spending on low priority areas such as administrative costs. To implement a strategy for the alignment and harmonization of financing and implementation mechanisms, Government has developed a Long Term Institutional Arrangements (LTIA) framework for the health sector. Under this arrangement, Government seeks to promote the budget support financing model for all development assistance to the health sector, and to compel Donors to support the strengthening of the local health institutions to implement projects and programs rather than to institute stand alone project management teams. The objective espoused in this measure is to reduce the overall financial burden of project management and to enable the aggregation of common results. While this strategy was initially proposed for programs funded by the Global Fund for TB, AIDS and Malaria, a section of budget- support Donors have agreed to a joint assessment of results by adopting a common Joint Budget Support Framework (JBSF) and the monitoring tool called the Joint Assistance Framework (JAF). 5. National Health Insurance (NHI) Scheme As part of Government s efforts to improve and re organise health financing and related outcomes, a Health Insurance scheme is being designed and developed for Uganda. This plan comprises Social Health Insurance which will operate concurrently with Community Health Insurance and Private Commercial Health Insurance. The Health Insurance plan will be introduced in a phased approach. The plan is designed to work in harmony with other social security benefits under development in other government sectors. The Ministry of Health shall work with the Social Protection Directorate of Ministry of Gender, Labour and Social Development to develop a regulatory system to address accreditation and pricing of health care services. 136

161 Progress Country wide regional sensitisation commenced in Karamoja, Busoga, Lango, West Nile, Acholi, Central, Kigezi, Buganda, Teso, Bugisu, Mbale and Bunyoro regions and is ongoing in other regions. Numerous technical studies have been finalised including stakeholder analysis, economic analysis, actuarial analysis, policy options for medicines benefit package, guidelines for private wings, and critical analysis of the proposed NHIS along health financing functions. The Ministry of Health submitted the drafting instructions Bill to govern the health insurance scheme to the 1 st parliamentary counsel for drafting the law. The MOH received comments from the counsel on the Bill and has responded to them. The Bill is planned to be tabled in Parliament in 2011 and the Scheme envisaged to be launched in Major challenges 1. Absence of a legal framework Mto implement the scheme 2. Inadequate funding to roll out some country wide activities. 3. Capacity building of local institutions Recommendations There is need to strengthen capacity building of local institutions and have a continuous awareness campaign 6.0 Health Financing in Local Governments Health financing in Local Governments is mainly through Central Government PHC grants transfers. The following are some of the grants disbursed to Local Governments; PHC conditional grant for wages, PHC Non wage grant, PHC NGO facilities non wage grant, PHC development grant, NGO Wage subvention grant, General Hospitals Non wage grants, Projects funds from donors both on and off-budget, Peace recovery development program, Northern Uganda Social Action Fund, Local Government service delivery and management program. The Central Government transfers to the health sector account for almost 98% of the funding to health services in Local Governments. Out of shs 1.3 trillion transferred to Local Governments for service delivery in all sectors, the health sector share of the total transfers to Local Governments is Shs 192 Billion which accounts for about 15% of the central Government transfers to Local Governments for service delivery. Some Local Governments co- finance up to 1% of the health services using their own locally raised resources (table 4.2). Resource Allocation In financial year 2009/10, the Government had planned finance Health services in Local Governments at a cost of Shs Billion which represents 46% of the GOU health sector Budget, However Shs Billion was released and spent for health service delivery in Local Governments in financial year 2009/10 representing 95% actual performance. This translate to Shs 6274/= per capita or about $3 per capita per year. There has been a growing concern that the present grants formulas are not adequately servicing the purpose of establishment of a sufficient level of equity in decentralised health service delivery. Whereas resources allocated to decentralised health services have been increasing steadily, the per capita expenditure has been 137

162 fluctuating from USD 4.4 in 2007/08 to USD 3.0 in financial year 2009/10. An issue in District resource allocation arises on how to compensate for external inflows of funds (off- budget) in Districts with lower inflow of external off budget funds to help solve equity issues. Equity in this case requires that areas with greater health needs receive relatively more financial resources than areas deemed to have less health care needs. A total of Shs 37.2 Billion (20 % of local government health expenditure) was spent on health infrastructure development and procurement of medical equipments while Shs 102 Billion was spent on health workers salaries (56 % of Local government health expenditure). There has been general increase in decentralised health service financing from financial year 2008/09 with significant improvements recorded in 2009/10 compared to financial year 2008/09. Figure 4.3 : Central government transfers performance FY 2009/10 Source: MOH- Budget and Finance Division. The performance targets in Local governments have not fully been achieved due to limited resources; greater attention should be paid to issues of equity to ensure access to the most vulnerable population. For example immunisation coverage has reduced in most Districts to an average of 76% and most targets have not been achieved in financial year 2009/10 as indicated in the District League table. The key outputs achieved by Local Governments include; construction and rehabilitation of health units, maternity wards, general wards, staff houses, OPD and theatres. Medical equipments were procured and supplied to Health facilities under the ORET project. 138

163 Figure 4.4 : Central government grants percentage share of various grants FY 2009/10 Source: MOH- Budget and Finance Division Human Resources Significant disparities exist in staffing levels with staff establishment filled on average at 48%. This has affected health service delivery, further more limited resources has made it difficult to attract some health cadres especially in hard to reach and hard to stay areas. The existing staff appraisal system has been rendered redundant hence cases of absenteeism and attrition are so high in Local Governments resulting in resource wastage. According to UBOS, National panel survey report 2009, up to 37% of health workers are absent from their duties due to reason of being off duty or on night duty. The most affected category of health cadres on absenteeism rate are health assistants. Some staff seconded to support projects especially under HIV/AIDS regularly abandon their routine government responsibilities in health units and that weakened health service deliveries in public facilities and PNFPs in financial year 2009/10. On issues of Governance, the performance of councils, committees and commissions in Local governments has not been satisfactory due to capacity issues in areas of leadership, management, planning and budgeting. Most Health unit/hospital management committees have not been able to deliver to the expectation of the Ministry; issues of functionality of statutory committees need to be addressed through institutional capacity building. Key Challenges in Decentralised Health service Delivery during financial Year 2009/10. i) Inadequate resources for delivery of the UNMHCP. ii) Rampant Drug stock outs and delays in delivery of drugs iii) Poor health infrastructure especially in general Hospitals. iv) In adequate supply of safe blood to health facilities. v) Under staffing vi) Increasing cases of drug abuse vii)low immunisation coverage compared to 2008/09. viii) Low functionality of VHTs ix) Weak and non functional governance structures 139

164 7.0 Efficiency of service delivery Efficiency of service delivery is among the key strategies of the sector to improve access amidst resource constraints. Efficiency means obtaining maximum output possible from available resource inputs given the available technology. This analysis looks at productive efficiency, which is the efficient production of a basket of goods. In this instance, the goods refer to a set of outputs produced by service delivery levels (districts). Within productive efficiency we distinguish, technical (operational) efficiency, allocative efficiency and X- efficiency. This section will only focus on technical efficiency which looks at the comparison between the observed and optimal quantities (given inputs and outputs). In other words we measure the observed or actual level with the potential optimal level. Efficiency analysis was undertaken using the Data Envelopment Analysis technique (DEA). Data envelopment analysis also referred to as comparative analysis, analyses the relative performance of different entities performing similar functions. The provided efficiency scores are relative to the best performing entity based on peer group comparisons. The outputorientation has been used to identify districts that produce the maximum output mix from the given level of inputs. Analysis was undertaken at the district level, looking at the district as a production unit. Inputs included 26 : i) health expenditure per capita (PHC wage, recurrent non wage and development, NGO grant) ii) number of health units in the districts Outputs included 27 i) % children <1 received 3 doses of DPT according to schedule, ii) total Govt and NGO OPD utilization per person per year, iii) % Deliveries in Govt and NGO health facilities, iv) % Pregnant women receiving 2nd dose Fansidar for Intermittent Preventive Therapy (IPT) The NGO grant has been included because the outputs used include the PNFP sector. Regional referrals have been excluded because they serve more than one district and it was not possible to apportion their inputs and outputs to the districts they serve. These results should be interpreted bearing in mind that DEA uses comparative analysis. It compares with the most efficiency unit among the entities being studied. The comparator may therefore not be technically efficiency compared with the gold standard. Overall level of efficiency: 26 We have excluded number of health workers in post because data is not readily available 27 We have excluded availability of HIV services due to lack of data. 140

165 Nineteen (19) districts had an efficiency score below 80% as shown in figure 4.3. This means that they can increase their level of output by 20%, while those below 60% can increase their output by 40% at the same level of inputs. Figure 4.5: districts with an efficiency score below 80% This means that they can increase their level of output by 20% - 5% at the same level of inputs. There were however some districts that operated at 100% efficiency as shown in table 4.2 Table 4.2: Districts that operated at 100% efficiency ABIM KABAROLE KABALE MBALE AMOLATAR KALANGALA SIRONKO MBARARA BUDAKA KAMPALA SOROTI NAKAPIRIPIRIT BUDUDA KAMWENGE YUMBE OYAM BUKEDEA BULIISA KOTIDO RUKUNGIRI HOIMA DOKOLO KUMI KIBAALE ISINGIRO GULU LYANTONDE KIRUHURA MANAFWA KOBOKO KITGUM 141

166 Figure 4.6: Twenty nine (29) districts with an efficiency score ranging between 80% - 98% Details of efficiency scores and returns to scale for the different districts are shown in Annex II The first attempt to undertake this analysis was for the FY 2008/09 which showed that only 30 districts had an efficiency score of 36%. Between the two years, there has been improvement in technical efficiency scores for the majority of districts. Table 4.2 shows districts with significant reductions or improvements in technical efficiency scores. Details for other districts are shown in annex IV. Table 4.3: Districts with significant changes in efficiency scores between 2008/0 and 2009/10 District Efficiency Score 2008/09 Efficiency Score 2009/10 change in the efficiency score between 08/09 and 09/10 KIBAALE 100% 60% -40% NAMUTUMBA 98% 80% -18% KYENJOJO 93% 77% -16% KALIRO 89% 74% -15% RUKUNGIRI 100% 85% -15% KISORO 84% 76% -8% RAKAI 62% 92% 15% KASESE 77% 71% -6% NAKASONGOLA 93% 87% -6% BUSHENYI 81% 95% 14% 142

167 District Efficiency Score 2008/09 Efficiency Score 2009/10 change in the efficiency score between 08/09 and 09/10 MASAKA 85% 99% 14% BUGIRI 70% 86% 16% PADER 79% 91% 19% APAC 72% 92% 20% OYAM 100% 100% 37% BUNDIBUGYO 63% 85% 22% AMURIA 76% 100% 24% KATAKWI 74% 99% 25% IGANGA 57% 85% 28% PALLISA 74% 93% 36% MASINDI 57% 100% 43% The highest reduction in efficiency score between 2008/09 and FY 2009/10 was registered in Kibaale which reduced by 40% while the highest improvement was registered in Masindi which increased by 43%. 8.0 Financial Contribution from the Facility Based Private Not for Profit Sector (FB-PNFP): 2009/2010 In the financial year 2009/2010 the facility-based private-not-for-profit (FB-PNFP) sub-sector mobilized financial resources amounting to 124 billion shillings compared to 113 bn reported in 2008/09 (FY). The 10% increment is attributed to a combination of capital donations and the MOH- DP Bursary funds for PNFP Health Training Institutions. Overall, user fees and government subsidies reduced in their relative contribution to the PNFP budget by 5.5% and 4% respectively. Government contribution continues to finance PNFP services less and less in both absolute and relative terms. In 2007/08 the total (PHC CG, Drug Credit Line, and Laboratory Credit Line) all made up 19.6 bn. Shillings, financing 22% of the PNFP expenditures. In 2008/09 the total support dropped to 18.9 bn. shillings and financed only 20% while in 2009/2010 it only financed 16% in relative terms as total cost increased because of both the increased volume of work and output but mainly because of increased unit cost of services. This represents, in relative terms, a further decrease in budget support to both PNFP Hospital and Lower Level Health Units by 5% and 2% respectively. Data from a sample of 27 PNFP hospitals indicates that the amount of PHC CG allocated to them for 2009/10 totaled Sh. 7,029,808,417. But they reported actually received only Shs 6,602,434,665, this being 94% of the allocation for the year. The sample of 12 health training institutions (HTIs) (UCMB health training schools) reported actually receiving a total of sh. 333,038,671 for two consecutives years and was only (80%) out of a total allocation of sh. 416,342,920 for each of the respective financial years. In 2009/10 financial year 20 PNFP 143

168 HTIs received funds from the MOH-DP- Bursary Account to support disadvantaged students from the underserved districts. This amounted to sh. 602,000,000. PNFP facilities have in the past not only reduced user fees but also flattened them selectively as a result of budget support from government. But rising unit costs of services along with now reduced budget support from government to individual facilities means that facilities have to struggle to raise more money through user fees to finance the services. Inflow from users has relatively reduced in its share by 5.5% compared to an increase of both in absolute and relative terms (+4%). This FY user fees financed up to 50% of the overall recurrent cost incurred by health facilities to deliver services. The level of recurrent cost recovered from user fees is still higher in Lower Level Health Centers (68%) compared to Hospitals (43%). Lower level facilities receive relatively less budget support. They are the more rural, placed among the poorer. The external donation both in kind and in cash increased in terms of relative contributions to the PNFP budget by 10% from 24% to 34%. This unpredictable source increased slightly after a consistent reduction over 3 financial years since 2007/08. This increase was observed only in the Hospitals (13%) while the Lower Level reported a reduction of 4%. It is mainly due to capital investments. Donors are less willing to support recurrent costs. The structure of income, financing recurrent cost, described in the graph below, shows the relative proportion of the different source of income for operational cost over a period of 12 years for the FB-PNFP health sub-sector. The sustainability of services is unpredictable as evidenced by the gradual decrease from User fees and Government contribution which are the main sources of financing for recurrent operations in the PNFP sub sector. Figure 4.7: Trends in income for recurrent cost in the PNFP health sector (Hospitals + Lower Level Facilities) 100,000,000,000 PNFP Health Sector - Trends in Income for Recurrent Operations 90,000,000,000 34% 80,000,000,000 70,000,000,000 39% 32% 30% 25% 60,000,000,000 29% 50,000,000,000 40,000,000,000 30,000,000,000 20,000,000,000 10,000,000,000-26% 50% 55% 20% 48% 42% 38% 43% 24% 30% 22% 43% 45% 22% 45% 58% 47% 63% 31% 29% 36% 23% 24% 22% 20% 16% 22% 33% 15% 18% Source: Bureaux databases Govt. Subsidies (money and drugs) User Fees Aid 144

169 Hospitals In this 2009/10 FY, income from user fees contributed (44%) and the main source of financing with an increase of 3% as compared with previous financial year. Aid in form of cash from outside the country (donation of goods, equipment and drugs as well as project moneys) was the larger source of financing (42%) with a slight decrease of 2% compared to the previous financial year. This is the third consecutive year in a row that contribution from aid moneys is reducing. Moreover 79% and 70% of aid money represented the Global Health Initiatives related programs (HIV, TB and Malaria) in 2008/09 and 2009/10 respectively. Government subsidies represent now a proportion of only 14% of total hospital income (a decrease of 1% from 15% recorded in 2008/09). Figure 4.8: Relative sources of income over time FB PNFP Hospitals 100% Relative sources of income over time - PNFP Hospitals 90% 80% 33% 36% 37% 35% 36% 43% 40% 44% 47% 45% 44% 42% 70% 60% 50% 40% 30% 56% 49% 44% 38% 36% 34% 36% 36% 35% 39% 41% 44% 20% 10% 0% 27% 27% 23% 24% 19% 20% 15% 18% 16% 11% 15% 14% Govt. Subsidies (money and drugs) User Fees Aid Source: Bureaux databases Total service output of a sample of 65% of PNFP hospitals (Standard Unit of Output SUO) increased by 17.4%% in the last year. But the increasing dependence on user fees is likely to affect accessibility if the trend is not reversed. Rural facilities, placed among the poor will be most affected. This underlines the need of an increase of Government support to reduce the increasing share from patients and improve service utilization. Lower Level Health Centres (LLHCs) The largest source of financing in LLHCs is represented by user fees (64%) that have registered an increase of 6% compared to 58% reported last 2008/09 FY. From figure 4.5 below it can be noted that donors input and Government subsidies have decreased for the 4 th year in a row in their relative contribution. The decrease in the previous 2 years was 2% and 3% for Government subsidies and Aid respectively. Reliance on user fees negatively affects both the Govt and PNFPs objective of increasing accessibility to services. The prevailing reducing Government budget subsidy against rising unit cost of services make user fees the current option of financing health services. 145

170 Figure 4.9: Relative sources of income over time - PNFP LLUs 100% Relative sources of income over time - PNFP LLUs 90% 22% 24% 25% 18% 15% 80% 70% 53% 43% 60% 46% 41% 38% 36% 60% 50% 40% 30% 36% 44% 26% 32% 31% 43% 43% 35% 37% 49% 58% 64% 20% 10% 0% 11% 13% 14% 8.0 Monitoring Framework- 22% 28% 35% 33% 27% 27% 26% /10 Govt. Subsidies (money and drugs) User Fees Aid Source: Bureaux databases The financial performance is monitored through the following modalities; i) Review of financial plans and reports submitted by the various sector institutions. Local Governments submit quarterly Performance Form B while center Sector Institutions submit Performance Form A reports to MoFPED -the basis on which funds are released to the respective institutions. ii) Participation in area team visits. iii) Supervision visits. 9.0 General Health Sector Challenges i) Funds allocated to the sector are insufficient for the sector to implement its activities fully. ii) Unpredictability of donor disbursement due to challenges in meeting the precedent disbursement conditionalities, iii) Increased cost of inputs distorts the set plans and allocations. iv) High population growth puts pressure on existing resources since some activities are for universal coverage e.g. immunization. v) Financial management skills are inadequate among health facility managers at lower level facilities. vi) Monitoring and documentation of off-mtef investment in health is still a challenge. There is high off-mtef Donor Project spending. These funds are often spent without stakeholder prioritization in line with HSSP. Much of this is spent in the private sector, and with limited involvement of the private sector in the government HMIS, this creates difficulty in estimating actual per capita investment in health. 23% 21% 146

171 4.2 Human Resources for Health Human Resource for Health Management in the health sector is coordinated under the oversight leadership of two key divisions of the Ministry of Health, namely the Human Resource Development Division (HRDD) and Human Resources Management Division (HRMD). The HRMD handles the personnel aspects of recruitment, deployment, workplace safety, remunerations, retention, exit and post exit functions. The HRDD on the other hand handles the HRH aspects of education and training such as basic, post-basic, postgraduate and in-service training training to improve skills and technical competences, quality performance and productivity of the health workforce. Some management aspects of HRH are jointly handled by both divisions such as HRH policy development and review, HRH planning, motivation etc Human Resources Management The role of the Human Resource Management Division (HRMD) is to ensure availability of trained and motivated human resources for health and have them equitably distributed throughout the country to contribute to effective delivery of the Uganda National Minimum health Care Package (UNMHCP). The Division spearheads personnel management strategies and processes to strengthen institutional capacity and Stakeholder s coordination to ensure effective delivery of the UNMHCP. a) Main Achievements of HRM Division The main achievements of HRM Division are jointly coordinated with HRDD and are as presented in Table 4.1 below on staffing norms, HRH Policy formulation and reviews and the HRHIS information Systems development. Table 4.4: Main Achievements of the Human Resource Management and Development Divisions Indicator 2004/05 baseline 2005/ / / / /10 Staffing Levels increased from 68% to 90% by end of 2009 (HSSP I ) 68% as per HSSP I norms of 90% No data captured. Staffing norms reviewed and new target set at 65% 38.4% (Target of 65% for HSSPII) 38.4% 53% 56% An integrated HRHIS in place by Dec Data collected for development of HRHIS HRHIS developed at MoH headquarters HRHIS piloted in 2 districts of Mbale and Kapchorwa HRHIS extended to Professional Councils HRHIS extended to 10 districts Extended to 33 more districts HRH Policy and Strategic Plan in place by end of 2006 Consultative process for development of the policy HRH Policy and Plan developed Policy and Plan in place Policy implemente d Policy implement ed 147

172 b) Other achievements of the HRM Division To support staff attraction and retention a number of measures have been put in place: A comprehensive motivation and retention strategy has been developed to guide the sector on management and implementation of the hard-to-reach and stay (HTR&S) in an effort to increase staff retention and reduce attrition; and the general staff Motivation Strategies for health workers. i) A Hard to Reach policy has been finalized. Government gave 30% increment to all civil servants in the hardship districts starting FY2010/11 ii) Salary enhancement for scientists has been implemented. iii) iv) Workplace health and Safety policy and guidelines were developed and disseminated to all districts during FY 2008/09. Three districts of Oyam, Amolatar and Kabarole have been facilitated to operationalise the Workplace Health and Safety policy and formed committees to oversee the implementation. Draft restructuring report for the National and Regional Referral hospitals and MoH headquarters has been produced and submitted to Ministry of Public Service for approval. v) The posts of Hospital Director for the 13 Regional Referral Hospitals have been approved and declared to Health Service Commission for filling. vi) In order to make Regional Hospitals more efficient and effective in their operations, the following interventions were undertaken: a. Establish leadership and management positions in hospitals. It envisaged that it will make regional referral hospitals efficient and effective in their operations b. Performance Appraisal training was conducted in all Regional Referral hospitals. c. Pay roll support supervision was done in Regional Referral hospitals. d. All Personnel Officers, Medical Superintendents, and Chief Administrative Officers were trained in pay roll management. Progress on the implementation of the 7 th JRM undertakings Resolution Implementation of Hard To Reach and Hard To Stay strategy to increase staff retention Lobby Government to increase salaries of Health Workers Progress Hard To Reach strategy was defined by MOPS, and a 30% of basic salary allowance has been incorporated into salary of health Workers in designated Hard To Reach areas w.e.f July A Cabinet paper was submitted to parliament and so far a 30% increment was awarded to the scientists w.e.f. July Implement the staff motivation strategy The strategy was developed and is being costed for implementation Districts that have not reached 60%of their wage bill to recruit Recentralization of health Workers Districts were guided to submit recruitment plans to fill up to 65% for the FY 2010/2011 Cabinet paper was submitted and a response awaited 148

173 Major Challenges v) Poor attraction and retention of staff across the country remains critical. The situation gets even worse for cadres like-; Doctors, Midwives, Anesthetic staff, Radiographers Pharmacists and Dispensers. vi) vii) viii) Limited funding for recruitment, Salaries and wages has resulted into high vacancy levels. Inequitable distribution of Health Workers to districts due to peculiar disadvantages of such districts has resulted into some districts not performing to the minimum staffing levels. Inadequate tools and equipment result into staff not applying their skills thus demotivation. Recommendations i) Implement the comprehensive Motivation and Retention strategy. ii) Continue to lobby MOFPED and MOPS for more funding for further salary enhancement, adequate wage bill provision and work facilitation. iii) Enhance capacity for HRH policy formulation, monitoring and review. iv) Strengthen mechanisms for inter-sect oral linkages, coordination and networking maintaining high level representation with minimum delegation to lower cadres. v) Expedite the Recentralization of the function of Recruitment and deployment of Health Workers to reduce inequitable distribution among districts. vi) Harmonize staffing standards and structures at all levels. vii)develop strategies to strengthen and streamline HRH planning, recruitment and management in districts Human Resource Development The Human Resource Development Division (HRDD) is charged with the Human Resource for Health (HRH) policy development, planning and ensuring education and training of competent, quality and productive health workers. The core functions of the Human Resource Development Division (HRDD) are to provide input to the formulation of HRH policies, strategies and plans; setting standards for health professional training, and in collaboration with professional councils and Ministry of Education and Sports ensuring compliance to the set standards. 149

174 The other functions include supporting districts in determining the personnel needs, both in numbers and skills in line with the national health policy and standards. The Division has a responsibility to establish mechanisms for continuing education in priority technical areas. It operates in three sections of HRH Policy and Planning, Pre-Service and post basic/graduate training; and In-service Training. Objectives of the HRDD in HSSP II: The mission of HRDD is to develop and maintain an adequate and competent health care workforce that avails people in Uganda an equal access to quality essential health services in line with the development goals of the country. The overall objective of the HRDD in HSSP II was to increase availability of quality trained, competent and motivated staff (public and PNFP) that are equitably distributed throughout the country and who would contribute to effective delivery of a quality Uganda Minimum Health Care Package (UNMHCP). The specific HRD objectives for HSSP II were to: Provide and maintain an HRH policy and strategic framework to guide the HRH process. Avail in an equitable and balance way the human resource capacity to deliver the UNMHCP with the available envelope. Strengthen institutional capacity for HR policy, planning and management (HR PPM) Enhance capacities and relevance for training of health workers in partnership with other stakeholders. Upgrade and enhance competencies and performance of health workers. Key Strategic Targets for HSSP II (FY 2005/ /2010: i) Develop, produce HRH policy and the Strategic Plan and disseminate them at national, regional referral hospitals and district levels. ii) Develop the HRD Information System in line with the HRHIS and HMIS to enable better HRD and HRM programs planning, monitoring and evaluation. iii) Systematically manage and operationalise the HRH Training function in the country. iv) Set standards for professional training in collaboration with Professional Councils, Local Governments and MOE&S and ensure compliance. v) Build capacity of National, Regional Referral Hospitals and District level health workers in establishing and managing HRD structures at national, district level, in hospitals and at health centres including formulating HRH Development/Training Plans at their levels. vi) Establish mechanisms for continuous facilitation of the districts and health facilities to determine and meet their HRH needs in line with the National Health Policy and Standards. vii)networking, dialoguing, advocating for HRH development, quality health care delivery and keeping the HRH on the agenda. 150

175 The planned HRDD key outputs for 2009/10 were: i) HRH development policy and planning issues aligned to the NHP II and the HSSP III, and integrated into service delivery at national, district and facility levels. ii) Production of 4000 copies of each of the HRH Policy and the Strategic Plan well coordinated, produced and subsequently disseminated and popularized. iii) Capacity to formulate, review and implement HRH policy, planning and management at national, district and facility levels equitably built. iv) HRH development and management information system developed to facilitate data generation, maintenance and dissemination to HRH stakeholders at all levels. v) Resources for and processing sponsorship of students for post basic and post graduate training mobilized and coordinated respectively. vi) Competences and performance of critical health workforce in priority subject disciplines and for hard to reach and stay areas targeted and improved for better service productivity. vii)capacity for Continuing Professional Development / In-service training (CPD/IST) strengthened. viii) Strengthen the five HRD CPD Centers to promote Distance Learning and e- learning. ix) Mechanisms for coordination of in-service training and/or Continuing Professional Development established and functional. a) Human Resources Development Main Achievements in FY 2009/10 i. HRH Policy development and planning Through a participatory process, contemporary HRH Policy and Strategic Issues have been identified and incorporated in the NHP II 2010 and the HSSP III. A corresponding HRH Rollout Plan 2010// /15 is being developed to guide costing the HSSP III HRH Component and subsequent implementation. Substantial copies of the HRH Policy (2006), the HRH Strategic Plan (June 2007) and the HRH Strategic Plan Supplement 2008 (Health for the People Scenario) have been reprinted for use in HRH agenda dissemination and popularization. ii. Development and operationalisation of Human Resource for Health Information System. An HRH Information System (HRHIS) has been developed in the health sector and is being rolled out to districts and regional referral hospitals to capture data and information on health workforce in the country. There is now regular production of the Biannual HRH Report. 151

176 The basics of HRHIS infrastructure and software were procured and installed in HRM, HRD and Resource Centre Division of the ministry. Various cadres of health workers at national, regional referral hospitals level and district levels are to be trained in the use of the system and the establishment of the subsystems such as the HRDIS. Biannual HRH Report development and production is becoming a regular with rich information on HRH in Uganda. The second issue for 2009/10 came out in May 2010 and is currently in circulation. iii. Mobilisation of resources for and coordination of post basic and postgraduate training Funds for sponsorship of post basic and postgraduate training for in-service health workers in both the Public and PNFP sectors for various types of courses were mobilized. The main source of funding was from GoU, Belgium Technical Cooperation (BTC), DANIDA and ADB. Shortage of Health workers remains a serious constraint to provision of quality health care in many districts especially the hard to reach and stay districts. The Bursary Fund initiated by the Ministry of Health in partnership with the Health Development Partners and the Private Not for Profit (PNFPs) in consultation with the Ministry of Public Service and the Solicitor General was implemented in July A total of 390 students benefited from the Bursary Fund through bonding and are undertaking nursing, midwifery and medical laboratory technicians courses in the various health training institutions. They will work in the underserved districts for a period equivalent to the duration of their training. A total of 725 students post basic/postgraduates were on GoU sourced funding sponsorship during the FY 2009/10, of whom 519 were 1 st. year new entrants awards and 206 were continuing student awards (See summaries in Table 4.3 (i) and Table 4.3 (ii) below). Only 86 (about 12%) of the sponsored students got funding directly from GoU MoFPED funding and the rest were donor funded. All sponsored students signed bonding agreements regardless of source of funding to ensure that they remain in Uganda working on completion of their studies for several years. Table 4.6 (i): Post Basic / Postgraduate 1st. Years GoU Scholarships Awards in FY 2009/10 Health Cadre groups Up country excluding Mbale, Jinja & Mbarara Regional towns. Urban covering Mbale, Jinja & Mbarara Regional towns including Kampala Doctors for specialization Doctors for general courses Nurses Allied Health Non Medicals Total Total 152

177 Table 4.7: POSTBASIC AND POSTGRADUATE GOVERNMENT SPONSORSHIP in HTIs FY 2009/10: Funding Source New students (1 st Years) Continuing Students (All other Years) Total Sponsored studentsfy200 9/10 MoH/GoU direct Finalists / graduating students FY 2009/10 MoH / BTC Not available MOH /Devt/Partners/PNFPs Bursary Bonding Fund 390 none 390 None, just starting MOH/ADB/SHSSP Total Source: HRD Division/MoH FY 2009/2010 iv. Strengthening Coordination of the HRH interventions and Support Agencies Various organisations and agencies among the Health Development Partners have taken up interest in HRH issues and are providing financial, technical and infrastructure support to the GoU, the PNFPs, the PHPs and the communities in general. These include agencies such as the European Union, DANIDA, JICA, the World Bank, USAID, SIDA, Belgian Technical Co operation etc through programs such as UHSSP. UCP, PEPFAR etc. This, however, has brought in plenty of challenges of equity, duplication, uneconomical use of resources, ineffective delivery of services etc This multiplicity of actors in HRH interventions, much as it is desirable, requires interventions optimisation and harmonisation; geo-political, economical and gender equity; resource allocation and disbursement coordination etc. Coordination structures must as of necessity be established at the various levels of service delivery and be facilitated to function. The HRDD has developed proposals for reestablishment of Training Committees, Professionals Development Committees, mapping the interventions and support agencies at various levels to take care of such challenges. These coordination mechanisms will be presented during the 1 st quarter FY 2010/11 to key stakeholders, the SMC and the TMC for more input and sanctioning. v. HRH leadership and management skills enhancement. A human Resource for Health Policy, Planning and Management (HRH PPM) course has been developed through the HRH Technical Working Group and within the auspices of strengthening the Capacities for HRH policy, planning, Leadership and Management. The course will initially target health managers at national/central, regional referral hospitals and district levels but resources permitting, it should be able to move to general hospitals and lower level health centres. Within the HSSP III period, the plan is to train 150 health managers annually at an average of 30 participants per course. The HRH PPM course curriculum has been developed, costed and with a course management arrangement proposal. It is to be circulated for final input of the SMC quite soon. Initially 153

178 MUSPH will start off the course as further arrangements are made to involve other Institutions of higher learning. Plans are under to enhance other health systems managements in collaboration with other departments/sectors and the health development partners vi. Review of the HRH career guidelines. The 1997 Career guidance documents for potential pre-service and in-service HRH trainees were reviewed and await production and dissemination/circulation. The review was done to provide within the guidance for some old courses for health workers that do not appear in the guide and for the new courses introduced into the health profession but do not feature. This would give students a variety of courses to choose from when making choices for their future careers. The review revealed salient career guidance issues that included: Lack of appropriate dissemination or distribution of the available information on Health Career Guidance Career path for some health professions are either not known or not clear The Health Career Guidance then focused on Nursing and Allied Health Professionals but not on Medical and Dental Professionals (Doctors) and Pharmacists. Documents for Health Career Guidance then were targeting entrants to Pre service training and little to Post Basic and In-Service potential trainees. Parents and guardians were not appropriately empowered in the provision of Career Guidance to students. vii. Enhancement of Competences, performance and productivity of the health workforce HRH Strategic Plan was reviewed applying the Health Action Framework (HAF) tool and a 5 year Rollout Plan (2010/ /15) was at finalization stage by end of the FY 2009/ DHTs underwent a course in district planning and management to improve their management skills for the health services and developed District Plans of Action, including HRH Plans. Accreditation system and standards for Continuing Professional Development were launched and are being operationised. A multiplicity of technical skills improvement courses are conducted by various departments, Programs and Health Development Partners but unfortunately these outputs are not captured centrally but by individual providers. It is hoped that the HRDIS subsystem will subsequently harness such achievements. 154

179 Table 4.8: The Achievements on Key HRD Indicators FY 2009/10 Indicator Strengthened Training Management Capacity Training Programs having performance accreditation system Proportion of Health workforce exposed to quality IST/CPD Baseline 2004/05 HRD Achievements FY 2009/10 HRH Strategic Plan was reviewed applying the Health Action Framework (HAF) Tool and provided policy input into the NHP II and interventions proposals into HSSP III. Work on HRH Information subsystems at the four (4) Health Professional Councils and HRH Information system at the MoH was completed and bi-annual reports are produced to guide planning and decisions at the various levels. To strengthen further the HRHIS, an HRDIS subsystem is being developed to capture data and information on HRH education, training and professional development. Course on Policy, Planning and Management for health managers in the sector was developed with assistance of the school of Public Health. 34 DHTs underwent a course on district planning and management to improve on their management skills for the health services. Accreditation system and standards for Continuing Professional Development were launched and are being operationised. The four (4) Continuing Professional Centres (Arua, Jinja, Lira and Mbarara) received training equipment including internet connectivity Reviewed and repackaged one MLT Distance Education course 22 district health teams were trained on conducting Training Needs Assessment and used the tools for developing draft training plans. 725 students were awarded GoU sourced funding sponsorship during the year, of whom 206 were continuing students among whom 45 were finalists. Source: Data from the RC, HRM & HRD Divisions of MoH Uganda 2009/10 Change b) Progress on HRD Resolutions of the 7 th National Health Assembly i. Accelerating the strategy of Task Shifting: Documentation of task shifting initiatives, practices and their magnitude in Uganda was done. Drafting of the concept paper started and stakeholder consultation meetings have been planned as part of the development process of the strategy. ii. Reviewing the curriculum of enrolled and registered comprehensive nurses: A taskforce for evaluation of the ECN/RCN program was constituted; preparatory meetings held, Terms of Reference were developed and an external consultant identified and engaged to

180 evaluate the comprehensive nursing training Programmes at enrollment and registered levels. An internal consultancy to support the exercise is yet to be identified and engaged to join her. The evaluation will consider the purpose why the program was established and its relevancy to date, the curriculum design and implementation, the facilities and trainers skills availed to trainees including period of exposure; the competences of the products from the training schools and their utilization in service after qualifying. Reviewing of the ECN/RCN curriculum will therefore be considered following the recommendations of the evaluation. iii. DHOs monitoring and ensuring that schools training nurses and midwives are registered: Various fora with the DHOs, including Area Team supervision visits, were used in requesting them to report to the Health Professional Councils and Ministry of Health the illegal schools training health workers. A list of accredited schools has been developed and circulated in the media by the Uganda Nurses and Midwives Councils for attention of the relevant authorities and the public in general. The vigilance has helped guide the health professional councils, the Human Resource Development Division and the Ministry of Education and Sports on how to follow up quality of training by the schools. On putting in place and building capacity of Health Units Management Committees (functionalise) as part of community involvement in service delivery, the guidelines and the thematic training materials for HUMCs have been reviewed. An initial national training team of 20 trainers has been established and the current functionality of the HUMCs assessed in a few regions. The next step is to focus on training regional training teams which will subsequently train district level trainers and the Hospital Boards members. Training materials are to be printed and used for dissemination and training. The District Trainers will train, orient or sensitise the lower health units HUMCs. These are slated for FY 2010/11. iv. Banning the Training of Nursing Assistants A circular has been sent out by the Ministry of Health banning the formal training of the Nursing Assistants/Aides. Training on job for those already in employment should be done by their supervisors to enable them do their work better. The position of the Nursing Assistant/Aide will be phased out gradually. c) Progress on the priority actions of the 15 th Joint Review Mission for the Health Sector i. Equipping all managers with leadership and management skills: As a start, the health sector under the leadership of the Ministry of Health has jointly with Makerere School of Public Health developed a course in Human Resources for Health Policy, Planning and Management. The course targets health managers at various levels of service delivery and is slated to start in October It will be conducted jointly by experts in health systems development from MUSPH, MoH, Intrahealth International and other health development partners. 156

181 ii. Prioritising training of health cadres who are hard to attract and retain in particularly unique areas: Scholarships for training targeted health workers and school leavers who wished to undertake training in health courses focused in preference to applicants from distances beyond 140 kms from Kampala and also from rural health facilities (hard to attract and retain HTA&R ). Table 4.9: POSTBASIC AND POSTGRADUATE GOVERNMENT SPONSORSHIP Funding Source Hard To Attract & Retain dstricts Other considerations Total GoU Direct MoH/BTC MoH/Devt Partners Bursary Fund Total Source: Human Resource Development Division/MoH FY 2009/2010 For instance, as indicated in Table 4.5 above, out of the 483 sponsorship awards during the FY 2009/2010, 295 recipients were from the Hard to Attract and Retain (HTA&R) areas as per the following distribution: 38/57 directly by MoH; 32/36 sponsored from MoH/Belgium Technical Cooperation and 225/390 from the MoH/Devt Partners PNFP Bursary Fund. In addition the sponsorship focused on the MoH Training Priorities. Challenges i) The Division remained very understaffed, especially so, following the departure of several officers from the Division during the same financial year. ii) Low capacity at Health Manpower Development Centre and its unclear legal status in the MOH structure. The legal position of the Health Manpower Development Centre remains unclear as a national Continuing Professional Development Centre and so are the four other regional CPD centres of Arua, Lira, Mbarara and Jinja. A proposal for HMDC to be a semi autonomous Training Institution implementing its own Business Plan was forwarded in the MoH Restructuring Proposal and is still awaited. The CPD centres were also proposed to be provided for under the Regional Referral Hospitals budgets. The units unfortunately continue to miss out funding support and infrastructure development from development partners due to this uncertain position and lack of management structure. iii) Maintenance of relevance of health training policies and strategies in light of health reforms, and changing health needs and technologies. iv) Funding of IST which is largely by vertical programmes with specific agenda makes it difficult to integrate IST as envisaged by HSSP II, donor dependent and difficult to sustain. v) Marked misdistribution of health workers between urban and rural areas and between districts for various peculiar/unique disadvantages of some districts. vi) Insufficient capacities of leadership and management among HRH managers at various levels endangers effective planning for and funding of IST/CPD 157

182 Recommendations I. Strengthen the capacity of HRD Division through promotion and population of the existing vacant positions. II. III. IV. The Mbale Health Manpower Development Centre (HMDC) should be revamped as directed by the Auditor General and fully implement the Business/Strategic Plan perform its mandatory function. Furthermore the four Regional CPD Centres should be strengthened and linked to Mbale HMDC. Implement mechanisms and strategies for increased funding for HRH functions by looking beyond local resources for instance; using advocacy tools including HAF for resource mobilization; improve efficiency and effectiveness in utilization of human resources including those geared to improved HRH management, community resource, task shifting. Review and harmonize the existing laws and regulations in order to have unified accreditation system. V. Revitalize and strengthen the Inter-Ministerial Standing Coordination mechanisms with the Ministry of Education and stakeholders in Health Training using programme of work and maintaining high level representation with minimal delegation to lower cadres Human Resources for Health in the PNFP Sector Once again the Private-not-for-profit (PNFP) subsector has remained an important partner complementing government effort in providing health services in Uganda. This section of the report covers PNFP health workers coordinated by the three medical bureaus (UCMB, UPMB and UMMB). With slightly over 11,600 health workers in the medical bureau networks alone, the PNFP still contribute about 30% of a combined Public-PNFP workforce. Ninety percent of these are privately employed. The other 10% comprises of staff seconded by missionary congregations, the local governments, and the Ministry of Health. Over many years the workforce in the PNFP has been perceived and appreciated for being highly productive. But this performance remains under threat by the persistently high levels of staff turnover especially of the clinical staff, a factor that remains most outstanding as affecting human resource for health in the subsector. Gladly there is some stabilization seen in the staff turnover over the last few years and the trend of attrition in both hospitals and lower level health facilities seem to show a downward trend (Figures 4.10 and 4.11 below). 158

183 Fig 4.10: General trend of attrition among clinical staff in the PNFP hospitals 40% 35% 30% 25% 20% 15% 10% 5% 0% Trend of Attrition - Clinical Staff in 65% of PNFP Hospitals 36% 22% 23% 20% 20% 22% 2003/ / / / / / /10 20% Figure 4.11: General trend in attrition of clinical staff in PNFP lower level health facilities 40% 35% 30% 25% 20% 15% 10% 5% 0% Trend of Attrition - Clinical Staff in 65% of PNFP Lower Level Units 34% 27% 26% 32% 2005/ / / / /10 22% There could be multiple likely reasons for this stabilization. Available data (from exit interviews) indicate that over 46% of the leavers in 2009/2010 joined government services as compared to 60% in 2007/2008. This might be because either government recruitment has been less aggressive than earlier envisaged or a combination with other non-monetary processes improving retention in the facilities. Low salaries remain the most common reason given for leaving. Further stabilization of the PNFP is very important considering the significant contribution the sub-sector makes to the HSSIP processes and performance. While retention has remained a challenge to the PNFP facilities due largely to financial constraints, the absolute numbers of staff is always maintained due to rapid recruitment and replacement with fresh graduates

184 The biggest problem caused by staff turnover in the PNFPs is therefore not majorly of numbers but of loss experience and capacity and the repeated rigor and distress of the attritionreplacement cycle. The PNFP networks therefore still remain some sort of centres for internship or transit routes to civil service and may be for other employers. Figures 4.12, 4.13 and 4.14 below indicate the trend of attrition of key clinical cadres in 65% of the PNFP hospitals and Lower Level Facilities. The staffing situation in UCMB hospitals Figure 4.12: Trend of attrition of key clinical cadres in PNFP hospitals 2003/04 to 2009/10 Trend of attrition of key cadres of clinical staffs in 65% of PNFP Hospitals 40% 35% 30% 25% 20% 15% 10% 38% 35% 36% 34% 30% 28% 29% 26% 26% 26% 21% 22% 21% 22% 32% 29% 30% 25% 26% 16% 14% 5% 0% MO CO Combined EN + EMW 2003/ / / / / / /10 Turnover rates for medical officers and clinical officers in hospitals remain high and are even increasing while a pattern of reduction similar to that in lower level facilities is seen for the enrolled nurses and midwives. In the last three years the attrition among enrolled nurses and midwives in hospitals rose from 25% in 2006/07 to 32% in 2007/08 before reducing to 30% in 2008/09 and now to 26% in 2009/

185 The situation in Lower Level Units Figure 4.13: Attrition of key clinical cadres in lower level PNFP health facilities 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% Trend of attrition of key cadres in clinical staffs in 65% of PNFP lower level units 30% 34% 42% 40% 38% 39% 33% 46% 46% 37% 0% CO Combined EN + EMW 2005/ / / / /10 In lower level PNFP facilities the movement of enrolled nurses and enrolled midwives is beginning to stabilise Figure 4.9 above suggests that attrition rate for enrolled nurses and enrolled midwives has further reduced from 46% in 2007/08 to 39% in 2008/09 and now 37% in 2009/ This is favouring of the lower level facilities that serve the poor, operate in much more rural localities and are often constrained to retain key cadres. Attrition in hard to reach districts 28 For some years PNFP staff attrition in the hard-to-reach areas has been higher than the overall network situation. Considering 12 hard-to-reach districts, mainly in post-conflict situation, there is now a similar stabilisation for nurses and midwives and a similar rise in attrition for clinical officers and doctors working in hospitals. In fact the attrition rate for enrolled nurses and midwives (23%) is slightly lower than the overall average for the PNFP network hospitals (26%). Figure 4.14: Staff attrition in PNFP hospitals in hard-to-reach districts Attrition rates in PNFP hospitals in 12 hard to reach districts 2007/ /09 60% 50% 40% 30% 34% 31% 27% 44% 43% 39% 28% 23% 23% 54% 39% 35% 20% 10% 0% CO EM EN MO The districts referred to here are the 12 top in level of hard-to-reach according to the classification used for the inclusion for payment of hard-to-reach allowances. They are Pader, Kitgum, Nakapiripirit, Kotido, Moroto, Kaberamaido, Katakwi, Bundibidyo, Apac, Gulu, Lira and Soroti. 161

186 There is a similar trend in stabilization in the lower level facilities. But disaggregation of attrition among enrolled nurses and midwives shows that the overall drop is more influenced by the drop among midwives while enrolled nurses attrition remains high and even increased again in the last year. The reason for this is not clear but. It could indicate that nurses have more diverse opportunities for employment in various organisations and projects. But it is not clear why this particular trend is only observed at the lower level and not in the hospitals. Figure 4.15: Staff attrition rates in PNFP lower level units in 12 hard-to-reach districts 70% 60% 50% 40% 30% Attrition rates for selected PNFP health worker cadres in 12 hardto-reach districts 38% 30% 25% 61% 40% 27% 66% 52% 58% 20% 10% 0% CO EM EN Critical Human Resource for Health in PNFP health care in general It should be noted that the PNFPs health facilities have the highest staff attrition rate compared to the government facilities. From the health facilities that reported their performance for this financial year the staff in the Lower Level health facilities reduced compared to last year, with doctors and clinical officers reducing greatly. Table 4.10: Human resources for health Financial year Doctor Clinical officer Lab Assistant Enrolled Midwife Registered Midwife Enrolled Nurse Registered Nurse Double EN Comp Nurse Double Reg. Comp Nurse Nursing Assistant Nursing Aide Support staff 2009/ / Health Service Commission The Health Service Commission is mandated under Article 170(1) (a) and (b) of the Constitution of the Republic of Uganda to advise the President on Recruiting Health Workers in accordance with Article 172 of the Constitution (for Health Workers at the level of Head of Department and above) and also directly appointing all other Health Workers who fall under the jurisdiction of 162

187 the Commission, i.e. Public Health Workers, other than those under the Authority of District Service Commissions (see Article 200 of the Constitution). Accordingly, the HSC is responsible for recruiting Health Workers for the Ministry of Health Headquarters, National and Regional Referral Hospitals and Specialized Health Institutions under the Ministry of Health. The Commission has also been recruiting Health Workers for the Prisons Health Services. Over the years, the Commission has been setting a Recruitment Target of 800 Health Workers per year except in the FY 2009/10 when the target was revised to 1000 Health Workers. These Workers include all Health Workers as defined under Section 3 of the HSC Act 2001; hence includes Support Staff. Table 4.11: The total number of Health Workers recruited per Financial Year over a period of 6 years. FY Target Recruitment Actual No Recruited 2004/ / / / / / Total (2004/ /10) ,389 Due to increased recruitment over the years the recruitment has been revised back to 800 Health Workers. However, it is expected that the number will surpass 800 given that validation exercises of the new Regional Referral Hospitals of Mubende and Moroto as well as the Uganda Heart Institute and the Uganda Cancer Institute will be bring more appointments through regularizations and filling of the remaining approved vacancies. The recruited figure may not be impressive given the staffing demands in relation to the actual work load but given the recent analysis of actual staffing situation at Mulago, Butabika and three Regional Referral Hospitals, the recruitments have greatly revamped staffing of the National and Regional Referral Hospitals over the years. 163

188 164

189 HOSPITAL CATEGORY APPROVED POSITIONS FILLED STAFFING LEVEL JINJA Medical Officers and Dental Surgeons % as at Aug 200 Pharmacists % Allied Health Professionals % Nurses and Midwives % Scientific Staff % Administrative Staff % Support Staff % Overall % MBARARA Medical Officers and Dental Surgeons % as at Aug 200 Pharmacists % Allied Health Professionals % Nurses and Midwives % Scientific Staff % Administrative Staff % Support Staff % Overall % HOIMA Medical Officers and Dental Surgeons % as at Aug 200 Pharmacists % Allied Health Professionals % Nurses and Midwives % Scientific Staff % Administrative Staff % Support Staff % Overall % SOROTI Medical Officers and Dental Surgeons % as at Oct 2007Pharmacists % Allied Health Professionals % Nurses and Midwives % Scientific Staff % Administrative Staff % Support Staff % Overall % KABALE Medical Officers and Dental Surgeons % as at July 2010Pharmacists % Allied Health Professionals % Nurses and Midwives % Scientific Staff % Administrative Staff % Support Staff % Overall % Source : Staff lists submitted to HSC by user institutions 165

190 Table 4.12 also reflects the HR challenges the Commission has faced over the years. i) It has been very difficult to attract and recruit Medical Specialists and Medical Officers for Regional Referral Hospitals. ii) Equally difficult to attract and recruit have been some cadres in the Allied Health Professionals, especially Laboratory Technologists and Dispensers. iii) Advertisements for nursing posts have been attracting big numbers of Applicants. Coupled with Support Staff, Scientific and administrative Staff, the Commission has had to handle huge amounts of applications; thus making recruitment exercises lengthy and costly. Under FY under review, the candidates for the post of Nursing Officer had to be subjected to selection exams in order to rationalize numbers for interviews. This is in addition to the Administrative and Scientific cadres. During the Financial Years, 2007/2008 and 2008/09, the Commission filled all posts of Medical Officer, declared for the National and Regional Referral Hospitals as well as PNFP Hospitals. However, in FY 2009/10 both the Ministry and National Referral Hospitals declared posts for filling. The Commission is therefore interested in knowing the exact number of Medical Officers who actually report and remain on duty for at least two years. Apart from HR attraction and recruitment challenges, the Commission has been bedeviled by logistical challenges such as: i) Under-funding leading to the Commission advertising only once each FY and limiting selection exercises only to selection interviews. This FY, the Commission will require the Ministry to assist with funds for the validation exercises ( approximately 100m Ushs). ii) Inadequate work performance tools e.g. computers, and general ICT. This has had a crippling effect on the HR Data base for the HSC. iii) Inadequate staffing at the Secretariat level iv) Inability to carryout Support Supervision in targeted District Service Commissions and RRHs due to inadequate funds and vehicles. During the course of recruitment and arising out of Support Supervision Visits the Commission has been able to conduct; the following recommendations geared at enhancing staffing across the Health Sector and thus improving health service delivery are herewith provided: i) Recentralize recruitment of Health Workers to improve deployment and distribution of Health Workers across the Sector. ii) Enhance the Financial, Human Resource and Logistics components of the Commission as a matter of priority. iii) Affirmative action in supporting training in some specialties such as Anaesthesia, ENT, and Pathology be undertaken by the Ministry of Health. 166

191 iv) As a matter of urgency the terms and conditions of Health Workers be improved especially on housing and transport; in order to revamp attraction and retention of Health Workers. v) Government should provide funds for filling 100% of approved Staffing Structures in Local Governments. vi) Staffing Norms of cadres should urgently be reviewed upward e.g Clinical Officers in decentralized health services. vii)the performance management principle of Task Shifting should be studied in order to determine its possible value on addressing acute clinical under-performance in Health Centres. In summary, despite the constraints and challenges outside the Commission s control, the staffing situation in aggregate terms and average is above 80% for National and Regional Referral Hospitals. Emphasis should be placed on Clinical Areas which are generally below the 68% baseline Recruitment Figure provided in HSSP II and indeed below the 90% recruitment target. 167

192 4.3 Health Infrastructure Development and Management The overall objective of the HSSP II on health infrastructure is to consolidate existing health facilities to enhance their functionality and to increase accessibility to health services and quality of health care delivery within the available resource envelope. During the reporting period, some progress has been obtained towards the achieving this objective but due to the limited resources a lot remains to be done. The following are the specific objectives of the HSSPII intend to achieve the above overall objective: 1. To consolidate functionality of existing lower level health facilities 2. To strengthen the referral system 3. To rehabilitative secondary and tertiary health facilities 4. To strengthen management of health infrastructure and establish a sustainable maintenance programme 5. To Increase accessibility to within 5km walking distance from 72% to 85% Progress The progress attained on implementation of the planned interventions within the reporting period is as in the annexed table. Additionally, the following achievements have been attained in respect of the resolutions of the 7 th National Health Assembly and the priorities agreed upon at the 15 th Joint Review Mission. (a) Status resolutions of the 7 th National Health Assembly 1. Improve the release and effective use of the development budget to improve functionality of the existing health infrastructure i) Advised all RRHs to prepare mater plans ii) Support regional referral hospitals in preparation of work plans for utilisation of the capital development budget allocation iii) Increased support supervision of the infrastructure improvement programmes at RRHs 2. DHOs should regularly provide and update the infrastructure and equipment inventory i) Guidelines provided to district for inventory update using pictures and equipment to ease understanding. Response of district has greatly improved. 3. Maintenance of equipment should be prioritised In the FY 2009/2010, ring fenced funds for medical equipment maintenance were provided under the development budget to regional referral hospitals. This was an improvement; but the amounts are still meagre to meet the maintenance requirements of regions. Furthermore, the funds provided are only for maintenance of equipment leaving out the other constituents of health Infrastructure (i.e. buildings, Transport & Ambulances and Communication facilities) 168

193 (b) Priorities of the 15 th Joint Review Mission 1. Focus and consolidate / repair of existing structures before embarking on the construction of new facilities i) This prioritisation has been incorporated in the HSSP III ii) Consolidation has been emphasised in all our current development programmes iii) Districts were asked to concentrate on completing work started on in the past years. 2. Start the process of securing land titles for all health facilities. i) Circular written to all districts (CAOs), Medical Superintendent of RRHs 3. Develop and implement guidelines for the operation of ambulances i) Initiated discussion with World Health Organisation, UNFPA and World Bank Funded health systems strengthening project Discussions still ongoing. 169

194 Table 4.11: Achievements in health infrastructure over the HSSP II period HSSP II Target / Indicators 2004/ / / / / /10 Data Source Comments 100% availability of maternity wards at HC III & HC IVs HC III 69% 70% 71% 74% 77% 80% District transfers 8,7,22, 21 & 21 at HC IIIs respectively HC IV 92% 92.50% 95% % 97.50% 1, 4,1, 3 & 1 at HC IVs respectively 100% availability of general wards at HC III & HC IVs 100% of hospitals with at least one form of communication facility HC III 79% HC IV 36% 79% 79% 80% 80% 80% District transfers Added on one ward annually except and 2009/10 (3) - 55/55 (100%) 55/55 (100%) 55/55 (100%) 55/55 (100%) 55/55 (100%) All hospitals can be reached on mobile phones 100% of hospitals with ambulances Allocation Schedule Total number of GoU hospitals = 55 7 HC IV along highways provided with specialised diagnostics services 51% (with 28 New Units) 58% (with 4 New Units) 67% (with 10 New Units) (6 JICA; 22 Chogm) (SHSSPI) 5 GoU + 5 PNFP (SHSSPII) (14%) 1 (14%) 1 (14%) 1 (14%) Lyantonde Masafu & Kyenjojo Katakwi The percentages refer to the cumulative numbers of hospitals with ambulances Upgrading the HCs with specialized services is still ongoing 70% of general hospitals rehabilitated 1 (2%) Nakaseke 80% of regional referral hospitals rehabilitated 100% of regional referral hospitals provided with mental health services 100% of hospitals equipped with a medical waste incinerator 8 (17%) Bududa, Masafu, Itojo 2 (18%) 4 (36%) 4 (45%) 11 (100%) 11 (100%) 11 (100%) 46% (Fort Portal & Soroti) Added Mbale (6 out of 13) 7% 9% 11% 11% Mulago, Arua, Gulu (Added Fort Portal) (Added Butabika) (Added Entebbe but decommissioned & Mubende) Mubende s after serving for 4 years) One national incinerator constructed Planned to be set up NDA but No fruitful action achieved 2No. Engineers / Technicians trained in Biomedical Engineering annually 95% hospitals having a maintenance technician 7 technician, 5 (11%) Abim, Kaabong, Tororo, Entebbe 11 (23%) Apac, Nebbi, Kambuga Technician 1 Engineer 13% 20% (7 RRH) (4 RHH added) 12 (25%) Masafu, Tororo, Itojo Annual performance reports These are cumulative numbers. In all cases the rehabilitation was partial. The hospitals highlighted are those were substantial work was done. Ongoing: using capital development allocations % 100% Ongoing at Masaka, Lira, Mubende, Jinja, Moroto, Mbarara, Mbale under SHSSP Project 11% 11% Activity delayed due to delayed finalisation of the standard incinerator and Health Care Waste and Management Plan 0 Constrained by the lack of a training institution in Uganda. Plans advanced to introduce Diploma Course at Kyambogo University 13% 13% 13% Recruitment has been slow because of delays in declaring vacancies Increase accessibility to 85% 72% 72% 72% 72% 72% 72% Very few new HCs were added and have not significantly increased accessibility. The focus was on consolidation of existing. Notes Seventeen (17) General Hospitals had their imaging departments X-Ray & Ultra Sound refurbished under the ORET programme over the HSSP II period namely: Bundibugyo, Itojo, Kitagata, Kagadi, Kayunga, Apac, Kiryandongo, Kitgum, Moroto, Iganga, Pallisa, Anaka, Moyo, Yumbe, Gombe, masindi and Kalisizo. The remaining hospitals are to be covered in financial year 2009/

195 Major Challenges i) Inadequate structures infrastructure management and maintenance staff at the centre, regional referral hospitals and general hospitals ii) Inadequate funds for maintenance of infrastructure Recommendations i) Adequate funding should be provided for management and maintenance of all components of health infrastructure to avoid having to resort to Rehabilitation. ii) The restructuring exercise should consider strengthening the maintenance (Engineering) units at Hospitals, the district and Ministry of Health both in numbers and skills to enable proper Health Infrastructure Development and Management. 171

196 4.4 Management of Essential Medicines and Supplies The Ministry of Health has continued to collaborate with development partners to support pharmaceutical activities in the country: support has been received from WHO, DANIDA MeTA, SURE and Malaria Consortium. Activities of Pharmacy Division were guided by HSSP II and under takings in the Aide memoiré of the 7 th National Health Assembly and 15 th Health Sector Joint Review Mission The following achievements were realized: i) The National Pharmaceutical Sector Strategic Plan has been developed and is awaiting costing. (WHO) ii) Evaluation of 2007/2008 procurement plan and update of 2009/ /12 three years rolling procurement for Essential Medicines and Health Supplies (MeTA)and with support from SURE the Division plans to continuously evaluate performance of PSM(Pharmaceutical Supply Management in financial year 2010/2011 iii) Participated in the finalization of National Clinical Guideline 2010 under the leadership of Quality Assurance Department which is now being disseminated. iv) Conducted an policy option analysis on medicine management activities where both merits and deficiencies of current practices at current levels of supply chain were assessed.(sure) this option analysis will inform future strategies v) Reviewed Logistic training manual and tools with a view of harmonizing data collection tools by different stake holders vi) Vote 116 for medicine and health supplies was created and is managed by NMS: this improved the financial base of NMS. And addressed the challenges associated with the old system of credit line and sending medicine funds to districts and hospitals vii)an MOU on modalities of Vote 116 is in the final stages but operational guidelines were developed and disseminated to stakeholders viii) Routine Monitoring and support supervision to hospitals and districts on medicine management activities,with special focus on forecasting and rational medicine use, to improve management of EMHS was conducted in hospitals and districts Despite the above mentioned achievements and innovations many challenges still exist. Poor access to medicines in health units persisted mainly due inadequate financing of medicines and health supplies, and poor medicine management at health unit level The continued challenge of inadequate human resources for health in generally and for medicines management in particular still affects the health system and jeopardizes the benefits achieved and capacity development efforts made thus far. Due to lack of capacity at unit level especially at health centre II and III, Kits for essential medicines have been introduced at health centre II and III level; until adequate capacity is developed. DANIDA a major funder for essential Medicines and health supplies and has also been funding a sizeable proportion of the Pharmacy Division s budget has pulled out of the sector. This has led to the reduction of funds available for these two components. We have not yet got a replacement for DANIDA funding for essential medicines and health supplies but for 172

197 other medicine management activities SURE(Securing Ugandans Rights on Essential Medicines) and the World Bank will mitigate the withdraw of DANIDA, DELIVER and SCMS The creation of Vote 116 meant that all funds for procurement of medicine and health supplies were remitted to NMS and therefore NMS should be able to supply all the required medicines to all public health facilities. Prior to the creation of Vote 116, it was anticipated that GoU would contribute 5.17 and DANIDA 6.7 bn and the allocation of funds for the districts and hospitals was based on this. NMS only received 5.17 bn through Vote 116 and this affected its capacity to supply medicines to health facilities. For FY 2009/2010 DANIDA made a provision and most likely they will do the same for 2010/2011 However, there was a mixed picture of the level of availability of EMHS in the districts and the different facilities. In some of the districts poor documentation of movement of medicines within units and the overall supply chain is visibly prevalent in most of the facilities. While in some districts there is some semblance of good records, the majority hardly kept any meaningful records. Table 4.12: Availability of Essential Medicines at various health facility Levels All levels FY FY FY FY FY % HU Num of HU % HU with no stock out (AL green included) without stock out (AL green not included) Num of HU with no stock out % HU Num of HU % HU Num of HU % HU Num of HU % HU 35 21% 41% 34 26% 36 28% 36 35% 28 27% HC II 11 18% 24% 13 17% 13 33% 11 12% 9 25% HC III 13 22% 59% 12 24% 13 30% 15 47% 13 32% HC IV 11 24% 39% 9 39% 10 22% 10 47% 6 23% Comments: There was overall improvement in availability from improved 26% to 41% when coartem is not include in the analysis with the improvements seen at level III health centers. When availability of Coartemwas included in the analysis, the availability fell to 21%. As shown in the table two Coartem was not available in half of the facilities on a monthly basis. (for comparison when Coartem is dropped from the results of 2008/2009 the improvement is negligible from 26%to 28% but in 2009/2010 when coartem is dropped the availability improves from 21% to 41%) This is important to note because availability of Coartem is largely not dependant to the performance of NMS or Health facilities but on GLOBAL fund honoring its obligations 173

198 Table 4.13: Availability of Essential Medicines by HSSP indicator drug Stock card months* FY FY FY FY FY % HU reporting stock outs Stock card months* % HU Stock card months* % HU Stock card months* % HU Stock card months* % HU Any HSSP indicator drug % % % % % Coartem Green % % % % % Sulfadoxine Pyrimethamine tab % % % % % Cotrimoxazole 480mg tab % % % % % 5 6 Oral Rehydration Salts (sachet) % % % % % Medroxyprogesterone inj ("Depo") % 148 7% % % 93 36% Measles vaccine % % % 158 7% % Financing of Medicines and Health Supplies 2009/2010 With effect from financial year 2009/2010, GoU shifted the financing system for EMHS away from the decentralized PHC recurrent wage grant (Fiscal Decentralization Strategy) and the essential medicines account credit line A new vote (VOTE 116) was established for the National Medical Stores. The transition occurred after the release of the MoFPED Background to the Budget 2009/2010 but was subsequently incorporated into the Health Sector Ministerial Policy Statement 2009/2010. In the first year of operation of VOTE 116, MoFPED released 30% of the annual EMHS budget through the decentralized PHC grant system. This means the funds realized to NMS on vote 116 was 70% of the total EMHS budget expected to cover quarter two, three and four of FY2009/2010. In total MoFPED realesed 75.7 billions to vote 116 in FY2009/2010, this included about 47 billion for ACTS&ARVS, billion about 6.7 billion for Butabika and Mulago respectively.the 30% released to districts prior vote 116 is not considered because we are not sure how much of it was used for procurement of EMHS by health facilities. The amount that was available for EMHS for the whole public sector including Mulago complex and Butabika for FY 2009/2010 was about 28.7 billion; this compared to result of national quantification report of 2009 which put this requirement at about 100 billion means that the gap between available funding by Government and the need of the country in regard to EMHS is still very big. MoFPED did not transfer any funds to the EMA; whilst the approved MoFPED budget estimates 2009/2010 included the annual DANIDA contribution of UGX 6.8 Billion to the EMA, these funds were withheld. DANIDA instead transferred UGX 3 Billion directly to JMS to support the PNFP credit line 174

199 NMS is the de facto sole supplier for EMHS to all GoU facilities with VOTE 116 and has been set up as a designate service provider. MoFPED pays NMS a standard handling fee based on the value of commodities procured; 18% on EHMS, 7 % on ACTs and ARVs. The increasing contribution of global health initiatives like Global Fund PEPAR CHAI, GAVI and others is not captured The new arrangement addresses some inherent challenges posed by the decentralized PHC grants and EMA credit line. VOTE 116 eliminates i) lead times for transfer of funds to regional referral hospitals, general hospitals and health sub districts (12, 20 and 27 days respectively) 29 ii) delayed release of PHC funds earmarked for EMHS to districts as a result of non compliance with accounting guidelines iii) health facilities non compliance with PHC grant expenditure guidelines iv) reallocation by local governments of funds earmarked for EMHS to other budgets v) accumulation of unpaid debt that negatively affected NMS capacity to procure EMHS In addition, it addresses non-utilization by health facilities of PHC funds at NMS or JMS as well as significantly shortening the NMS operating cash cycle where payment delays by the MoH and health facilities stretched to over 3 months. There are strategic issues that need to be considered if GoU is to maintain the new system; the potential efficiencies outlined above have to be placed within the context that: i) Availability of EMHS in the entire public health system is dependent on the performance of NMS as the sole procurement and supply agency. ii) There is no provision for health facilities to procure EMHS from alternative sources in case of non-availability at NMS. Operationally, the National Medical Stores management and human resource capacity has to adjust to new challenges: i) Responsibility for allocation of funds to health facilities has shifted from MOH and HSD to NMS ii) NMS must now manage health facility accounts as opposed to 281 accounts iii) NMS is wholly dependent on service provider fees charged on ACT/ARV (7%), EMHS (18%) and third party handling fees to cover its operating costs. Utilization of services provider for Medicines (Vote 116) 175

200 Table 4.14: Funding for Essential Medicines and Health Supplies in 2009/10 DANIDA Contribution 3,000,000,000 (Through Joint Medical Store) Vote ,400,000,000 ARVs and ACTs 47,310,446,000 Third Party Supplies (RH) 1,500,000,000 TOTAL 80,210,446,000 DANIDA was supposed to contribute about 3.5 billion to Vote 116 Since DANIDA was winding up in June 2010 and again no provision was made to finance EMHS to PNFP through JMS for FY 2010/2011, DANIDA has decided to put the balance to this cause. Table 4.15: Utilization of vote 116 in 2009/1 Name Total Allocation Spent % utilization All Districts 17,169,329,501 13,311,415, All General Hospitals 5,617,320,451 4,457,078, All Regional referral Hospitals 5,074,759,511 4,609,930, BUTABIKA HOSPITAL 500,000, ,054, MULAGO HOSPITAL 6,907,679,000 5,199,229, UGANDA CANCER INSTITUTE 333,333, ,364, UGANDA HEART INSTITUTE 49,600,000 38,114, ,790,612,000 5,974,762, The general utilization of Vote 116 is at 77 % and yet it is expected to be above 90 given that the funds are released to NMS well in advance. For Districts, RRH and General Hospital the withholding of 3.5 billion by DANIDA affected their performance.. Also at the end of September most units had a balance on the 2008/2009 Credit line allocation this amount was also added to total amount available for 2009/2010 The denominator used in this report includes DANIDA funds and the balance from 2008/2009 Credit line allocation since NMS included it when allocating funds to these entities. This explains why most districts and hospitals did not hit the 100% mark. 176

201 Figure 4.16: Vote 116 utilization by Districts in 2009/10 Figure 4.16 above show that average utilization is around 78%; there are some districts that surpassed the 80% mark, districts like Isingiro, Masaka, Kabuula, Bushenyi, and Mayuge among others. This means districts that were ordering timely managed to utilize a big proportion of their allocated budget. While on the other side there are districts who performed poorly (Kabarole53.95%, Nakaseke24%, Arua 51% Nakasongola 23%, this performance cannot be explained by the withholding of funds by DANIDA or by inability of NMS to supply. The problem must be from the district and there is need to understand this further. 177

202 Overall average utilization by general hospital stands at 79% but again there those hospitals that performed exceptionally well with 90% and above, hospitals like Mityana,Tororo,Entebbe,Kamulii,Masafu and Kitagata while only Yumbe was below 50%. Figure 4.17: Vote 116 utilization by General Hospital in 2009/10 The average utilization for this category of hospitals is 91% utilization. It is only Jinja and Hoima which were below 80%. Graph: Vote 116 utilization by National Referral in 2009/10 178

203 Figure 4.18: Vote 116 utilization by Regional Referral in 2009/10 Mulago performed at 75% Bitabika at 82% Cancer insititute 98% Heart Insititute 77% Since the financing and management of Vote 116 is different from the way PHC and Credit line funds were managed we are reluctant to compare the two. However, Vote 116 in FY2009/2010 had fewer funds for EMHS than PHC non wage and credit line in FY 2008/2009 but at the same time Vote 116 had a high utilization than PHC non wage and credit line in FY 2008/2009. Figure 4.19: Vote 116 utilization by National Referral in 2009/10 179

204 180

205 Batch no Amount Date submitted ,254,402/= 16/10/ ,921,004/= 19/10/ ,567,730,902/= 27/01/2010 Total 4,177,906,308 It is unlikely that the Ministry of Health will settle these outstanding debts given that Danida pulled its support out of the Ministry of Health effective 1st July To that end we went ahead to request for the Accountant General s inclusion of the said debts in the domestic arrears. OTHER DEBTORS Global Fund settled the outstanding amount of Ushs1.8billion but this excluded the Vat Tax element of Ushs 1.1 billion that has since been forwarded to the Ministry of Health and also included in the domestic arrears request. Other debtors include the Uganda Aids Commission with an amount of U Shs 395 million. The bill for UAC has since been routed to Ministry of health as advised by project administration. Clinton Foundation had an outstanding amount of U Shs 114million which was settled in July UNFPA has an outstanding amount of UShs 666million they promised to settle this amount as soon as they receive funds from the Federal reserves. PHC DEBTORS This debt amounts to a figure UShs 722 million. The settlement of these amounts stagnated on the granting of the vote as most facilities had no funds to use for settlement of these debts. We have however gone ahead to agree on schedules of how to deduct them from the various facilities allocation in a phased manner. Some funds have been recovered from numerous facilities allocation as agreed upon and this amounts to Ushs. 233million. Challenges and Way Forward Introduction of the vote status: With this, NMS had to procure specialized medicines for which it had no prior pre-qualified suppliers. To resolve this, and in addition to the in-house pre-qualification, NMS has adopted the PPDA register of suppliers to enrich the supplier data-base, increased funding for trading stock procurements, but without equivalent increase in appropriate human resource. Challenges arise from the poor interfaced between the MACS Management Information system and the SAGE financials system which has required the Finance team resort to manual information analysis. However, the Corporation has sought technical support to resolve the MIS constraints.. Continuous activating and reactivating of health facilities as new information emerge. This has led to the manual transfer of funds from facility to facility in line with the changes requested for but without any system log to refer to the changes at a later date. Need to publish the facilities database to obtain a holistic feedback about its accuracy. The delayed submission of delivery returns that has made compilation of invoicing and accountability difficult and in other cases to debts that cannot be substantiated without proper 181

206 documentation. There is urgent need to fast track submission of delivery paper work from dispatch section to aid verification of domestic arrears as well as accountability of funds usage. The inability to process payments denominated in foreign currency due to lack of an EFT Cash Clearing account with Bank of Uganda. There is need to get away of paying foreign providers whose liaison offices in Uganda don t conduct local trade and therefore can t be paid in local currency. Way forward: The Department has been restructured and re-aligned to meet the increased workload for procurements of medicines and related medical supplies. Recruitments are underway to get the candidates suitable for the available positions JOINT MEDICAL STORE Credit line Table 4.16: Laboratory Credit Line overview by beneficiaries Hospitals HCIV HCIII Total UCMB UPMB UMMB Local NGO/CBO Private Total Table 4.17: Laboratory Credit Line overview by level of care Number units of Level of care Credit shs line Utilization shs May 09-April 10 % tage utilization Balance shs 56 Hospitals 441,354, ,567, (212,979) 3 HCIV 11,597,353 9,647, ,949, HCIII 1,406,636,355 1,341,565, ,070, ,861,588,214 1,792,780, ,807,

207 Number units of Authority Credit shs line Utilization shs May 09-April 10 % tage utilization Balance shs 150 UCMB 848,189, ,195, (81,005,327) 86 UPMB 530,988, ,833, (8,844,904) 23 UMMB 128,137, ,681, (4,544,153) 57 LNGO/INGO 338,715, ,225, ,490,342 3 Private 15,556,770 14,844, , ,861,588,215 1,792,780, ,807,901 The funds under the laboratory credit line for HIV test kits, associated accessories and cotrimoxazole were utilized 100%. The utilization increased from 60% in FY08/09 to 96% in FY09/10. This has been attributed to the inclusion of sundries in the supplies. In addition there has been improved utilization of laboratory services by most health units prior to treatment. Figure 4.20: Distribution of beneficiaries of laboratory credit line Figure 4.20 and Figure 4.21 show the number of units and the performances. There is high probability of maintaining this high level of utilization as emphasis is being put more on laboratory analysis for most of the major illnesses prior to treatment. 183

208 Figure 4.21: Laboratory Credit Line Utilization by authorities %tage /7 2007/8 2008/9 2009/ UCM B UPM B UMM B Othe rs Total Essential Drug Program Credit Line JMS has continued to play a key role in the health service delivery through the implementation of the Essential drug credit line program. During the year MoH issued commitment for the first cycle covering period September to December Thereafter, JMS received a deposit of UGX 3bn for serving the EDP needs for the PNFP health units. By end of June 2010, the total amount utilized was UGX 3.2 bn out of UGX 3.3 bn allocated. This figure included some balances brought forward from the allocation of year III of the program. The utilization for the months of July & August 2009, the other half of the third cycle for year III was UGX 417,179,658. Table 4.19: Essential Medicines and Health Supplies utilization by authority Category Allocation Utilization %Utilization Balance UCMB 1,393,689,016 1,345,507,511 96% 48,181,505 UPMB 898,271, ,799,922 96% 37,471,221 UMMB 229,443,353 1,000,894,201 98% 22,138,653 INGO 135,053,859 LNGO 527,120,999 Others 131,414,463 Total 3,314,993,013 3,206,307,433 97% 108,685,

209 Table 4.20 Essential Medicines and Health Supplies Summary of utilization Authority Credit line (UGX mn) Utilization (Sales UGX bn) %tage utilization UCMB 1,394 1,345 96% UPMB % Others (UMMB, NGOs) 1,023 1,001 98% Total 3,315 3,206 97% Tables 4.19, 4.20, 4.21 and figures 4.22 and 4.23 summarize the utilization by the various authorities. The total utilization level of 97% has been the highest among all years we have operated the credit line. This is an indication that with an early availability of funds, the absorption rate for the credit line can improve significantly. Table 4.21 Percentage utilization trend over four financial years Category UCMB UPMB Others Figure 4.22: EMCL utilization in Million UGX Credit line Sales UCMB UPMB Others Total 185

210 Figure 4.23: EMCL utilization over the last four years %tages /7 2007/8 2008/9 2009/ UCMB UPMB Others Total 186

211 4.5 Diagnostic and Blood transfusion services Laboratory services The Central Public Health Laboratories is a unit under the National Disease Control of the Ministry of Health. It provides laboratory support for disease surveillance through investigation and confirmation of disease outbreaks and feeding into the HMIS database at the Ministry of health resource centre. It is also currently the unit in charge of coordination of health laboratory services in the country and is as such responsible for development of policy/guidelines, training and of implementing quality assurance schemes for laboratories. With funding support from GOU and PEPFAR through the MoH-CDC Cooperative Agreement, CPHL has played a key role in strengthening laboratory services through support supervision, HIV TB and malaria diagnosis. Through monitoring and evaluation CPHL has used this as a platform for strengthening and improving other areas of health laboratory services. Strategic objectives for laboratory services in the HSSP II i) Develop a comprehensive National Health Laboratory services policy ii) Build capacity in laboratory service delivery at National, regional, district, health sub district and primary health care levels iii) Establish a sustainable laboratory supplies system as part of the Essential Medicines and Health supplies management system that will ensure availability of laboratory reagents, equipment, reagents and supplies at all levels. iv) Consolidate and strengthen the National Laboratory Quality Assurance Scheme and establish laboratory linkages within the region to ensure an effective sustainable laboratory referral system v) Establish and effective management structure in the Ministry of Health to provide stewardship, coordination and management of laboratory services Progress on implementation of interventions planned in HSSP II Targets set (activities) for year 4 of HSSP II i) Finalize and disseminate the National Health Laboratory services policy ii) Develop a comprehensive National Health Laboratory Strategic Plan (NHLSP) iii) Advocate for creation of laboratory coordination structure at MoH HQ iv) Upgrade or establish National Public Health Laboratories as national institution as proposed in HSSPII with clear mandate. v) Secure land and draw up plan for the construction of CPHL. vi) Participate in human resource development at pre and post service levels vii) Implement an external quality assessment scheme (EQAS) in 250 (25%) laboratories viii) Establish boisafety and bioecurity progammes in the laboratory network ix) Maintain the laboratory supplies credit line for 100% of all government and PNFP health facilities x) Support 80 districts to conduct support supervision of laboratories xi) Conduct quarterly support supervision and mentoring of regional /district laboratories xii) Provide laboratory support for investigation and confirmation of all disease outbreaks Major achievements and output (impact) attained during the 4 th year of HSSP II

212 1. Health laboratories policy finalized during 2008/2009 and eventually launched during Q1 of 2009/ The process to develop a NHLSP is in the final stages 3. Land for construction of a new CPHL building at Butabika was secured and the construction process will soon be underway. 4. Proposal for a semi-autonomous CPHL presented to the restructuring committee for approval. 5. New National Health Laboratories Technical Committee appointed and facilitated to meet. This committee provides technical advice stewardship on laboratory issues 6. Up to 1000 laboratory staff were trained in HIV testing, blood collection and shipment for early diagnosis of HIV among infants (EID), T.B smear microscopy, laboratory management districts were supported to conduct 2 rounds of support supervision of peripheral laboratories 8. EID was integrated into child days plus and the number of sites offering EID increased to Continued to collect and collate laboratory data from peripheral facilities for forecasting of laboratories supplies needs and feeding into the resource centre for surveillance 10. Provided laboratory support for the investigation of various out breaks including, Cholera, typhoid fever, brucellosis, epidemic meningitis, bacillary dysentery, food botulism, H1N1 influenza, Hepatitis in various localities in the country. 11. Conducted one round of support supervision of general and regional hospital laboratories in 80 districts 12. Participated in writing grant applications for funding of laboratories services in Uganda to the World Bank and to CDC. Under the CDC proposal, CPHL, all General and Regional Hospital Laboratories would be supported. Under the World Bank Proposal, the National T.B reference laboratory, 5 regional Hospital laboratories and CPHL would be supported. Major challenges 1. Lack of a strategic plan for laboratory services in the country 2. Lack of a defined structure for coordination of laboratory services at the Ministry of Health Headquarters 3. Status and mandate of CPHL(NPHL)not at national institution level and no written mandates 4. CPHL is accommodated in a rented residential house in the middle of the city 5. Recruit personnel to fill the vacant GoU positions at CPHL 6. Slow release of funds dedicated to activities for improvement of laboratory services 7. Weak regulatory framework for laboratory services in the country 8. Limited number of available laboratory professionals to implement the activities 9. Biosafety and bio-security in laxity status and limited 10. Insufficient funding from Government for laboratory services, rely heavily on donor funds 188

213 Table 4.22: Achievements of the CPHL during the HSSP II period HSSP II target/ indicators 2004/ / / / / /10 Data source comments Develop a comprehensive National Health Laboratory services policy No Policy in place No Policy in place Drafting initiated Drafts 2-3 Policy Finalized Policy launched and dissemination started Lab Policy document Policy has been launched during Q1 of 2009/2010. Strategic plan for its implementation is being developed Advocate for creation of laboratory coordination structure at MoH HQ Started advocacy Included in the restructuring of MoH Included in the restructuring of MoH Included in the restructuring of MoH restructuring Stewardship of laboratory service is very crucial for organised ans systematic management Upgrade or establish National Public Health Laboratories as national institution as proposed in HSSPII with clear mandate Proposal in the HSSPII Proposal the HSSPII Included in the restructuring of MoH Included in the restructuring of MoH Included in the restructure of MoH HSSPII WHO(IHR),CDC Requirement that countries establish National ref labs at international level and standard Secure land and draw up plan for the construction of CPHL. MoH communicated to ULC MoH communicated to ULC,Butabika Hospital Survey of the CPHL land at Butabika design and NEMA clearance done CPHL/CDC Important to have a dedicate accommodation befitting national reference labs Number of heath facilities with functional laboratories (Government and PNFP) Surveys by CPHL Numbers have increased but personnel still lacking Number of laboratories receiving supplies on the National Laboratory Credit Line Surveys by CPHL However, stock outs have been frequent due to delays in responding to orders Training: Participate in human resource development at pre and post service levels CPHL/ partner databases Many in-service training program by CPHL and partners Consolidate and strengthen the lab quality assessment scheme CPHL Additional EQA Establish bio-safety and biosecurity progammes in the laboratory network 2 CPHL staff attended WHO training in Nairobi attended WHO/ACILT training in NHLS Johannesburg CPHL Essential function of health laboratories 189

214 4.5.2 Uganda Blood Transfusion Service The main goal of the Uganda Blood Transfusion Services is to make available adequate quantities of safe blood and blood products for the management of all patients in need of blood. The specific objectives are to: i) Expand blood collection to operate adequately within a decentralised health care delivery system ii) Increase annual blood collection necessary to meet all the blood requirements of all patients in the hospitals iii) Test all blood for transfusion transmissible infections and operate an effective QA program iv) Ensure continuous education and training Progress UBTS has been implementing the PEPFAR grant for Rapid Strengthening of Blood transfusion Service in Uganda in addition to the Government of Uganda funding through Vote 151. The total grant for year 5 ended 31 st March 2010 and a no-cost application was submitted for April - 30 th September 2010 to bridge the gap as a decision was awaited for the application submitted to PEPFAR 11 for the period The strategies that were implemented to expand the blood collection within a decentralised health care delivery system included: i) Operationalising two Regional Blood Banks and the expansion of Nakasero Blood Bank ii) Securing of additional space at Kitovu hospital and land for Gulu Blood Bank. Also, plans for construction of Gulu/Fort Portal Regional Blood Banks are in final stages iii) Improvement of institutional capacity Three generators for three Regional Blood Banks Computers procured and distributed Vehicles: 7 Suzukis, 1 minibus; 4 land cruisers procured and distributed iv) Expansion of staffing structure to include Economist, Procurement officer, internal Auditor were recruited Not achieved: i) Completion of external works Mbale/Mbarara Regional Blood Banks ii) Provision of alternative source of power for Arua Regional Blood Bank iii) Adequate equipment for Regional Blood Banks iv) Exploration of alternative testing techniques v) Full functionalisation of BBMIS in regional Blood Banks vi) Efficient handling of vehicles in the Regional Blood Banks 190

215 Blood collection is the largest activity of UBTS. It includes: Recruitment of Blood donors, Blood donor education (pre-donation counselling), and selection, collection of blood and post-donation counselling (notification) and donor retention. This activity is jointly carried out by the staff of UBTS and Uganda Red Cross Society (URCS). Increment in collection depended largely on the dedicated operation of mobile teams that collected up to 90% of all blood units while fixed sites collected 10%. For instance, each blood collection team had a target of 37 units per session and a total of 740 units per month. The 20 teams and all the fixed sites collected a total of 170,191 out of the targeted 195,360 units. This was an overall 0.56% increase in blood collections for the FY 09/10 as compared to FY 08/09 Figure 4.24 summarizes this information for collections by centre and shows that the largest increase is attributed to the central region. Figure 4.24: UBTS units collected per Regional Blood Bank UBTS UNITS COLLECTED PER RBB FOR JULY2009-JUNE2010 COMPARED TO THE SAME PERIOD UNITSJULY2008- JUNE2009 UNITSJULY2009- JUNE2010 TARGET UNITSJULY2008- JUNE2009 UNITSJULY2009- JUNE2010 KITOVU F/PORT AL MBALE ARUA GULU CENTR AL MBARA RA TARGET In order to secure blood safety, it was necessary to ensure that all blood was tested for TTIS as well as operationalise a nationwide quality assurance (QA) program. Progress was realised in that: 191

216 i) All blood that was collected in the 2009/10 was tested for HIV, Hepatitis B, C and Syphilis in addition to grouping before issue to hospitals in a quality controlled manner. ii) An effective testing algorithm has been established and is already in use. iii) Quality manual for QA processes for Blood donor recruitment, Blood donation, laboratory testing and issuing of blood was reviewed and is now ready for print thanks to support from SCS. Consolidation of quality control practices will include ensuring that samples are sent to reference laboratories for quality control tests, supervision is strengthened in all departments and that there is continued improve in occupational safety and waste management. It will also be necessary to strengthen the clinical interface. iv) Component production has commenced in the Regional Blood Banks, though on a small scale. v) Hepatitis B vaccination was conducted for all staff Figure 4.25 shows that the target for prevalence of hepatitis amongst donors has been met in 2009/10. Figure 4.25: Trends of Hepatitis C among blood donors July 2009 to June 2010 UBTS TREND OF HEPATITIS C AMONG BLOOD DONORS FOR A PERIOD OF JULY2009- JUNE2010 COMPARED TO THE SAME PERIOD JULY2008-JUNE HEPCJULY2008- JUNE2009 HEPCJULY2009- JUNE2010 TAREGT KITOVU F/PORTA L MBALE ARUA GULU CENTRAL MBARAR A HEPCJULY2008-JUNE HEPCJULY2009-JUNE TAREGT Training has been a core activity of UBTS in the past FY. All cadres of staff including nurses, technicians, doctors and administrative staff have benefitted from capacity building exercises locally and internationally. A number of staff has been trained at Sanquin Blood Bank in the Netherlands. Clinical seminars were conducted in all regional Blood banks for improvement of Hospital transfusion practice and clinical interface In the previous YR, UBTS has conducted M&E activities to improve efficiency and effectiveness of BTS activities. Supervision from the headquarters to the regions was strengthened. Area team supervision was introduced. Efforts will be made to improve on the supervision reports and appropriate feedback to supervisees and follow up on recommendations are made. 192

217 4.6 Information for decision making Resource Centre The National Health System needs information in order to ensure that the needs of the population particularly the vulnerable groups are catered for, measure the effects of the interventions, inform policy and assess and improve health sector performance. Substantial progress was made in HSSPII, with increasing data available on health services utilization and system performance. The MOH, Research Institutions, Universities, other government ministries and departments, NGOs and partners are involved in generation and utilization of health information. We hereby outline the Health Management Information System as an integral part of the National Health system. The overall objective of the HMIS is to strengthen the health information system to enable timely and quality data collection, analysis, dissemination and utilization at the local, districts, national, regional, global levels and assist in the measurement of progress towards achieving the HSSP, PEAP and MDG goals. Health information is important for monitoring the performance of the health sector. During HSSP1, guidelines and generic data analysis formats for all levels were developed and distributed in order to improve the analysis and interpretation of HMIS data. New quarterly performance assessment formats for the HSSP and programme indicators for all levels were developed and distributed to all districts. This is an effort to improve HMIS data. Timeliness and completeness of HMIS reporting (a key process indicator for the implementation of the HSSP1 and whose 5year target was set at 80%) improved during the HSSPI and II. HMIS reporting has improved from a national average of 21% in 2000, 53% in 2001, 63% in 2002, 79% in 2003 and 84% in 2009_10 financial year. Challenges of the HMIS The major challenge has been harmonization and streamlining of various data sources and ensuring that they are leveraged to provide a better impact measurement of health sector interventions. The on-going analysis of the old HMIS data revealed lack of accuracy, timeliness and completeness of reports, consequently affecting decision making at all levels. Lack of coordination, leadership, clear strategy, policy and guidelines, as well as shortage of skilled human resources, were the key factors affecting the HMIS performance. Furthermore, the effect of parallel reporting with multiple and redundant formats compromised data quality and increased administrative workload. Among the many shortcomings, we have the following; 1. The multiple information systems (silos) largely contributed to by donors and disease specific vertical information systems leading to fragmentation of health information. We have therefore come up with a draft National Health Information Strategic framework that will inform all stakeholders on criteria for setting up information systems, standards, and codes allowing for interoperability. In this case, much greater advocacy is required to build the case for a country owned, harmonized and coordinated health information system. 2. Integrating public and private practitioner s information system is still a challenge. Data from private practitioners (clinics and hospitals) is critical for having a holistic picture of a population s health. We plan to engage them in a dialogue to get them on board through public private partnership initiative. 3. Need for increased prominence and support There is need for leaders, both within government, and within the Ministry of Health, to provide much required financial and human resources for an effective and efficient integrated HMIS. They also need to champion principles of transparency and the value of good information for good governance of a health system. 193

218 4. Developing a culture that values and uses information is still a challenge: The sector needs to promote use of data for evidence based decisions, planning, and performance measurement and reporting. This will inevitably lead to increased demand for data and improved quality, reliable and complete data. 5. Lack of data collection tools at facility level remains one of our biggest challenges. Due to lack of adequate financial support HMIS forms are not adequately distributed to data collection facilities thus making it difficult for the records officers to fill them and submit on a timely basis to the next levels. 6. Training and follow-up supervision of district information and records officers: Funding has been inadequate to meet the demands of training, and follow-up of these carders. 7. Regular data quality checks cannot be conducted within districts and across the country as is expected due to inadequate funding. 8. Ever increasing number of districts makes data entry at the national level difficult and allows for lots of transcription errors. This requires carrying out double data entry in order to clean the data yet have a small staff structure. We plan on developing a versatile electronic HMIS at district ands facility level. Lessons learnt 1. Involve all stakeholders in revision of HMIS One way to instill an appreciation for good health information is to involve people from all levels of the data chain in determining what data is needed and how it will be used. This is particularly critical for local health workers who may be skeptical about changes to what data is collected and how it is to be collected. The aim of any changes should be to try and reduce the amount of data collected at clinic level and should focus on how data can be better used at a local level. 2. Start with perfecting the paper based system Much attention in HMIS has been given to improving IT aspects of the information system, when in fact the fundamentals of diagnosis, coding and reporting are not yet in place. The most successful experiences of HMIS in resource poor countries have been those that ensure that the routine record keeping is of sufficient quality before considering the use of IT systems. 3. Ensure the feedback loop is continuous and reliable Health workers and managers who have to undertake the data collection are more likely to remain motivated if they see the outputs of their work. This can be further enhanced if data generated is used for performance management. 4. Human resource capacity One of the most difficult parts of improving HMIS is ensuring that the people filling in the forms at health unit level are skilled enough to report accurately, whether on diseases diagnosed or resources used. Further more, the staff examining these forms at the National level have to be suitably qualified for the tasks they are performing, and the numbers of staff dealing with the data have to be increased too especially bearing in mind the fact that the system is purely paper based. 194

219 5. Data storage and use One of the temptations in HMIS has been to get carried away with the technical aspects of data storage and analysis, rather than focusing on the more fundamental issues of making sure the data is correct in the first place. In terms of data use, the centre has been consistently poor at providing adequate facilitation for district information officers to carry out lower level support supervision. Some observers speculate that facilitating greater local use of data could improve data quality overall, as those doing the data collection should be more facilitated. Recommendations 1. Improving prominence of the Resource Centre and finalizing the National Health information Strategic framework 2. Country ownership, harmonisation and coordination of all parallel health information systems (silos) 3. Provision of adequate human and financial resources 4. Establishment of a MoH data warehouse that is accessible by all stakeholders 5. Provision of revised integrated data collection tools 6. Operationalise the Community-Based Health Information System 7. Provision of quarterly web-based feedback to all stakeholders 195

220 Information and Communication Technology (ICT) for Health Care Delivery ICT in the ministry of health has undergone many changes in the health care sector and management over the years. Specifically looking at improving the business processes for effective and efficient health care delivery system; ICT are useful tools that enable transmission of health information between geographically distant parts. It makes it possible to ensure that information is available in real time for evidence-based decision making. National Health Information Strategic framework is being finalised. Besides health information, the HIS Strategic Framework will also provide direction on electronic and mobile health (e-health and m-health respectively). A number of interventions have been undertaken: i) ICT appreciation and behavioural change towards the use of ICT ii) Expansion of the Local Area Network to a Wide Area Network and availing it wirelessly at the Headquarters. iii) Redesigning of the Website and constant updating iv) A number of systems have been developed to ease the storage, retrieval and analysis of health data such as the HRIS system for Human Resource, HMIS for Medical records v) Addition of human resource with the help of development partners vi) Acquiring a state of art server room at the ministry of health. vii)improvement of internet connectivity at the headquarters from 256 kbps to 2 Mbps over the years. viii) Management of our own mail server. ix) Maintainace of the LAN at MOH has greatly improved over the years. x) Allocation of an ICT budget this year. xi) Internet connectivity and LAN establishment to most of the districts Health Offices with help from UCC xii)establishment of basic Tele-medicine at most hospitals with help from UCC and its on going. Challenges 1. Limited awareness about ehealth, 2. Lack of enabling policy environment, 3. Weak leadership and coordination, 4. Inadequate human capacity, 5. Weak ICT infrastructure and services, 6. Inadequate financial resources and 7. Weak monitoring and evaluation. 196

221 Despite the challenges there are existing opportunities: rapid advances in ICT, increasing accessing to mobile phones and broadband connectivity, increasing donors and in country support through strengthening health systems and partnerships. Recommendations i) To strongly advocate for presentation to TWG of all new ICT projects which seek to use government health structures or employees and have an impact on the national HIS,while they are still at Concept Stage, for review and recommendation for implementation ii) To provide recommendations on project alignment to current programmatic objectives and strategies of the MoH and the developing HIS framework iii) To assess viability of initiatives, ensuring that they use appropriate technologies, and are sustainable, replicable, scalable, and interoperable. iv) Provision of adequate human and financial resources. v) Redesign the Wide Area Network by adding MoH remote sites like UNEPI, Health Infrastructure Wabigalo, Chemotherapy and TB vi) Upgrade connectivity from leased copper lines to fibre for fast speeds and reliable connectivity. vii)upgrade from 2 Mbps to 5 Mbps both upload and down load viii) Establish an intranet at MOH ix) Establish an area storage network x) Shift from the use of analogue phone communication to IP telephone technology xi) Increase technical support to the hospitals and districts, training in basic ICT to deliver health services. xii)establish Hospital Profiles on MOH website. xiii) Establish a Data Ware House at the MoH Head quarters to streamline reporting of the different health system modules.establish a Document Management System. 197

222 4.7 Health policy, research and development Policy Analysis Unit The policy Analysis unit is under the planning Department, it is entrusted with the responsibility of formulating, reviewing, analyzing researched policies and legislations for the sector. These units were instituted in all line ministries to have a streamlined way of dealing with policies and programmes. Also in collaboration with other divisions of the planning department, has taken part in developing of the sector papers in respect of National Development Plan and the Ministerial Policy Statement. Functions of PAU i) Advising Permanent secretary on important policy changes ii) Legislation process iii) Liaison with relevant units on Ministerial policy statement iv) Result Oriented Management (ROM) v) Regional integration of Health policy vi) Optimal utilization of resources Achievements in Financial Year 2009/2010 i) Carried out 2 consultation workshops ii) Carried out 4 health acts workshops iii)attended 4 workshops for policy document development. iv)carried out 4 policy surveys v) Conducted 6 legislation task force meetings. vi)attended 2 international conferences/ courses vii) Procured furniture and equipment for PAU office viii) Procured 2 consultancies for legislation on human organ transplant and policy effectiveness Table 4.24: Health Policies/Bills and their status No Name Status 1 Pharmacy Practice and Profession Bill Referred back to MOH 2 Traditional and Complimentary Medicine Principles Cabinet 3 National Drug Act Cabinet/Top Management 4 Health Tertiary Institutions Bill Cabinet 5 Mental Health Act MOJCA

223 No Name Status 6 Public Private Partnership in Health Policy Top Management 7 National Health Insurance Bill MOJCA 8 Draft NHPII Task Force 9 Draft HSSPIII Task Force 10 Mental Health Policy MH Division 11 Human Resource for Health Policy Referred back to MoFPED 12 Research Policy MoFPED for certificate of Financial Implication Note: A great number of policies have remained unapproved by the cabinet due to challenges of meeting cabinet requirements. Costing policies and plans remains one of the biggest challenges in the sector. Challenges i) Lack of integration and linking into the development of policies. ii) There is a limitation of funds. The funds allocated to the unit are limited and thus carrying out some activities is put on hold. Recommendations i) Strategies should be made to integrate and link the development of policies. 199

224 4.7.2 Uganda Virus Research Institute a) Mandate and objectives UVRI is one of the constituent institutions under UNHRO an -autonomous organization under the Ministry of Health (MoH). The Institute s broad mission is to carry out scientific investigations concerning communicable diseases especially viral diseases of public health importance and to advise government on strategies for their control and prevention. b) The General objectives for research and development are to:- i) Improve coordination, dissemination and utilization of health research results ii) Mobilize and establish a funding mechanism for health research iii) Develop capacity for health research at the district level c) Specific objectives to UVRI: i) To conduct relevant research in viral and other infectious diseases ii) To contribute towards the strengthening of laboratory networks iii) To contribute to effective infectious diseases, surveillance and monitoring systems iv) To provide critical information from research for policy, development and decision making The requirements for the above objectives to be achieved are adequate infrastructure, wellequipped laboratories, highly trained and well motivated personnel to ensure retention. Summary of achievements The Institute s programmatic activities currently comprise basic research, applied research (intervention, diagnostics, clinical, operational), social/economic research, capacity building, and advice for regulation, policy development and quality improvement in health care. The Institute has played a major role in surveillance for the world AFP polio and is happy to report that no cases exist in Uganda. In addition, the institute had 666 sites provided with QA services from 30 th September 2008 to 29th September 2009 and 439 sites as of 15 th may 2010.The Institute with support from our collaborators from MRC IANPHI, EDCTP, Welcome Trust and THRIVE among others is carrying out a lot of capacity building in the area of clinical research to improve and strengthen health research in the East African region. There is, in addition, a major function of training that is spearheaded by a Training Committee and the UVRI Clinic that serves both Institute staff as well as the surrounding community and also undertakes research. 200

225 Table 4.25: Achievements of the Uganda Virus Research Institute in 2009/10 Indicator 2004/ / / / / /10 Baseline Strengthened outbreak/epidemic detection and response Reduce the Case Falality Ratio ( CFR) for plague 1% Overall CFR plague mortality was <26% within a care facility setting Overall CFR plague mortality was <20% The overall mortality was <20% Overall CFR plague mortality was <14% No cases of Plague were reported Co-infection of malaria and aarboviruses Surveillance of arboviruses in patients duly infected with malaria and arboviruses. No cases detected out of the 30 samples collected from Kisubi,Entebbe and Nsambya hospitals No isolates out of the 22 samples collected from Kisubi,Entebbe and Nsambya hospitals Results of 188 samples awaited Surveillance Not done because funds were not availed Laboratory confirmation of Measles outbreaks 201 (13.8%)out of 1453 suspected cases of measles confirmed and 5 out of 12 suspected cases rubella cases confirmed. Investigated 2273 and 739 (22.5%) measles cases confirmed 350(15.4) suspected cases rubella cases confirmed and 5 out of 12 districts confirmed with Rubella I out of 207 (39) i.e 2.56% measles suspects confirmed and I out of 39 districts confirmed with Rubella Of the 270 suspected cases 12 (4.4%) were confirmed with measles and 14.9 confirmed Rubella suspects. No measles cases reported Zero cases of Acute AFP Polio Mosquito resistance to indoor residual spraying No cases reported No cases reported No cases reported No Polio cases reported World AFP case confirmed in Amuru district although OPV was potent There was no indoor residual spray (IRS) no indoor residual spray (IRS) Observed some resistance to IRS in Islands of lake Victoria with variable prevalence DDT resistance of 7% in Nsanzi Island, 22% in Rakai 26% in and Mbale. Icon: 4% in Nakiwogo,5% in Kigungu- Entebbe,19% in Mityana and 5% in Rakai. Deltamethine: 25% in Mityana and 5% in Rakai Mosquitoes were collected from lake Wamala,Mbale and Bugala. Molecular insecticide resistance allele detected and no Kdr- W detected. No AFP Polio in Uganda Only two populations have been tested in Mityana and resistance detected in Kamuli but testing was incomplete due to insufficient funds. 201

226 Indicator 2004/ / / / / /10 Baseline National Quality Strengthen QA provided to 33 antenatal QA provided to QA provided to 350 antenatal 666 sites were provided 439 sites provided with Assurance Scheme regional labs to sites 210 antenatal sites sites with QA services from QA services as of 15 th provide 30 th September 2008 to may surveillance for 29th September Quality assurance Health management Information System Resource Mobilization for Research To set up a centralized data management unit, Resource centre and a website Resource Mobilization for Research from MoH/GoU and collaborating institutions/agencie s mainly:- WHO,CDC,IAVI and MRC No centralized data management unit, Resource centre and website Resource Mobilization for Research from MoH/GoU and collaborating institutions/agencies mainly:- WHO,CDC,IAVI and MRC No centralized data management unit, resource centre and website Resource Mobilization for Research from MoH/GoU and collaborating institutions/agenci es mainly:- WHO,CDC,IAVI,MRC and IANPHI Resource centre completed Functional centralized data management unit and Resource centre Resource Mobilization for Research from MoH/GoU and collaborating institutions/agencies mainly:- WHO,CDC,IAVI,MRC IANPHI, EDCTP and Welcome Trust Resource Mobilization for Research from MoH/GoU and collaborating institutions/agencies mainly:- WHO,CDC,IAVI,MRC IANPHI, EDCTP, Welcome Trust and THRIVE Maintained the data unit and resource center More efforts are being made to solicit for support for health research for policy. 202

227 UVRI Investments in 2009/10 i. Expansion of the National HIV drug resistance laboratory. The laboratory is equipped and its functional. ii. Accredited laboratories for polio and measles isolation with support from WHO. iii. National and central data management Unit established Challenges 1. Weather fluctuations affected mosquito activity and probably the population size of required samples. 2. Inadequate funds were availed for expansion and equipping the laboratory. External funding was obtained 3. No funds were availed for Monitoring of diseases, performance of their interventions and investigate out breaks. Funding was obtained from CDC. 4. Monitoring districts for co-infection with malaria and arboviruses was carried out. Funds were inadequate to complete testing. Recommendations 1. More funding and attention should be accorded to health research than its currently the case in Uganda 2. More fora should be given to research institutions to disseminate their findings to inform and shape policies in Uganda 203

228 4.7.3 Natural Chemotherapeutics Research Laboratory The Natural Chemotherapeutics Research Laboratory is a government research and development centre under the Ministry of Health (MoH). It was created in 1964 with the mandate to carry out applied research on natural products (plants, animal parts and minerals) with the view of justifying therapeutic claims from traditional medicine practitioners (TMPs) in Uganda. The centre undertakes the development of quality natural products and services for improved health care delivery by applying both indigenous and modern technologies. NCRL is constituted of a multidisciplinary research team of skilled and technical scientists. This team, in collaboration with other partners and stakeholders, ensures that the centre fulfils its mandate to coordinate research and development on traditional medicine. Its goal is the Transformation and sustainable utilization of Traditional and Complementary Medicine contributing towards its integration into the Health Care Delivery System. In order to attain the aforementioned goal, NCRL undertakes the activities described hereunder: 1. Spearheading national policy formulation in the area of traditional medicine, in cooperation with other policy agencies. 2. Standardization of products, involving the promotion and evaluation of their safety, efficacy and quality. This involves: a) Identification of specimens b) Phytochemical screening of both active and inactive ingredients c) Finger printing of analyzed products for consistency and reproducibility of both results and products d) Evaluation of efficacy, derived from both chemical and pharmacological analyses e) Safety studies in laboratory animal models f) Accelerated stability tests that give an indication of the possible shelf-life of the products among others g) Microbiological analyses h) Quantification of both micro and macro nutrients 3. Promotion of health and prevention of disease in the communities involved in the production and utilization of herbal medicines. 4. Collection and documentation of ethno-botanical information and its maintenance in a data bank. 204

229 Progress Financial Year 2005/06: i) Held the Third African Traditional Medicine Day who s Theme was: Traditional African Medicine Contribution to Preventing HIV/AIDS infections. ii) Zanthoxylum chalybeum was evaluated for anti-malarial, anti-cickling effects and painkilling effects. iii) Carica papaya was evaluated for anti-malaria and anti-diuretic properties. iv) Herbal products in the market were monitored and evaluated. v) Warbugia salutaris was evaluated for anti-fungal, ant-malarial and expectorant properties for cough. vi) A leader of 200 Traditional Healers from Bushenyi (Issa Nkondo) was facilitated with a motorcycle to assist him with his mobilization activities. Financial Year 2006/07 i) Scientifically verified the non-effectiveness of the Ellahi anti-hiv/aids product. ii) Trained herbalists and herbal research students. iii) Developed anti-cough herbal syrup based on natural herbs. iv) Coordinated medicinal plants and biodiversity network for the East African Region. v) Participated in the development of the Draft TCM Policy Implementation Guidelines. Financial Year 2007/2008 i) Draft policy in place ii) Code of Ethics for Traditional Health Practitioners developed. iii) Embarked on Scientific validation of a commonly used immunobooster herbal. Financial Year 2008/2009 i) 6th and 7th Annual African Traditional Medicine days held. ii) Safety and efficacy of priority medicinal plants in reference to Malaria carried out. iii) Conserved medicinal plants in Maziba, Kabaale District. iv) Conducted research of herbal plants used for immune booster in Kitgum District. v) Held official introduction of herbalist representative on NDA Board to stakeholders. vi) Held a stakeholder training workshop on quality of herbal medicine. vii) Currently carrying out police investigation of herbal material exhibits from Traditional Healer s shrines in Wakiso District. viii) Carried out Routine Laboratory work in relation to a herbal detox formulation from Bugiri. 205

230 Major challenges The main challenges are: i) Late release of funds affects the schedule of activities. ii) Staff not promoted affects morale and performance. iii) Inadequate office equipment. iv) Delays in procurements of services e.g. vehicle repairs etc v) There is lack of a national database for research done hence hindering it difficult to access. Recommendations: 1. Operationalisation of the UNHRO Act. 206

231 4.8 Legal and Regulatory Framework National Drug Authority National Drug Authority (NDA) was established by the Act of Parliament in 1994 currently the National Drug Policy and Authority (NDP/A) Act, Cap. 206 (Laws of Uganda 2000 Revised edition). The mandate of NDA is to promote use of safe, efficacious and good quality medicines. TARGETS FOR FY 2009/10 i) Evaluation of dossiers (applications for registration) within 6 months ii) Number of counterfeit and substandard drugs identified and removed. iii) Number of samples picked from the market for analysis iv) Regularly inspect local manufacturing facilities. 1 cgmp audit and 3 follow-up inspections per factory. v) Support supervision carried out in 87 districts. vi) At least one inspection team sent out every month to inspect 6 foreign manufacturing facilities vii)all drug promotions and adverts are authorised by NDA Progress Product Registration:- i) Of the 513 human & 37 veterinary medicine applications received; 365 and 12 were approved for registration respectively. ii) 250 applications underwent initial assessment while 175 of these have been reviewed by a second assessor. iii) 26 applications for notification of Dietary supplement applications were evaluated. iv) 31 applications for notification of herbal drugs were evaluated. v) 07 applications for notification of Public Health Products were evaluated. vi) 588 registration amendments were received, of which 352 were approved and 236 applications deferred. GMP Inspection and Licensing of Manufacturing sites:- Conducted GMP inspection of 119 foreign pharmaceutical manufacturing plants. Out of which 94 were compliant, 17 non-compliant and 8 partially compliant. 12 (92.3%) local pharmaceutical facilities were inspected. 2 were licensed while others were requested to provide corrective actions prior to consideration of licensing. Also the first local Medical Device manufacturing facility called Astel Diagnostics was approved. 207

232 Licensing of Drug outlets i) Inspected 516 and approved 459 (89%) pharmacies ii) Inspected 4,497 and approved 4,077 (90.6%) drug shops iii) Controlled import and export of medicines through issuance of verification certificates; 3,058 verification certificates were issued Post Market Surveillance i) Support supervision was conducted in 70 districts at regional level and 51 districts for the Veterinary unit. ii) 1,905 samples of products from ports of entry and market were picked for analysis out of which 593 passed, 63 failed and 1249 are pending outcome of analysis. iii) Recalls of drugs was implemented following the NDA procedure for product recall. 20 products manufactured by facilities in Uganda, Kenya, India and China were recalled. iv) Supervision of drug destruction was made in 14 trips with total weight of 49.3 tonnes. v) Investigation in the quality of Pethidine used in Nakasero hospital where patients experienced adverse drug reactions were made. The sample provided was confirmed to be registered; tests from the laboratory reveal the presence of Pethidine and no contamination by Suxamethonium. Quality Control: Testing of medicines samples Table 4.26: Analyzed drug samples at the laboratory Category Tested Passed Counterfeit Failed %age Failure ARVs Anti-malarials Antibiotics Vet Medicines Analgesics IV Antiprotozoals LLINS Other Medicines

233 209

234 Figure 4.28: Trends of outcomes of gloves tested in FY 2010 Vetted 147 applications of drug promotions and adverts; 140 applications were approved and 07 rejected. Pharmacovigilance Activities (a) Support Supervision on Pharmacovigilance Activities Conducted support supervision to support the core team members improve on the implementation of Pharmacovigilance activities in the regions. The following were the health units visited; 58 Hospitals 83 HC IV 135 HC III 24 HC II 9 Health Training Institutions Sensitized 576 health workers and 1,073 students from training institutions on Pharmacovigilance activities especially on reporting adverse drug reactions in the regions. Sensitised 177 District Veterinary Officers and other Veterinary Professional (Private), 600 stakeholders (public) on monitoring and reporting adverse drug events in the districts of Kabarole, Budibujo/Rwebisengo, Kyenjonjo, Hoima, Kibale, Kiboga, Masindi, Bulisa, Mubende and Mityana. 210

235 (b) Adverse Drug Reaction Reports Received 162 ADR reports (human) during the financial year. As of December 2009, a total of 556 reports had been received. The five (5) most reported drugs were; Cotrimoxazole (58 reports), Nevirapine (49), Zidovudine (43), Atemether / Lumefantrine (41) and Triomune (35). The graph below shows the number of reports received. Figure 4.29: Adverse drug reaction reports from 2005 to to 2009 Num ber of ADR reports received through spontanous reporting RReports Figure 4.30: Adverse drug reactions in FY 2009/10 211

236 Skin reaction (with Cotrimoxazole, Nevirapine and Artemether / Lumefantrin) was the most reported reaction. Other reactions were Gastro intestinal events (nausea vomiting and diarrhea), and anemia Most of the reactions reported are expected. Approximately 80% of reports have missing information. 159 ADR reports were entered into vigiflow database, 123 ADR reports were committed to UMC. Received more than 220 reports of adverse events resulting from clinical trials. Issues of concern were; Tenofovir and birth defects Tenofovir and renal toxicity Artemther Lumefantrin and birth defects (c) Follow up of adverse event reports Table 4.27: A summary of adverse event reports Drug/complaint Complaint source Action taken Results Pethidine injection reported to have caused fasciculations and convulsions. It was suspected to be contaminated with Suxamethonium. Malaria medicines implicated to have caused steven johnsons syndrome 223 cases of Gulteal fibrosis and 17 of quadriceps fibrosis were identified in 2008 and Nitroxinil (troxahel 34%)batch no.1323/3 loss of 6 Friesian Nakasero hospital Newspaper about 2 cases of death in Jinja Kumi hospital during sensitization on pharmacovigilance Kyenjojo Survey of 10 regional referral hospital. Batch tested in NDQCL Presented to NDA Technical Committee and CNF; the case is still to be presented to Pharmacovigilance & Clinical Trials Committee To be notified to MoH Sensitized farmer to consult a professional when using drugs and to report adverse events if observed No similar reaction observed and no conclusion drawn as we could not get post mortem results. Lab results showed no contamination with Suxamethonium Case could not be concluded due to incomplete/poor records at the facility Irrational drug use was cited as the problem The drug was not expired but was administered by a quack and injected the drug using a wrong route, site and there was an overdose 212

237 Conducted studies on Quality of Medicines on the Ugandan Market 1. Post Marketing Surveillance (PMS) Study commissioned by the Authority and focused on various essential medicines i.e.: antibiotics, analgesics, anthelminthics, antifungals, antiasthamatics, and antiprotozoal agents. GPHF Minilabs were used and full scale QC testing for those for which no Minilab procedures existed. Samples were drawn from 7 sentinel sites, these being the 7 regional offices of the NDA. Findings: i) 5.1% of samples failed Minilab testing including visual, identification, disintegration and thin layer chromatography (TLC). ii) 11.5% of samples failed full scale Laboratory testing iii) Only two (2) samples from the public sector failed 2. Quality of Antimalarials in Sub-Saharan Africa (QAMSA) study A survey was conducted on the quality of SELECTED antimalarial medicines circulating in Madagascar, Senegal and Uganda; they included ACTs & SP acquired from the public sector, the regulated private sector and the informal market. 90.4% of samples were subjected to testing using Global Pharma Health Fund (GPHF) Minilab test kits. The remaining 9.6 % of samples, for which there were no Minilab procedures, underwent full scale laboratory testing at the USP Headquarters (Rockville, Maryland, USA). They were: i) Artesunate+amodiaquine (co-packaged) ii) Artemether/ Lumefantrine (fixed dose combination-fdc) iii) Sulfadoxine/ Pyrimethamine iv) Others (mefloquine+artesunate; dihydroartemesinin/piperaquine-fdc; sulfamethoxypyrazine/pyrimethamine-fdc) Findings: i) Failure rates using Minilab: 41% Senegal, 12% Uganda, and 6% Madagascar ii) Failure rates after full QC laboratory testing: 44% Senegal, 30% Madagascar and 26% Uganda. iii) Failures were attributed primarily to dissolution and impurity tests. iv) All samples taken from the public sector in Uganda passed the quality tests. 3. Presidential Malaria Initiative (PMI) / USAID sponsored project The survey employed the use of Global Pharma Health Fund (GPHF) Minilab test kits to ascertain the quality of antimalarials drugs. Testing was carried out primarily at Level 1 (mini lab) which employed thin layer chromatography (TLC) plates at 7 sentinel sites located at NDA regional officers. Level 2 testing at the NDQCL focused on product for which there were no mini lab testing procedures and those that failed testing at Level

238 4. MAMBA I & II Operation Mamba is INTERPOL-WHO initiative targeting counterfeit pharmaceuticals in Eastern Uganda. The first operation Mamba I (2008) took place in Tanzania and Uganda. It demonstrated the way in which multiple law enforcement agencies can be mobilized to achieve a common goal. Mamba II involved Police, Customs and Medicine Regulatory Agencies from Kenya, Tanzania and Uganda as well as the Fair Competition Commission (FCC), and the Office of the Presidency in Tanzania. This was a continued effort at fighting the dangerous trade of counterfeit medicines in the region. Findings: i) These operations succeeded in unearthing unscrupulous dealers, and the operations also identified substandard and counterfeit drugs at various levels; i.e. ii) MAMBA I: Products being peddled as general sales cosmetics, but which actually contained pharmaceuticals e.g. (corticosteroids). Follow-up and involvement of KACITA was enlisted to both educate and increase vigilance. Worst affected area was Kikuubo in downtown Kampala. iii) MAMBA II: confirmed two (2) cases of counterfeits (Metalkefin & Cialis), though the source could not be ascertained iv) MAMBA II: 18 court cases were opened (for among others, suspected dealing in smuggled drugs, re-packing of expired drugs; so far 6 convictions have been secured, while 12 of the 18 cases are still ongoing. Challenges i) Inadequate funding that has hindered: Recruitment and deployment of Zonal Inspectors Recruitment and deployment of Inspectors at all border entry points ii) Implementation of an integrated MIS for the entire organization iii) Delays in amendment of the legislation iv) Extended mandate to NDA not backed up by resources v) Liberalization of media industry and abuse by herbalists and other quacks vi) Conflicting mandates of professional bodies vii)inadequate capacity to handle expired drugs in both public & private health facilities

239 3.0 Budget Performance Table 4.28: A summary of performance for each budget line during the financial year 2009/2010 Output Description FY 2009/2010 FY 2009/2010 Budget Budget Ushs Performance Ushs (millions) (millions) 1 Dossier evaluation Inspection of medicines at ports of entry Inspection and licensing of local manufacturers 4 Inspection and approval of foreign manufacturers Recommendations Support supervision to districts Post Market surveillance Testing of samples Destruction of drugs Pharmacovigilance Training at Regional Centres 10 Sensitization, follow-up & collection of ADR forms i) Advocate for direct funding of NDA by Government of Uganda. ii) Initiate meetings with professional councils to improve working relations. iii) Enlist support of media council to combat media abuse by herbalists & other quacks. iv) Amendment of legislation to address weaknesses in the existing one. v) Increase presence of NDA at the community level through rolling out of Zonal Offices. vi) Establish an integrated MIS platform for all NDA operations with web-based provision for public access to relevant information. vii)strengthen collaboration with health professional councils and other agencies involved in the pharmaceutical sector. 215

240 4.8.2 Medical and Dental Practitioners Council The Uganda Medical and Dental Practitioners Council (UMDPC) is a statutory body, established under statute No 11 of Medical and Dental Practitioners Statute, Vision A reputable council that protects society from abuse of medical and dental practice as well as research on human beings in order to effectively contribute to a healthy and productive population Mission To regulate and enforce standards of medical and dental practice and supervise medical and dental education in Uganda Core Functions i) To supervise medical and dental education in all university medical and dental schools in Uganda. ii) To register all legible medical and dental practitioners and private medical and dental health units in Uganda iii) To inspect all private medical and dental health units in Uganda, to ensure compliance with established standards of practice iv) To enforce ethical standards and professional code of conduct among medical and dental practitioners in Uganda. Objectives for 2009/2010 i) To register and license qualified practitioners and all private health units that meet the requirements of the Council. ii) To conduct regular inspection of private clinics in Kampala area and up country. iii) To investigate all reported cases of alleged professional misconduct and take appropriate disciplinary measures. iv) Participate in the joint EAC Medical Council/Boards Activities. v) Ensure effective management of the Council Major Achievements i) Registered a total 500 practitioners, and licensed 2000 of them during the year while 1500 private health units were licensed. ii) Inspected 100 private clinics in Kawempe and Rubaga Divisions in Kampala area, and 85 private clinics in upcountry towns. 216

241 ix) iii) iv) Inspected 8 Reflexology centres in Kampala area to assess the activities of a self styled group of people called Reflexologists operating in Uganda and make recommendations to Ministry of Health in order for it to make an informed decision. Investigated four reported cases of professional misconduct in Mbarara, Masindi and Kampala and took appropriate disciplinary action. v) Finalized draft proposal on establishment of DSA vi) vii) Participated in EAC Medical Council/Boards meetings held in Arusha and Mwanza in Tanzania. Participated in the joint EAC Medical Council/Boards inspection of medical and viii) dental schools in Rwanda and Burundi in Febuary 2010 ix) Recruited 3 members of staff at the secretariat for post of Secretary, Finance and Administration Officer, Data and Research Officer. x) Overhauled one of the double cabin pick trucks Major Challenges i) Inadequate funding. The Council was allocated UGX 35m as subvention from government for the whole FY2009/10. ii) iii) iv) Inadequate staff at the secretariat. General malaise among practitioners to pay for their APL Inadequate guideline regarding establishment and operation of private clinics v) Lack of regulatory policy in Uganda on traditional and complementary medicine practice in general and for reflexology practice in particular. vi) Lack of efficient transport for field activities. Recommendations i) More funding ii) iii) iv) Expansion of staffing at the Council Secretariat, with creation of inspectorate division Regular inspection of Health Units in Kampala and up country Towns. Regular district support supervision. v) Establishment of District Supervisory Authorities vi) vii) viii) Establishment of an independent umbrella National Regulatory Authority Review of guidelines for establishment and operation of private clinics Operationalization of PPPH policy in Uganda in order to have traditional and complementary medicine practitioners regulated if they must exist. Purchase of a double Cabin Pick-up for field activities. 217

242 Table 4.29: Health Sector Annual Performance Report for 2009/2010 Output Description Annual planned target Actual output Comment Inspection of private clinics in Kampala Inspection of private clinics up country Inspection of reflexology centres in Kampala Inadequate Funding Nil 8 This was an exploratory inspection visit District Support Supervision Inadequate funding Investigate reported cases of professional misconduct Nil Investigated four reported cases of professional misconduct in Mbarara, Masindi and Kampala and took appropriate disciplinary action. Cases to investigate are handled as and when they come Attend meetings of EAC Medical Council/Boards 4 meetings Attended 2 meetings of EAC Medical Council/Boards in Arusha and Mwanza Participate in the joint EAC Medical Council/Boards inspection of Medical and Dental schools. Attending a course in EDMS Nil Nil Participated in the joint EAC Medical Council/Boards inspection of medical and dental schools in Rwanda and Burundi in Febuary 2010 Attended a course in EDMS in Nairobi Finalize draft proposal on establishment of DSA Recruit staff at the secretariat - Finalized draft proposal on establishment of DSA 3 Recruited 3 members of staff at the secretariat for post of Secretary, Finance and Administration Officer, Data and Research Officer. Inauguration of the DSA will take place in Sept 2010 Overhaul one vehicle

243 4.8.3 Pharmacy Council Mission: Protect the Society from Harmful and Unethical Pharmaceutical Practices. Overall Goal: Ensure National and International pharmacy practice standards and codes of ethics are adhered to, both in the public and private sectors and control the conduct and discipline of registered pharmacists. Specific Goals: i) Set and Enforce Pharmacy Practice standards and ethics country wide ii) Attain the Highest Educational qualification for pharmacists iii) Capacity Building of pharmacists and pharmacy auxiliaries iv) Community sensitization Objectives: i) Enforce standards of pharmacy practice in all districts ii) Regulate the conduct of and discipline of all pharmacists iii) Maintain a register of registered pharmacists iv) Ensure pharmacy training institutions conform to set standards v) Approve all pharmacy practice outlets both public and private vi) Conduct Continued Pharmacy Education vii) Empower the community to seek quality pharmaceutical services Relevance to HSSP II The pharmacy council contributes to the attainment of the HSSP program output 3; which focuses on ensuring a well functioning and operational Legal and Regulatory framework to support the attainment of the HSSP objectives. 219

244 Table 4.30: Achievements of the Pharmacy Council Output description Achievements Challenges Comments Setting standards and quality assurance -Guidelines for pharmacy practice developed and disseminated Bill not enacted into law by parliament yet Monitoring and enforcement of Standards/ethics. -1,900 copies of the pharmacy profession and pharmacy practice bill printed and disseminated 25 standard of practice/ethics enforcement visits In adequate logistics(hr, Financial and transport) Inadequate funds makes it impossible to cover all the over 100 districts hence need for commensurate level of facilitation Technical support to universities training pharmacy students Only a few lecturers are adequately trained to lecture, the gap is filled with (i.e. students recruited to teach after they are registered hence quality of out put is wanting in some cases. -KIU & Mbarara have an exchange program with lecturers abroad, hence high turnover and lack of consistency and problem of sustainability -difficulties in attracting and retaining local pharmacists at the universities Joint inspection of health units Health units in Kampala districts 100 health units(drug shops, clinics, nursing homes, maternity units &pharmacies were inspected) Investigation into reported misconduct Several cases were reported and handled within the provisions of the pharmacy and drugs act 1970 Overseeing internship training of pharmacists Collaboration with the three Universities (Makerere, KIU & Mbarara) strengthened i) Internship centers accredited in Jinja, Rubaga, Mbale, Kabale, Lira, Lacor, Gulu hospitals ii) Internship manual developed disseminated and in use -Continuous Professional Development guidelines developed and an interim CPD accreditation body is being established to implement the guidelines and the accreditation system Proper disciplinary actions hampered by the stagnation of the pharmacy profession and the pharmacy Bill 2006 Difficulties in attracting and retaining pharmacists in the government hospitals to supervise these interns Capacity building Funds for the operations of the CPD accreditation body an the CPD district supervisors Need for an affirmative action to train proper lecturers to serve in the pharmacy schools Very useful and must be supported with the logistics it deserves for wider coverage within Kampala and in the 100 plus districts An interim Pharmacy Board is being established to take care of disciplinary matters in accordance to the provisions of the Pharmacy and Drugs Act Need for alternative means of attracting and retaining pharmacists in the public service e.g. Government sponsored pharmacists be bonded Need for additional support to the health professionals current budgetary provisions to see this to fruition - the registrar pharmacy council sponsored for a management training course - Annual CPD for pharmacists and pharmacy assistants organized as required 220

245 Output description Achievements Challenges Comments A proposal is awaited for the task force Establishment of the national health professional authority The process is on and a taskforce has been appointed to make a proposal to the PS MoH Pharmacy Council Strategic Plan Developed awaiting printing and dissemination Implementation ought to be supported by an Act of Parliament as some activities have legal implications Monthly council meetings 12 ordinary council meetings and several special council meetings held each year, during the period Council decisions not backed by any legislation (Act of Parliament) hence difficulties in implementing them Procurement of office Stationery Office stationery were procured Delays in the procurement processes; even with the procurement plan, no change. Office equipment maintenance Two printers and two desktop computers & fax machine Hampered by slow procurement processes and fake service providers Telephone and fax Services provided as required Vehicle Maintained Vehicles repaired and maintained as required The one pickup is nine years old and not cost effective to maintain as it breaks down more Fuel, oils & Lubricants Vehicles serviced within the available finances As above As above The interim pharmacy Board will help push the PPP bill 2006 back to parliament There is an urgent need for the PPP Bill to be re tabled, supported and enacted into law. The procurement processes is always caught by the financial year leading to loss of funds Some service providers do not deserve to be on the list Need for a new vehicle Pharmacists registration Low annual out put from the universities and high International Pharmaceutical /health regulatory annual meetings Participation in the EAC Health professional Boards and association 153(51 Female 102 male) pharmacists registered during the HSSP II out of 450 registered pharmacists. Only three out of ten meetings attended Financial constraints Only one out of five meetings attended Financial constraints failure rate of Pre - registration and eligibility examination More effort required from the students. Challenges: i) Pharmacy Bill Stagnation ii) Inadequate logistics (Financial, HR, office space and lack of transport for field visits.) 221

246 Output description Annual output target Table 4.34: Pharmacy Council Planned activities to deliver the outputs Actual annual output Standards/ethics enforcement. 3 districts visited Standards Enforcement Visits 3 districts visited Technical support to universities training pharmacy students 3 universities (Makerere, KIU &Mbarara) Visits to the universities (Makerere KIU &Mbarara) 2 universities ( KIU & Mbarara) Joint inspection of health units All Health units in Kampala districts Inspection of status and quality of health care in private health units 100 health units(drug shops, clinics, nursing homes, maternity units &pharmacies were inspected) Investigation into reported misconduct cases handled as complaints arises investigations 4cases handled, but due to lack of appropriate laws, could not be disciplined as required Monthly meetings council 12 meetings Payment of allowances and TP refunds 13 meetings held Allied Health Professionals Council The Allied Health Professionals Council is a statutory body put in place by an Act of Parliament in The main functions of the Council are: 1. To Regulate standards, conduct and exercise disciplinary control of Allied health Professionals 2. Approve courses of study, supervise and regulate the training institutes for the different categories of AHPs 3. Approve qualifications awarded by the different institutes in respect of the different categories of Allied Health Professionals 4. Supervise registration of Allied Health professionals and publication of registered professionals in the Uganda Gazette 5. Advise and make recommendations to the government on matters relating to the Allied Health professions. 222

247 Planned activities: i) Registration and renewal of Annual practicing licenses of the professionals ii) Licensing of Private Allied health Units iii) Inspection of government and private health facilities. iv) Sensitization of employers of allied Health Professionals on annual practicing licenses in districts. v) Investigation of cases of unprofessional misconduct vi) Inspection of new Allied health training schools vii)visit to training Institutions viii) Develop terms of reference for Allied Health District supervisors. ix) Develop Continuing Professional Development work plans for all cadres x) Conduct meetings of Council, Committee and Professional Boards xi) Travel abroad to share practices with other Councils xii)creation of awareness on Council activities in some regions Achievements: i) Registration, renewal and licensing of professionals a) 1088 new professionals were registered b) 294 new allied health clinics were licensed c) 424 clinics renewed licenses d) 1234 professionals renewed their annual practicing licenses ii) Inspection of private health facilities. A joint inspection team of all the four Councils inspected reflexology clinics in Kampala district and the report was forwarded to top management. Another joint inspection was carried out in Kampala district covering Lubaga and Kawempe divisions. The Council and Board members carried out inspection in the districts of Wakiso, Mukono, Jinja, Iganga, Masaka and Kayunga. The findings were as follows: a) 90% of Allied Health professions are registered with the Council b) The majority of the allied health professionals do not posses practicing licenses. Only13% were found to have valid Annual practicing licenses. c) The majority of the units were found to be run by Nursing Assistants d) 50% of the health units visited have conducive working environment e) Most units have record keeping and referral system. iii) Sensitization of professionals and Employers Sensitization visits were conducted in the districts to inform the District health officers and Medical Superintendents about the legal requirement for registration and Annual 223

248 practicing licenses. The districts were visited: Wakiso, Mityana, Kayunga, Jinja, Masaka, Mbarara, Kabale, Bugiri, Bududa, Budaka, Mbale, Butaleja, Busia, Tororo, Nebbi,Zombo, Arua, Maracha, Terego, Yumbe, Moyo and Adjumani. The findings were: a) The majority of Allied health professionals working in government are not aware of the requirement to possess the annual practicing licenses. b) Complaints about the transport costs to process the Annual practicing licenses were highlighted in most districts. c) The delay in issuing of annual practicing licenses by the Council iv) Investigation of cases of unprofessional conduct 2 cases of unprofessional conduct of two Clinical Officers in Kamwenge and Kabale Districts were investigated. The disciplinary committee of the Council recommended reprimanding the two officers because of unprofessional conduct. v) Inspection of new Allied health training schools The education committee of the Council together with Ministry of Education and Sports conducted an Inspection of Gulu Institute of health sciences. The institute is planning to train Medical Clinical officers. vi) Visits to training Institutions Consultative meetings on pre-registration of students were conducted in Mulago Paramedical Schools, Fort portal school of Clinical Officers, Mbale School of hygiene and Kampala International University. The Council is planning to start pre- registration of students next financial year to track the students and reduce on forgeries. vii)continuing professional Development (CPD). The Council with assistance of the capacity program conducted a series of meeting to develop CPD work plans for all Allied health cadres. A document on CPD work plans has been developed. viii) District supervisory Authorities The Council planned to appoint district supervisors as away of reaching its members working upcountry. Terms of reference for appointing the District Supervisors were developed and appointments will soon follow. ix) Meetings of Council, Committee and Professional Boards a) Full Council and committee meetings were conducted as planned. b) Six board meetings were held to discuss issues on training and schemes of service for various cadres. These boards are Medical Clinical officers, Radiography, Orthopaedic Technology, Pharmacy and Medical Laboratory Technology. c) The Finance and Administration committee retreat was conducted at Sun-set Hotel Jinja to approve the budget, work plan and the new employment policy. x) Travel abroad The Registrar and Chairman traveled to Health Professions Council South Africa to learn and share best practices. The Registrar attended conferences in Rwanda and United states. xi) Staffing The Health Service Commission appointed the Deputy Registrar for the Council 224

249 Table 4.31: Summary of the main achievements of the Council during the FY 2009/2010 Output description Annual Target Planned Expenditure Registration of new members Renewal of practicing licenses Licensed of private clinics Inspection of Government and private health facilities Sensitization of allied health professionals and employers Investigations of unprofessional conduct Inspection of new training institutions 2,000 10, M 12.5M 2.5M Actual achievement Actual expenditure 1,088 members registered 1,234 renewed APLs 718 Licensed Clinics 40 districts 33.2M Inspection carried out in the districts of Kampala, Wakiso, Mukono, Jinja, Iganga, Masaka and Kayunga Districts 30 districts 50M 17 districts visited and meetings were held with employers (DHOs and Medical Superintendents) on registration and renewal of practicing licenses 8 cases to be investigated 4 schools to be inspected Visits to training Institutions 4 institutions to be visited for consultations 4.5M 2 cases handled in Kabale and Kamwenge districts 4.0M Gulu Institute of health sciences was inspected 3.5M 3 Government and 1 private institutions were consulted 1.0M 2.3M 1.86M Comments 54.4% were registered Only 12.34% renewed practicing licenses 89.75% private clinics were licensed 12.3M Not enough funds released in the 1 st & 2 nd quarter to complete the activity 24.59M The majority of professionals working in government institutions are not aware of annual practicing licenses. The funds released were not enough to cover all the planned districts 3.8M Only two cases were reported for disciplinary action. 1.7M The school to train Clinical officers 3 schools not ready. 3.6M Positive response received from consultative meetings on pre-registration of students. Continuing Professional Development meetings held 8 CPD meetings 2.5M 6 CPD meetings held in Kampala 2.3M CPD work plans for all allied health workers were developed 225

250 Output description Annual Target Planned Expenditure District Supervisory Authorities 40 districts to be covered Actual achievement Actual expenditure Comments 3.5M Not appointed yet 1.6M Terms of reference have been developed Development of employment Policy/guidelines 1 policy document 5M Employment policy developed 3.5M More staff to be recruited employed on contract terms. Meetings of Council, Boards and Committee 4 meetings 8 meetings 12 meetings 14.5M 28.8M 4 meetings held 6 meetings held 4 meetings held 14.5M 21.4M 100% achieved Funds not enough to conduct all meetings Retreats 1 retreat conducted Advert and public relations 4 adverts in news papers 5.4M 1 retreat conducted at Jinja Sun-set hotel 6M 2 adverts in monitor and New vision about regulation of Professionals Travel abroad 4 trips 25M 3 trips were made to South Africa, USA and Rwanda Maintenance of Equipment 6 computers 3M Equipments maintained 3 printers and serviced Vehicle repair and Repair 1 vehicle 9M Repair of Vehicle maintenance UG1654M Procurement of office 3 computers 4.0M 2 computers procured equipments 1 photocopier 10M Photocopier not procured 5.5M Budget proposals were approved by council. 3M Funds not enough to complete the planned activity. Awareness created by Media 17M A system of pre-registration of students was studied in South Africa to be implemented next financial year. 3M Equipments in good working condition 7.6M Vehicle in fairly good working condition 3.8M 0 Funds not enough 226

251 Challenges i) Some cadres practice beyond their scope of training and fail to refer patients on time ii) The majority of Professionals have not renewed their annual practicing licenses. iii) Funds were not released to council to carry out inspection of health facilities iv) Inadequate office space v) Understaffing vi) The Council has one old vehicle which is too costly to maintain Recommendations i) Increase vigilance in inspection of health units to eliminate quacks and ensure safety to the public. ii) Sensitization of employers to ensure that all the Professionals posses valid annual practicing license iii) Appoint district supervisors to work with the District Health Officers office to ensure compliance iv) Purchase of a new vehicle to carry out inspection in all health care facilities. v) Recruit more staff for the Council secretariat The Nurses and Midwives Council The Uganda Nurses and Midwives Council is a statutory Professional Body responsible for the regulation of the Nursing and Midwifery Professions in Uganda From 1964, the Uganda Nurses and Midwives Council was governed by the Uganda Nurses, Midwives and Nursing Assistants Act. This Act was later revised and replaced by the Uganda Nurses and Midwives Act, 1996 which continues to regulate the Council. Mission To protect the public from unsafe nursing practices through Regulation of Nursing Professionals Vision To develop, improve and maintain the quality of Nursing Services delivered to individuals and the Community in Uganda in accordance with government policies and guidelines of International Council of Nurses (ICN). Mandate Protect the public from unsafe practices Ensure quality of services Foster the development of the profession Confer responsibility, accountability, identity and status of the Nurses/Midwives. 227

252 Core functions of the council Regulate the standards of Nursing and Midwifery in the country Regulate the conduct of Nurses/Midwives and exercise disciplinary control over them Approve courses of study for Nurses and Midwives Supervise and regulate the training of Nurses and Midwives Grant Diplomas and Certificates to persons who have completed the respective courses of study in Nursing or Midwifery Supervise the Registration/Enrolment of Nurses and Midwives and publication of their names in the Gazette Advise and make recommendations to government on matters relating to Nursing and Midwifery profession Exercise general supervision and control over the Nursing Profession and to perform any other functions relating to the profession. Objectives i) To strengthen collaboration with line ministries (MoH, MoE & Sports) and other stakeholders on issues related to nursing training and practices ii) To assess the performance of selected health facilities and training schools iii) To renew and confer practicing licenses to eligible Nurses and Midwives iv) Assess the capacity and suitability of new schools intending to start the training of Nurses and Midwives v) Provide technical support to Nurses and Midwives in clinical placement. Achievements During the financial year 2009/2010 the Council was involved in the following activities: i) Committee, sub-committee and sector meetings ii) Registration/enrolment of Nurses and Midwives both locally and foreign trained iii) Licensing Nurses/Midwives intending to open up private domiciliary practice iv) Renewal of practicing licenses for Nurses/Midwives in private practices both general and domiciliary v) Inspection of health facilities around Kampala vi) Inspection of new schools intending to start the training of Nursing and Midwifery vii)technical support supervision to Nurses/Midwives on clinical placement attachment viii) Court/legal issues involving Nurses/Midwives ix) Inauguration of Nursing/Midwifery school 228

253 Table 4.32: Activities carried out during 2009/2010 fiscal year Output description Annual target Output achievement Comment 7.0 MEETINGS UNMC full council 1 One meeting of the full council was conducted Issues related to the operations of council were discussed and streamlined Finance & administration 4 Four meetings were held to review the financial status of the council Other sources for funding council activities were identified Disciplinary committee 1 One meeting was conducted to hear cases of alleged forgery and unethical conduct. In all twenty- seven Nurses/Midwives appeared before the committee Five Nurses had their documents returned, 1 Nurse was removed from the roll and 2 other cases were concluded Enrolment & training committee 4 Two meetings were conducted and addressed issues for Nurses and Midwives during training Specific issues were identified for discussion with the Ministry of Education & Sports- BTVET, Department Inspectorate committee 2 Two meetings were conducted Appropriate measures set for schools found training illegally and hospitals not providing a conducive environment for practicum Secretariat staff 12 Four meetings were conducted where the day to day operations of the council were assessed Some of the gaps identified were addressed to strengthen the UNMC secretariat 7.2 Inter-ministerial/sector meetings Representatives of the council attended over 57 inter-ministerial meetings organized by Ministry of Health, Intra Health and Ministry of Education and Sports Areas of collaboration were identified with various stakeholders 7.3 Registration & enrolment of Nurses and Midwives trained within the country 4992 Three thousand seven hundred Nurses and Midwives who trained within the country during 2009 and 2010 were registered/enrolled Eligible Nurses and Midwives who completed their courses were licensed to practice. 7.4 Registration &enrolment of nurses trained abroad 110 Sixty-five Nurses and Midwives from Japan, Palestine, Germany, UK, USA, Eritrea, Somalia Ethiopia were Those eligible were licensed to practice temporarily/ permanently 229

254 Output description Annual target Output achievement Comment registered/enrolled 7.5 Opening up of private domiciliary homes 7.6 Opening up of private nursing general homes 60 Twenty Midwives were licensed to operate private domiciliary homes 30 Eight Nurses were licensed to open up private nursing homes Eligible Private Midwifery Practitioners were licensed to practice. Eligible Nurse were licensed to practice 7.7 Renewal of private domiciliary practices 500 Three hundred and eighty two Midwives renewed their licenses for private practice Eligible private midwifery practitioners renewed their licenses 7.8 Renewal of private nursing general homes 50 Nineteen Nurses renewed their licenses of practice Eligible serving Nursing Private general nurses renewed their licenses 7.9 Inspection of health facilities around Kampala Three inspection visits of health facilities were undertaken This was to ascertain illegal health facilities & unprofessional nurses/midwives 7.10 Inspection visits to schools intending to start the training of nursing/midwifery Fifteen inspection visits were conducted to proposed schools: Busoga University, Saleem brotherhood, Victoria Institute of Health Sciences, Florence Nightingale, DAF College of Health Professionals, Good Samaritan International, Natiki, Mutufu Schools that met the required standards were given provisional licenses; Saleem Brotherhood, Busoga University & Florence Nightingale 7.11 Technical support supervision Twelve hospitals were visited: Arua, Gulu, Lira, Soroti, Mbale, Jinja, Masaka, Iganga, These hospitals were selected for visits as they are used for Nurses 230

255 Output description Annual target Output achievement Comment Kabale, Itojo, Hoima, Buhinga to follow up nurses and midwives and Midwives sent for attachment 7.12 Court/legal issues involving Nursing/Midwifery Three cases were attended as state witnesses - 2 at Buganda Road Court and 1 in Kapchorwa. On the later case further investigations are being carried out before final verdict is given One incident involving maternal death in Mityana Hospital was investigated 7.13 Inauguration of nursing/midwifery schools 1 One school of Nursing & Midwifery was inaugurated Saleem Brotherhood School of Nursing/Midwifery was officially opened to commence training Publishing a list of accredited training schools for Nurses/Midwives The full list of accredited Nursing/Midwifery training schools in Uganda was published Both public and private schools of nursing and midwifery were published in the New Vision to guide the general public 7.15 Regional and international conferences 2 Two conferences were attended Two officials attended the Association of Principals of Health Training Institutions in Kigali-Rwanda; the Registrar and SNO/T One official (Registrar) attended the Human Resource for Health in Accra Ghana organized by WHO Attendance at the two conferences was an opportunity to discuss issues related to the training of Nurses and Midwives in the region 7.16 International health days 2 Two health days were attended The international Nurses Day in Moroto World Health Day in Nakulabye - Kampala Issues and papers related to the Nursing Profession and the Health Sector were discussed Achievements i) Registered & Enrolled Nurses and Midwives who successfully completed their training ii) Sensitized nurses/midwives on professionalism, ethical code of conduct and the need to renew their practicing license iii) Participated in joint inspection of Health facilities in Kampala District iv) Granted practicing licenses to eligible nurses/midwives v) Published a list of accredited schools of nursing and midwifery in Uganda New Vision 231

256 Challenges Increased forgery of professional and academic certificates Inadequate staffing at the UNMC secretariat Many mushrooming illegal Nursing/Midwifery schools Inadequate mentors and clinical instructors to supervise students Inadequate office equipment Inadequate funding Training and employment of Nursing Assistants to carry out nursing duties Admission of too many students in some Government schools i.e. Jinja, Mulago, Kabale, Lira etc. Deteriorating standards of code of conduct & professionalism among some Nurses and Midwives Inadequate equipment in the practicum areas for students Establishment of District Supervisory Authorities Intensification of registration and enrolment of nurses and midwives Inspection of Health facilities and training schools in selected regions of Uganda Sensitization of nurses and midwives on professionalism and code of conduct. Streamlining the screening of professional and academic papers Development and operationalization of a Five-year Strategic Plan Review of the UNMC Act (1996). Strengthening of collaboration with line ministries and other stakeholders Development of strategies for resource mobilization to carry out planned activities Conducting research in Nursing and Health related issues Sharing of professional information with other councils in the region Consolidating the formation of the National Regulatory Authority of Health Professional Councils in Uganda. Renovation of UNMC office premises 232

257 4.8.6 Uganda National Association of Community and Occupational Health This report relates to the activities of Uganda National Association of Community and Occupational Health (UNACOH) that took place in the period July 2009 to June 2010 Tobacco Control program UNACOH has been an active member in the National Tobacco or Health Forum. During the reporting year, UNACOH developed a number of project proposals on tobacco control on submitted them to potential funders like IDRC, Canadian Public Health Association, Bloomberg Tobacco Control Initiative, among others The UNACOH 17 th Annual Scientific Conference and 8 th Dr. Mathew Lukwiya Memorial Lecture The 17 th Annual Scientific Conference and 8 th Dr. Mathew Lukwiya Memorial Lecture of Uganda National Association of Community and Occupational Health (UNACOH) took place on September 24 th 25 th, 2009 at Hotel Africana Kampala. The theme of the conference was The role of Health Systems in the improvement of the Health of Ugandans. The conference was attended by 111 participants. The conference drew participants from across the country, with over 22 districts represented, plus international participants from Finland. The 2009 Dr. Mathew Lukwiya Memorial Lecture was delivered by Dr. Joaquim Saweka, WHO Representative, Uganda. The Guest of Honour was Hon. Kakooza MP/Minister of State for Health PHC, who represented the Honourable Minister of Health, Dr. Stephen Malinga MP. The Lecture was also attended by the widows and family members of the late Drs. Mathew Lukwiya and Jonah Kule. Both doctors died of Ebola fever, in course of their duty, during two Ebola epidemics, coincidentally on the same date of 05 December 2000 and 05 December 2007 respectively. The respective families received from WHO and UNACOH, post-humus commemorative plaques on behalf of the deceased. In addition, UNACOH held the Annual General Meeting at the time of the Annual Scientific Conference in September, New office bearers were elected for the 2010/2011 term. Dr Joseph Herman Kyabaggu was re-elected President, and Dr.D.K. Sekimpi offered to continue as Acting Executive Director. ` Project Development Several project proposals were developed and submitted to prospective funders, including one on Pesticide Safety to DIALOGOS of Denmark and one on VHT in Kyenjojo/Kyegegwa Districts to UNICEF Uganda Office. These two proposals got funding. Canadian Public Health Association (CPHA) also invited UNACOH to participate in two international project proposal concepts to be submitted to European Commission on Injury Prevention and Human Resources for Health. In addition, two concept notes, one on Tobacco Control and the other ICT for Primary Health Care communication were submitted to IDRC, Canada for consideration. The response is still awaited. There was remarkable success in the local fund-raising drive for the 2009 UNACOH Annual Scientific Conference as reported above. On- going programmes The three year Pesticide Use, Health and Environment (PHE) Project started implementation in June, 2010 and will be focus on the districts of Wakiso and Pallisa. The other project is on Monitoring and Quality Assurance for the implementation of VHT training programme in Kyenjojo and Kyegegwa Districts. 233

258 Monitoring and Quality Assurance for the implementation of VHT training programme in Kyenjojo and Kyegegwa Districts. Representation at International fora UNACOH was represented, by the Acting Executive Director, at the Annual Conference of the Canadian Society for International Health in Ottawa Canada, October 2009, thanks to funding from the Canadian Public Health Association. UNACOH was represented by three members at the Second training of American Public Health Association s Strengthening of Global Public Health Associations Initiative in November 2009 in Durban, South Africa. The training workshop in Planning was funded by Pfizer Medical Group. The delegation also had the opportunity to attend the fifth Public Health Association of South Africa (PHASA) Scientific Conference and the Africa Public Health Associations Forum. WHO-AFRO was represented at these meetings by Professor Khaled Bessaoud, from WHO AFRO Headquarters in Brazzaville, Congo. UNACOH remained the Convenor of the East, Central and Southern Africa Public Health Association (ECSAPHA) and co-convener of the Africa Public Health Associations Forum, mainly communicating using ICT technologies. 234

259 4.9 Public Private Partnership in Health The TWG on PPPH and the drafting of NHP II and HSSP III After some years of slow pace implementation, due to thinning support from the MoH and external donors, the Public Private Partnership has gained new momentum during FY 2009/10. The Italian Cooperation and other donors (USAID, IFC) have renewed their commitment in support to the partnership activities, while the MoH appointed new staff and dedicated more time to the issues related with the Partnership. The TWG on PPPH has conducted several meetings during the year producing a relevant contribution to the drafting the NHP and HSSIP III. A stakeholder meeting was held, last June 2010, to validate the formulation proposed by the TWG with the additional comments and integrations received. Furthermore, the TWG contributed to the definition of the M&E log-frame which will guide the implementation of the program during the HSSIP. The TWG has developed a new Plan of Action (2010/12) to address the activities of the partnership in view of the new support provided by the Italian Cooperation, with the aim to operationalize the partnership at district level. The new PoA focuses on key activities, some of them already planned in the HSSP II, but never realized. Following a decision from the TWG on PPPH, a survey of private facilities has been conducted in the district of Kampala. The survey generated reliable data on the presence and distribution of private health facilities and will facilitate the process of regulating and defining an accreditation system for this sub-sector. It was also planned that similar surveys will be conducted in other districts of the country where the presence of PHP is more relevant. The approval of the National Policy on PPPH and other legislation Following the priorities defined in the Aid-Memoire of the 15 th JRM, new efforts have been devoted to the complete the legislative process for the approval of the National Policy on PPPH by the Cabinet. As required by the legislative procedure, an assessment of the cost implication of the National Policy on PPPH was conducted by a team of health economists, under the guidance of the PPPH Technical Working Group. Although the implementation of the policy may require additional resources, the benefits will largely outweigh the costs in all possible scenarios. Furthermore, the study was able to quantify the resources needed, mostly covered by already allocated HDP funding. Another important activity to finalize the policy draft has been its distribution to all the Ministries in the Country, through their Permanent Secretaries. Comments have been received from the Ministry of Tourism, Trade and Industry and from Ministry of Finance, Planning and Economic Development and incorporated in the draft. Additional comments were received and incorporated from the representative bodies of Civil Society Organizations (CSO) and consumers associations. A consultative meeting was conducted in July 2010 with the Social Services Parliamentary Committee. During that meeting additional comments and suggestions on the draft and the Cabinet Memo were received. The TWG has been also engaged in a discussion with members of the Cabinet secretariat to finalize the cabinet Memo and the agenda for submission. The new final draft of National Policy and Cabinet Memo were presented to the Top Management Committee (meeting of 22 June 2010) and endorsed as a final draft. Subsequently, 235

260 the MoH has requested the definition of a date for submission to the Cabinet Secretariat. Also, the regulatory bill for the Traditional and Complementary Medicine Practitioners (TCMP) is still undergoing revision after comments from the Top Management Committee of the MoH. A full involvement of this sub-sector will only be possible after the bill has been finalized and approved. Dissemination of the National Policy on PPPH The TWG on PPPH decided to proceed with the dissemination of the National Policy, even before its definitive approval from the Cabinet, in order to utilize the additional resources made available by the Italian Cooperation for such activities. After copies of the draft Policy have been distributed to all the Ministries a national dissemination workshop was organized (30 th March 2010) with the aim to contribute to the dissemination of the National Policy and lobby for its approval by the Cabinet. Members of Parliament, high officials from other Ministries and representatives of the Private Sector at national level participated to the workshop. The calendar for ten Regional Workshops 30 to disseminate the National Policy at district level was finalized and the implementation of the workshop started in September in Jinja. Twelve districts 31, with a relevant presence of private structures and representing all the regions of the country, were selected to pilot the district implementation. Support was provided to those districts by the Italian Cooperation to strengthen the PPPH desk officers making them able to perform their role as liaison with the private sector representative at district level and collect data on their contribution. Additional pilot districts will be selected and will benefit the support from Health Initiative for Private Sector (HIPS), an USAID funded project. Broadening the Partnership The HSSP II clearly spelt out the need to strengthen and broaden the partnership through more active engagement with other health related sectors, professional associations, private health care providers and TCMP, civil society and representatives of the principal consumers. To this aim efforts were directed toward a greater involvement of the private sector. A Workshop was conducted (15-16 June 2010) to facilitate the coordination and the establishment of representative structures for the PHP. The participants at the workshop decided to create a federation which will include health personnel with different qualifications from small, medium and big sized health facilities, and all the private entities which face the same problems and need a unique representation towards the government ministries. The workshop also presented the occasion to launch the International Finance Corporation program The Business of Health in Africa which aims to facilitate access to credit for the private health providers while supporting the organization of this sub-sector.. 30 Jinja, Moroto, Mbarara, Fort Portal, Gulu, Mbale, Wakiso, Rakai, Hoima, Arua, 31 Nakapiripirit, Moroto, Pader, Gulu, Kitgum, Jinja, Rakai, Bushenyi Bundibugyo, Kabale, Nebbi, Arua 236

261 Chapter FIVE Implementation Monitoring of the HSSP II Quality Assurance Department (QAD) has the mandate to ensure that the quality of services provided in the entire health sector is within acceptable standards. The departmental objectives are to: i) Ensure that standards and guidelines are developed, disseminated and used effectively at all levels. ii) Ensure that regular supervision and monitoring is established and strengthened at all levels. iii) Facilitate establishment of internal quality assurance capacity at all levels including operations research on quality of health services Development and Dissemination of Standards and Guidelines The Department of Quality Assurance has continued to play a leading role in developing and dissemination of key standards and guidelines for the sector. The Uganda Clinical Guidelines (UCG) 2010 edition were finalized and disseminated to 80 districts during the Area Team support supervision conducted in fourth quarter for the FY 2009/10. In addition the UCG is also currently available on the official MoH website The Patients Charter was completed and dissemination started with fifty three (53) districts in North, Eastern, West, Central and Karamoja regions. The two standards Uganda Clinical Guidelines and the Patients Charter are due for launching during the JRM meeting in Kampala, November The Clients Charter was disseminated to 24 districts in Central, West and Eastern Uganda. Six thousand (6,000) copies of the UCG are expected to be printed during the first half of the 2010/11 FY but the demand for UCG will still remain high. The sector currently has more than 20,000 (twenty thousand) health workers (HSSP II) a situation which gives rough estimate on the number of UCG needed to meet this demand. The Radiation and Imaging Standards have been drafted and are due for finalization and subsequent dissemination Supervision, Monitoring and Evaluation of the HSSP II Supervision, monitoring, and evaluation of the overall health sector performance is one of the core functions for the Ministry of Health. It is a key determinant of quality of services provided and the extent to which efficient utilization of resources within the system is achieved. During HSSP II supervision and monitoring visits to districts were carried out and the Yellow Star Programme (YSP) was taken on as the quality improvement strategy to be used for in districts. The Mid Term Review of HSSP II found that supervision was generally inadequate including areas for supervising the National Referral Hospitals and central level Institutions i.e. Autonomous and semi-autonomous institutions. Area Team visits although with some constraints, have continued taking place throughout the whole period of HSSP II addressing locally available challenges and also mentoring leadership in the districts. Area Team visits have faced a number of challenges like inadequate funding and lack of effective follow-up on issues 237

262 found in the districts. Senior Top visits were introduced in the later period of HSSP II to look into issues that Area Teams identified and considered more appropriate for members of TMC and HSC to handle. The Supervision and Monitoring framework for HSSP II aimed at supporting the local government, health facilities at all levels, the central programmes within MoH and the other central health institutions. Health sector performance indicators, regular reports on supervision and monitoring have been used to provide of information on sector monitoring during this period. The monitoring structures used currently in the sector include: the bi-annual National Health Assembly (NHA), the Joint Review Mission (JRM), the Technical Review Mission (TRM) and the Health Policy Advisory Committee (HPAC). HSSIP (2010/ /15) will focus on strengthening current system for supervision and monitoring in the sector Supervision Supervision of the Center, National Referral Hospitals and Institutions The supervision and monitoring of National Referral Hospitals, central level programs and other autonomous or semiautonomous institutions (e.g. Uganda Chemotherapeutic Research Laboratories, Uganda Blood Transfusion Services, National Drug Authority (NDA), National Medical Stores (NMS) and Uganda Virus Research Institute (UVRI) has been carried out within the long term institutional arrangements (LTIA) which is one of the mechanisms adopted by the Top management of the MoH. The LTIA process involves building the capacity of programs / institutions in the planning process and then supporting them develop their respective workplans and budgets. The performance of these central level institutions is monitored by reviewing their set targets in the workplans against actual achievements. This is done through the established structures such as the quarterly performance review meetings, the monthly departmental and senior management meetings and fortnightly Top Management meetings. In addition the monthly technical working groups (TWG) meetings offer an opportunity for discussion of various issues, while HPAC reviews program/institutional performances with a view of providing policy guidance. During the FY under review most of these structures carried out their functions effectively. All the planned four quarterly reviews were conducted (one review per quarter), the TWG, SMC and HPAC meetings were held regularly. The reports of the sector quarterly reviews were finalized in time, printed and disseminated to stakeholders. TMC has also used the process of preparing Ministerial Policy Statements to critically review the performance of MoH programs and institutions. The TMC carried out supervision and inspections visits to some of the central level institutions such as Mulago National Referral Hospital and the National Medical Stores. MTR for HSSP II points out lack of a well defined mechanism for supervising central level institutions (autonomous and semi-autonomous). This deficiency will need to be addressed in the new strategic plan for the sector. 238

263 Supervision of Local Governments Integrated support supervision, mentoring and monitoring of Local Governments and Referral Hospitals continued to be carried out through the Area Team Strategy in line with the UNMHCP. Five district support visits: three for area team integrated support supervision; one for district planning and another for the pre-jrm/nha of October 2009 were conducted. Members of the TMC participated in the 4 th quarter FY 2009/10 area team support supervision to selected good performing and weak districts which covered over 64 districts for a focused follow up of outstanding issues from previous visits that needed top level interventions. The participation of members of TMC is in line with the HSSP II Mid Term Review Report which recommended top leadership of the MoH to play a more active role in supervision activities. In addition the Political Leadership of the MoH carried out several impromptu inspections of health facilities. Technical programmes also carried out their own technical support supervision to the Local Governments and referral hospitals. The area team supervision, mentoring and monitoring visits main areas of focus included; follow up of actions taken to address issues that were identified from the previous visits, financial resources inputs, human resources for health, medicines and health supplies, support supervision by the DHTs and HSDs and quality of care issues, planning and performance assessment, general health sector management and partnerships and health infrastructure. The area team usually interacts with the district political and administrative leadership before visiting the health facilities, and thereafter conducts debriefing meeting with the District Health Teams. Internal supervision of health facilities Internal supervision of health facilities though very effective in improving service delivery has not been effectively done during the period under review. There have been attempts to build capacity for internal supervision of health facilities and districts by several quality improvement initiatives/programmes. These programmes have supported the districts to supervise HSDs and lower level facilities. The challenge is lack of harmonized performance measurement tool and supervision framework to guide the different stakeholders. This is compounded by inadequate human resource even at district level and lack of transport. The YSP strategy was designed for this purpose but presently will have to be reviewed and institutionalized in the new sector strategic plan for sustainability. 239

264 5.2 Monitoring of the HSSP II Indicators The HSSP II elaborated a monitoring framework for the sector with a range of indicators at various levels, regularity for reports, monitoring structures and source of information. The performance indicators for 2009/10 FY are outlined in the second chapter and are also summarized in the annex tables of this report. HSSP II performance monitoring is extended below the national level including the local government and health facilities District League Table The District League Table (DLT) and Hospital /HC IV Performance Assessment (HPA) initiatives were introduced during HSSP I and continue to be used in HSSP II. The performance for 2009/10 FY is summarized in the annex tables of this report. The District League Table in particular has been useful in stimulating interest and competitiveness among health service providers and other stakeholders with increased utilization of data at the different levels of service delivery. National average performance improved from 60.8% in 2005/06 to 65.9% in 2008/09. There is varying level of performance among districts with most newly created districts ranking lower than the parent districts. Figure 5.1: Trends in National Performance in the District League Table during HSSP II Districts in more disadvantaged environment like Karamoja have a challenge to compete favourably and appreciate change under the current league table ranking. The new strategic plan for the sector will have to address this with more contextualized analysis such that districts with similar characteristics can be compared in terms of performance each year. This has also been considered to some extent in chapter two section of this AHSPR. It is also important to have an M&E plan to avoid ad hoc indicators for assessing performance by the different programmes and at various levels of the sector Joint Action Framework (JAF) Indicators In 2007, the government of Uganda and development partners agreed on joint framework for budget support. This is in agreement with the Paris Declaration and the IHP+ contract for both of 240

265 which Uganda is signatory. The Office of the Prime-Minister is mandated to conduct monitoring of government performance and reporting on JAF is done every quarter. Currently there are ten development partners that have agreed to participate in the Joint Budget Support Framework (JBSF), including the World Bank, the European Commission, the African Development Bank and Governments of the United Kingdom, Germany, Ireland, Belgium, Sweden, Norway, Denmark, and the Netherlands, with anticipated annual disbursements of $300 million, equal to approximately 15% of Government revenue. Under the JAF agreement, GoU and development partners have agreed upon a JAF for budget support intended to lower transaction costs, strengthen country systems and foster mutual accountability. The JBSF is designed to support the GoU National Development plan, through a strong focus on improving service delivery. The final JAF includes three main sections: I. Preconditions for effective and efficient implementation of government policies. II. Cross-cutting reforms aimed to improve value for money in service delivery through removal of barriers in public financial management and public service management systems while reinforcing compliance with regulations and avoidance of leakages. III. Focused reforms in four key service delivery sectors: health, education, water and sanitation and transport. During JAF II for the FY 2009/10 there was noted decline in delivery in health facilities 33% against the set target of 50% while access to family planning supplies was extended to cover all the eighty districts. Performance on routine immunisation was reported at 79% (target set was 90%). The rate of absenteeism, contraceptive prevalence rate are both waiting for the panel survey currently being conducted by UBOS. The JAF III indicators for 2010/11 FY have been harmonised and aligned with the budget framework paper and Ministerial Policy Statement used by the Ministry of Finance and Economic Planning Decentralisation and heath service delivery The HSSP II was implemented through the decentralised system with clear roles for the central, district and lower levels of government in the delivery of health services. The central government concentrated on the policy and the strategic issues and moved away from the more operational and implementation issues. The local governments in line with the Health sub-district strategy, the routine management and delivery of health services were devolved further to the Health Sub-District. The challenges of some technical programes such as the control of vector-borne diseases being left to run as vertical programes resulting in poor ownership at the local government level was addressed. This was achieved through the DHO taking coordination roles an ownership of all the programs at district level. The DHOs Association was registered and played a key role in policy formulation. Also regional and national hospitals played a key role in contributing to policy formulation through annual meetings, making presentations to the social services committee of parliament and being key participants in implementation and policy reviews. Some of the national level institutions (e.g. Uganda Blood Transfusion Services UBTS, Natural Chemotherapeutics Research Laboratory NCRL) and the regional level (especially the Regional 241

266 Referral Hospitals) were adequately involved and made part and parcel of the central level of in the National Health System. UBTS and NCRL is active in Senior and Top Management committees and, Technical Working Group. During the implementation of the HSSP II, emphasis was put on making sure that the different levels carry out their mandated functions. This was achieved through: i) The sector developed Joint Assessment Framework indicators which are reported on both at a District and national level. However, the sector did not develop an elaborate monitoring and evaluation framework which has been addressed in the Sector strategic and investment plan ii) The sector used a resource allocation formula which is now being revised with assistance from WHO and the formula will be used in FY 2011/2. iii) Annual work-plans were developed at the different levels for the operationalisation of the mandates right from central level, both at regional referral hospitals and districts. They are now part and parcel of the Ministerial Policy Statement. iv) Quarterly, annual (including technical and Joint Review Missions), and mid-term reviews were carried out to ensure adherence of the different levels with the responsibilities/functions laid out for them. In addition, three National Health Assemblies were carried out ; v) Frequent assessment at the different levels including comparison of performance between like entities was carried out to encourage competition and better performance. The District League Tables were constructed in the s, and Hospital Performance Assessment using the Standard Unit of Output in the Annual Health Sector Performance Report were used in the plan period to access outputs. However, a league table for assessing Ministry of health headquarters was not made and this shall be considered in the HSSIP. League tables for Departments at National and Regional referral hospitals were also not made and this shall form a program of work in the next plan period The SWAp, and working together as partners in the health sector Thus, all the stakeholders in the health sector used the agreed on programme of work (the Health Sector Strategic Plan) and the point of involvement of the various players. Memorandum of Understanding The Government, Health Development Partners (HDPs) and Civil Society Organizations (CSO) worked under a Memorandum of understanding (MoU) that was signed for the implementation of the second Health Sector Strategic Plan. The MoU facilitated the implementation of the National health Policy and HSSP II using a Sector-Wide Approach (SWaP). The MoU is aligned with international agreements that have been ratified by the Government of Uganda (GoU) which include the Global IHP+, Harmonization for Health in Africa, Accra Agenda for Action and the Paris Declaration on Aids Effectiveness. 242

267 The GoU continues to provide a stewardship role in the health sector; strengthen links with with stakeholders working in the health sector; continuously improve on public financial management and procurement systems; ensure improved aid effectiveness and provide feedback on health sector performance to all parties. Sector-Wide Approach In this period, 2004/5 to 2009/10, the health development partners placed emphasis on providing financial, technical and management support through the broad framework of SWAp using government procedures for disbursement, procurement and overall management. However, some projects continued to be implemented in partnership with the central and local governments. Global Funding Initiatives (e.g. GFATM, PEPFAR, GAVI) carried out direct disbursement of funds Central level institutions, districts and both public and private providers of different health services for specific activities. During the HSSP II, there has been a strain in partnership with the Private Sector and specifically the Facility-Based PNFP providers. There are also still challenges in dealing with the Nonfacility based PNFPs, the PHPs and the TCMPs. Progress has been made with the PPPH policy and submitted to Cabinet for approval. The role of government as the overall steward was strengthened, and the other stakeholders accounted to government and through government to the population. This contributed to efficient and equitable utilization of all resources, from the government budget, global initiatives, development partners, the local governments and households while minimizing duplication and overhead costs. This was achieved through the following: i) The different roles and responsibilities of the government (at various levels) and the development partners was elaborated in the MoU for HSSP II implementation; ii) Regular assessment of performance against these roles and functions was carried out quarterly, by HPAC and the Inter-agency Coordination Committees, and annually by the Joint Review Mission. The Long Term Institutional Arrangement (LTIA) was elaborated on with support from WHO country office and published as the blue print for relationship of partners in the health sector. iii) The coordination and consolidation of activities was carried out by different players public, PNFP, PHPs and CSOs, with focus at the district and HSD levels; iv) Involvement of the community was main cornerstone in reaching households through VHTs Delivering an integrated package of services The UNMHCP was delivered as an integrated package of services. This was particularly done at the service delivery levels where the same health workers and similar inputs were used to provide the whole range of services to the population. The horizontal linkages between the clusters was emphasized but posed challenges especially with programs which are donor driven like some aspects of HIV/AIDS control program sometimes with duplication. The challenge was due to the need to account for resources separately for the resources provided and failure to develop an integrated reporting system at some levels. 243

268 Integration during the HSSP II was achieved through: i) Using Generic Planning Guidelines to develop district and HSD work-plans and are being updated to further help the different entities to work towards the provision of an integrated package of services. These guidelines put emphasis on: ii) Use of Generic Inputs and logistics systems - allocation of these inputs is determined by level of care and therefore by health care needs, and the minimum service standards and not generic supervision, monitoring and evaluation framework for example: o a comprehensive performance assessment framework like the district Planning Guidelines; o the use of the integrated Teams for supervision and monitoring the Area Teams; and o the use of generic Quality of Care tools like the National Supervision Guidelines and the Yellow Star Checklists. 244

269 5.3 Quality of Care Addressing quality of care issues is important as it is one of the key elements of the right to health. Over the years the MoH in collaboration with Development Partners has built capacity for establishment of internal quality assurance at all levels. Due to increasing number of districts and demand for improved quality of services the QA department is faced with the challenge of ensuring that it is able to address this demand across the country. During the last financial year human resource capacity for the department was increased from 3 to 5 officers Quality Improvement Initiatives Since 2005 a number of quality improvement initiatives have been introduced in the country mostly donor driven basing on the principles of; meeting the needs of the clients, focusing on systems and processes, using data to improve services, teamwork and better communication. Some of the initiatives are programme specific such as the Uganda Capacity Programme (UCP) Performance Improvement with focus on human resource improvement, while others are disease specific such as Health Care Improvement (HCI), HIV QUAL, STOP Malaria. Maternal and clinical death reviews/audits are irregular yet are mandatory for any deaths on table in theatre, maternity, psychiatric and peadiatric wards. Death audit committees have been formed in a number of RRHs. General Hospitals and HC IVs are yet to be covered. The 5S Total Quality Management (TQM) which focuses on continuous improvement through all aspects of life by improving standardized activities and processes was piloted by JICA in Tororo hospital since Other sites that are implementing this initiative are; Kapchorwa GH, Mbale RRH, Gombe GH, Busolwe GH and Kabale DHO. The differences between these initiatives are in the approach to implementation but the concept and principles are largely similar. All these initiatives have registered improvement in quality of care and therefore need to design and implement a national roll out strategy. The current quality management system is not well developed and needs to be reviewed and improved. There are weak mechanisms to coordinate the many QI initiatives both at the Central and Local Government levels. The initiatives are not harmonized and integrated within the existing health care system for continuity. Each quality actor has their own standard and approach. This weak coordination and the obscure reporting mechanisms tends to weaken the intended result of the initiatives and also raises concerns of effectiveness and sustainability of such initiatives especially when donor funding dwindles. In addition it becomes very difficult to assess, evaluate and measure quality improvement after an intervention has been initiated. The QA department has identified the need to develop a national quality improvement framework and Performance Monitoring Plan to guide coordination and institutionalization of quality improvement. 245

270 5.3.2 Responsiveness, Accountability and Client Satisfaction Responsiveness of the health system is measured by the level it meets peoples expectations as regards the way they desire to be treated by providers of preventive, curative or health promotion services. During this FY no study was conducted but there is one scheduled for 2011, 2013 and 2015 in the new health sector strategic plan. All districts and health facilities are expected to establish feedback mechanisms like suggestion boxes for regular feedback. The MoH passed a circular regarding operationalization of suggestion boxes and their functionality needs to be assessed. Other feedback mechanisms like the media indicate that clients are mostly dissatisfied with cleanliness of facilities, long waiting time even for emergency cases, non-availability of medicines and qualified staffs, health workers attitude to patients, inadequate access to specialized services, etc. These are much similar to the 2008 client satisfaction survey findings which showed that the level of satisfaction with regard to physical access to physical to health services was above average (66%), hours of service was 71% and waiting time by users in health facilities was 46%. The Clients Charter was launched in 2008 and has been disseminated to 24 (twenty four) districts out of the current 112 (one hundred and twelve) districts. There is need for wider dissemination and sensitization on the purpose for its effective utilization. The Charter spells out roles of the different stakeholders in health and is due for review in the year The Patients Rights are recognized as the inherent dignity and the equal and unalienable rights of all members of the human family. In Uganda, The Patients Charter was completed early this year and has been disseminated to 53 (fifty three) districts in the country. There is a big gap to bridge in-order to improve level of awareness on patients rights, responsibilities and obligations in the community. The Charter will have to be translated into the key different languages in the country and sensitization carried out widely to increase demand for quality services. Other strategies to improve responsiveness, accountability and client satisfaction include empowerment of individuals, households and communities to take their role as health producers and consumers. Guidelines for establishment of Health Unit Management Committees (HUMCs) are in place but need to be reviewed. All HUMCs at Regional referral Hospitals are functional however; functionality and guidelines for establishment of HUMCs at general hospitals and lower level units need to be reviewed. The sector together with Civil Society Organizations have to get the community more involved in ensuring quality services are delivered in the health system in the country Coordination of Research The Quality Assurance Department as per its core mandate has continued to coordinate research through the Supervision, Monitoring, Evaluation and Research (SMER TWG). The SMER TWG actively participated in preparation for the Uganda Demographic Health Survey (UDHS) which will be conducted during 2010/11 and 2011/12 financial years. Collection of baseline information on Non-Communicable Diseases has been integrated in the forthcoming UDHS. The proposal from the implementing agency Uganda Bureau of Statistics (UBOS) was discussed by the SMER TWG and the Senior Management Committee. The tools were reviewed and the relevant working committees to get the work done have been set-up. This survey takes place every after five years and the final report is expected to be ready by January There is need to strengthen the research coordination function of the Department in order to promote evidence based policy making and planning. 246

271 Challenges for supervision and monitoring i) Lack of a comprehensive supervision and performance measurement framework. The mechanism for the inspection function is also not clearly set up for this to be properly accomplished by the Ministry. ii) There is a poor feedback and follow-up mechanism on issues identified during supervision visits conducted. iii) Weak coordination in implementation of quality improvement initiatives by a number of agencies operating in the country at present. Quality improvement initiatives like the Yellow Star Programme introduced in several facilities in the country has not been well integrated into routine support and supervision. iv) Inadequate resource allocation to the centre and districts for them to carry out proper supervision in their respective areas of operation. Supervision by local government to districts is irregular, inadequately facilitated, and is further hampered by lack of transport and inadequate staff in districts. Most districts particularly the new ones don t have reliable means of transport to conduct the required top downward supervision. The center also does not receive enough funds to conduct regular support supervision and mentoring as required. Recommendations for supervision and monitoring i) Review the current supervision mechanism in the country and develop a comprehensive national supervision framework with an elaborate inspectorate function to address the current inadequacies in the supervision system in the sector. ii) Review the supervision tools (YSP) to enable full integration and utilization of the capacity built in the country. iii) Introduce a framework to coordinate and institutionalize all quality improvement initiatives in the country. iv) Expedite the restructuring process in order to increase capacity for Quality Assurance Department to fulfill its growing mandate v) Improve funding for supervision both at national and district levels. 247

272 5.4 Health Services and health status in recovery areas Following the restoration of peace in the Northern region, the Government of Uganda in 2007 launched the Peace Recovery and Development Plan for by then 40 districts in the region. This is a comprehensive three year plan whose implementation is coordinated by the Office of the Prime Minister (OPM). The plan aims at addressing the causes of conflict and instability in the region, restoring livelihoods and revitalize social sectors. The Health Sector Component of the Peace, Recovery and Development Plan focuses on ensuring equitable access to communities in conflict and post-conflict districts of Northern Uganda (PRDP) to Uganda Minimum Health Care Package. Though the launching had been done, full implementation of PRDP could not start immediately due to lack funding. However, in financial year 2009/10 funding was availed and implementation of the plan started. Table 5.1: Grouping of the forty 32 districts in Northern Uganda under PRDP as of 2007 Location Northwest (West Nile) North Central North East Type of Conflict Armed Rebellion Armed Rebellion Deterioration of Law and Order Districts Moyo, Adjumani, Nebbi, Arua, Yumbe, Koboko, Maracha Gulu, Kitgum, Pader, Lira, Apac, Amuru, Dokolo, Amolatar, Oyam, Masindi and Buliisa Kotido, Moroto, Nakapiripirit, Soroti, Kumi, Pallisa, Kapchorwa, Mbale, Sironko, Kaberamaido, Katakwi, Abim, Kaabong, Bukwo, Bukedea, Budaka, Achievements During the last financial year, PRDP district received financial releases from the Government of Uganda through Office of the Prime Minister to implement planned activities. Priority for this initial funding was Health infrastructure development. Follow up supervision by MOH teams indicated that districts were at different stages of utilization of these funds. Most districts had committed funds for infrastructure development. The target for the funds was in rehabilitation/construction of health facilities and staff houses. The figure below show one of the 8 staff houses being constructed using PRDP funds in Amuru district. All the 8 staff houses were at that advanced stage of completion. Similar progress was note in other PRDP district 32 Please note that PRDP focuses on geographical area. Thus, the splitting of PRDP district, increases on the numbers of district in the PRDP plan. The PRDP districts are currently 55 in total 248

273 Figure 5.2: Amuru district, one of the 8 staff houses in final stages of construction using PRDP funds The MOH health with support from World Health Organisation and other development partners worked with Uganda Bureau of Statistics (UBOS) to establish district specific baseline data on key health indicators in Acholi and Karamoja sub-regions. A Mini-Uganda Dermographic and Health Survey was conducted during the first half of FY 2009/10. Preliminary reports results were disseminated to key stakeholders. The results indicate the followings: i) Contraceptive use by currently married women (modern methods) 9.8% for both Acholi and Karamoja sub-regions were low ii) Total Fertility Rate for both subregions were higher than the national average (6.7), highest in Pader 9.4 and lowest in Gulu and Moroto district 7.7 iii) Unmet needs for family planning for both regions was 57.5% iv) Pregnant women aged who slept under an ITN the night before was 50.8% and 64.4% for Acholi and Karamoja sub-regions respectively v) Children <5 years with fever in the 2 weeks preceding the survey who took coartem within 24 hrs after developing fever was 6.9% and 5.6% for Acholi and Karamoja subregions respectively vi) Full immunization coverage (12-23 months) was 72.5% and 57.9% for Acholi and Karamoja sub-regions respectively vii)proportion of children who had diarrheal disease and were given any ORT was 62.8% Planned activities for 2010/11 i) Inadequate supervision of the construction works by the local governments leading poor quality work in some districts ii) Inadequate human resources to operationalise the new infrastructure though there had been improvement in many PRDP districts in some the staffing level (key cadres) was still poor 249