Assessing Malaria Treatment and Control in Selected Health Facilities th Quarter Support Supervision Report July 2010

Transcription

1 Assessing Malaria Treatment and Control in Selected Health Facilities th Quarter Support Supervision Report July 2010

2 Plot 2 Sturrock Road, Kololo Opposite Lohana Academy P.O.Box 8045 Kampala, Uganda Tel: +256 (0) Tel: +256 (0) Fax: +256 (0) The Stop Malaria Project (SMP), funded by the U.S. President s Malaria Initiative (PMI), is managed by Johns Hopkins Acknowledgements University Bloomberg School of Public Health Center for Communication Programs Stop (CCP), Malaria Project with consultancy support from F Malaria Consortium (MC), the Associates Infectious performed the activities that led to the c Diseases Institute (IDI), and the Communication for Development assessment report. The Assessment report is based on inf Foundation Uganda (CDFU). by Stop Malaria Project (SMP), analyzed and reported by F SMP is designed to assist the Government Associates a management and Development Cons of Uganda reach the PMI and consultancy Roll Back team comprised of Patrick Nsamba Oshabe, Malaria (RBM) goal of reducing malariarelated mortality by 50% by and 2010, Dr. and Kayita Godfrey. Special Thanks goes to Dr. William subsequently contribute to the Muhumuza, attainment and Flora Gombe from SMP who aided the sm of the Millennium Development Goals (MDGs). this report. In addition we appreciate the efforts of superv Officers and the in-charges and staff of visited facilities the assessment activities and cooperated with the supervis

3 ANC SUMMARY OF KEY FINDINGS... V 1.0 INTRODUCTION THE STOP MALARIA PROJECT INTRODUCTION TO THE ASSESSMENT... DHO APPROACH AND METHODOLOGY ASSESSMENT FINDINGS IPTP/ANC ASSESSMENT Access to ANC Services on a daily basis... HC Access to IPTp during ANC visists... HF Access to Folic acid/de-worming of pregnant women Availability of ANC materials... HMIS HEALTH MANAGEMENT INFORMATION SYSTEMS Existence of Registers/information systems HW Existence of HMIS/records staff Existence of a Health Unit Data base... IEC Proportion of facilities that conducted self assessment... IMCI Support supervision to lower health facilities Meetings of the Health Unit Management Committee... IPTp CASE MANAGEMENT... ITNs Existence of staff trained in Management of Malaria Cases Appropriateness of malaria Treatment... JMS Appropriateness of Malaria Diagnosis... LLNs Access to Guidelines and Standards required M&E Referral system for emergency cases Existence and visibility of IEC materials for health workers... MFP LABORATORY MANAGEMENT MO Availability of skilled laboratory personnel Techniques Used to Diagnose Malaria in Health Facilities... MoH Functionality of Microscopes in Health Facilities... NA Availability of Job Aids at Laboratory Preparation of stains used in the laboratory... NR Availability of an established System for Quality Assurance... OPD Lab Records/data Management Replenishment of Lab supplies... QBC DRUG VERIFICATION... RDT IEC VERIFICATION SMP Access to Health education talks about malaria Community Awareness Activities... SP SUPPORT SUPERVISION DISCUSSION AND IMPLICATIONS OF ASSESSMENT FINDINGS ACTION POINTS FOR FURTHER ASSESSMENT ACTIVITIES CONCLUSION END NOTES STATISTICS BS CO DOT DSS HUMC USAID Antenatal Care Blood Smear Clinical Officer District Health Officer Direct Observed Therapy Demographic Surveillance System Health Center Health Facility Health Management Information System Health Unit Management Committees Health Worker Information, Education, and Communication Integrated Management of child illnesses Intermittent Preventive Treatment in pregnanc Insecticide-Treated Nets Joint Medical Stores Long Lasting Insecticide-Treated Nets Monitoring and Evaluation Malaria Focal Person Medical Officer Ministry of Health Not Applicable No response Out Patient Department Quantitative Buffy Coat Rapid Diagnostic Test Stop Malaria Program Sulfadoxine-Pyrimethamine United States Agency for International Develo

4 Project. Improved service delivery and quality of care is one of the major database that could be used in manageme components of the five year project. As support supervision is a key information. intervention for improving and maintaining service quality, this activity o is Majority of facilities did not have a computer on w extremely timely. Below is a rundown of key findings in the report. Access ANC/IPTp services o Majority of Health Facilities (HF) were found to be offering IPTp with exception of 6 HCIIIs in Kiboga, 2 facilities in Masaka, 3 facilities o in Although many facilities indicated that they carry o Mityana, 3 facilities in Rakai and 8 facilities in Sembabule district. most facilities there was no evidence to show co o 20 facilities; 8 from Sembabule, 8 from Masaka 3 from Kiboga and 1 records/reports for at least 2 years from Nakaseke district indicated that they do not provide IPTp under supervision. o 18 facilities; 5 from Sembabule, 2 from Rakai, 4 from Mityana, 3 from Masaka, 2 from Kiboga and 1 each from Mubende and Mukono Indicated that they do not have reliable safe water in the ANC clinic Case Management o Although most facilities were found to be providing folic/deworming o Most facilities especially in Mpigi expressed the nee services regular stock outs of Folic Acid were recorded in almost all courses in Malaria case Management. health facilities. o Mpigi district had the highest number (28) of faci o 24 facilities; 6 HC IIIs from Mityana, 6 HC IIIs from Masaka and 6 HC IIs sure whether they had any training in severe Malaria from Sembabule district indicated that they had inadequate cups for o Majority of health facilities indicated that they ha administration of IPTp. provide technically appropriate treatment of malar o Kiboga District had almost half of her facilities supervised lacking IEC o Only 5 facilities from Masaka, 2 facilities from Semb Materials on ANC services including 2 HC IVs and 5 HC IIIs. Also 3 indicated that their health providers are not at the f facilities in Mityana and 3 in Mpigi exhibited absence of IEC materials. o 13/23 facilities in Sembabule, 5/9 facilities in N o With exception of 10 facilities; 3 from Mukono, 2 each from facilities in Mpigi, 18/36 facilities in Masaka indica Nakasongola, Mpigi and Kayunga and 1 facility from Kiboga district, out presumptive management of malaria cas almost all facilities donot dispense ITNs/LLINs. laboratory diagnosis HMIS o With exception of 6 facilities in Mityana and 4 in Kiboga which never gave their opinion on client registers, the rest of the facilities in the data set indicated that they have up-to-date client registers. o Majority of health facilities indicated that they make monthly summary reports. It was only 2 facilities in Kiboga, 3 facilities each in Mityana and Masaka and 2 facilities in Mukono that indicated that they were not making monthly reports. o There was a significant number of facilities that failed to show whether they had summary reports. These included 11 facilities in Masaka, 12 facilities in Rakai, and 9 facilities in Mityana. Kiboga and Mubende had 5 facilities each, Mukono, Nakaseke and Sembabule had 3 facilities database could be run. Only 1/10 facilities in Kayun Kiboga, 8/35 facilities in Masaka, 5/20 facilities in Mi in Mpigi, 7/29 in Mukono, 3/11 in Nakaseke Nakasongola, 4/23 in Rakai, 1/23 in Sembabule f that they had a data management computer o Rakai had 12/23 facilities, Nakasongola had 6/9 fac 8/20 facilities, Mukono had 7/29 and Masaka had indicated that their Health Unit Management Comm previous quarters to review their performance. o It was only 3 facilities in Kiboga, Mityana and Mas that they had not had access to any type of malari of health facilities had them. o Some facilities especially hospitals and sometimes H ambulance services; however it was noted that mo experienced continuous breakdown and most of th Laboratory Management o Masaka (11/36) and Sembabule (11/23) district number, Mpigi district had 8/30 facilities, Mube Nakaseke 4/11 facilities and Mukono with 3/29 faci they did not have a functional laboratory space. o 4 facilities in Mubende, 4 facilities in Sembabule, 4 fa

5 o Only 6/14 facilities in Kiboga, 7/36 facilities in Masaka, 5/20 facilities in because they neither had minutes documented, no Mityana, 12/30 facilities in Mpigi, 12/29 facilities in Mukono indicated reference. that they have functional systems for quality assurance o It was only Kayunga district which had 8/10 facil o In Kayunga District 5 facilities indicated that they experience stock they carry out routine supervision to lower health outs, in Mpigi 11 facilities indicated the same, in Mukono 10 facilities, in none of the 14 facilities indicated that they carry Rakai 16 facilities and in Sembabule 6 facilities lower health facilities. In Masaka only 14/36, in M Drug Verification Mpigi only 6/30, in Mubende only 4/17, in Nakase o With exception of 9 facilities in Masaka, 2 facilities in Rakai and 2 Nakasongola 4/9 indicated that they carry out s facilities in Sembabule majority of facilities had updated stock cards at health facilities. the facility stores. o Most facilities that had updated stock cards, indicated that they experienced regular stock outs of essential malaria drugs. IEC o It was only 4 facilities in Mityana, 4 facilities in Nakasongola, 3 facilities in Nakaseke and 2 facilities in Kiboga that indicated that they do not provide sensitization of communities on malaria prevention, control and treatment o Although facilities indicated that they conducted health education talks, supervisors failed to find documented records/reports on attendance, response and achievements that could have been shared among staff or submitted to the district. o Masaka had 8/37, Mityana 7/20 facilities, Mpigi and Kiboga had 5 facilities each that indicated that they lacked materials for health education talks o Majority of health facilities in the assessment indicated that they often sensitize communities on key malaria areas.

6 disease in Uganda. While those with low immunity- pregnant women, children under five years and people living with HIV/AIDS- are particularly vulnerable, To improve and implement malaria prevention pro all people living in Uganda are at risk of being infected with malaria parasites the national malaria strategy. and suffering from resulting illness. According to the WHO World Malaria To improve and implement Malaria diagnosis and Report 2009, there was an estimated 12 million malaria cases in Uganda in through laboratory strengthening On average, 10.7 million malaria cases were reported annually during To strengthen the capacity of the national malar , with no declining trend, and transmission occurs all year round in thus improving monitoring, evaluation and supe most parts of the country. activities. According to Ministry of Health (MOH) records, malaria is endemic in 95% In the of first 3 three years the project intends to extend its se the country. Malaria accounts for 25-40% of outpatient visits to health facilities districts enlisted above. By the time of this report, the pro and is responsible for nearly half of inpatient pediatric deaths. According year to of operation. the 2006 Demographic and Health Survey, 16% of households nationwide Districts where SMP intends to Operate owned one or more insecticide-treated nets (ITNs) and 10% of pregnant Year 1 women and children under five had slept under an ITN the night before Rakai the survey. The proportion of children under-five treated with an antimalarial Sembabule drug Year 2 Kibaale Hoima Year 3 Mbarar Ntunga within 24 hours of onset of fever was 29%. The proportion of women receiving Masaka Buliisa Kasese Mpigi Masindi Kamwe two doses of intermittent preventive treatment in pregnancy (IPTp) was 16%. Mubende Amuria Kyenjojo Kiboga Katakwi Kamuli 1.1 The Stop Malaria Project Luwero Kaberamaido Jinja The Stop Malaria Project is a five-year program ( ) of development Mityana assistance funded by the Presidential Malaria Initiative and United States Kampala Soroti Kumi Iganga Pallisa Agency for International Development (USAID). Kayunga Bukedea Tororo Mukono The overall goal of the project is to assist the Government of Uganda to reach its goal of reducing malaria-related mortality. During the five years, As the a way of monitoring and evaluating project activities project endeavors to reach 85% coverage of children under five years of on age a number of interventions including rapid assessments, and pregnant women in the 45 partner districts, with proven preventive and facility Assessments therapeutic interventions: This report is a product of facility assessments carried supervision in districts where the project operated in year o Artemesinin-based Combination Therapy (ACT) for treatment of uncomplicated malaria, Intermittent Presumptive Treatment (IPTp) of malaria in pregnancy, and Long-lasting Insecticide Treated Nets (LLINs).

7 as part of her routine supervision activities in the 11 districts of central Uganda which were targeted by the project in year one. The purpose of the assessment was to investigate the capacity and gaps of selected health facilities in controlling and treatment of malaria related cases. The assessment desired to investigate issues related to availability of services, quality of services, and utilization of services. Key services investigated included; ANC/IPTp services, Health Unit Management systems, Case Management, Laboratory management, Drug Verification, IEC verification and Support Supervision. The assessment was carried out in Government, NGO/PNFP, and Private Health facilities especially those at the level of Hospitals, HC IVs, and HC IIIs. 1.4 Approach and Methodology A check list was used as a supervisory tool for the activity. It was adopted from the ministry of health and was reviewed and revised in the supervisory orientation meetings. In each district Supervisors comprised of two team members from SMP, a district malaria focal person, the HMIS focal person and Laboratory technician. These could be joined with other members who were previously trained as facilitators in IPTp. A team of two would visit two facilities in each district in one day. While at the facility, the team divided into two subgroups, case management and drug management. The assessment collected data in 12 districts of central Uganda, but data analysis captured information from 222 facilities from 11 districts with Luwero data missing. Masaka District had the highest number (36) of facilities visited, followed by Mpigi (30) and Mukono (29). Nakasongola (9), Kayunga (10) and Nakaseke (11) had the least number of facilities assessed. 14 HFs in Kiboga, 17 in Mubende, 20 in Mityana, 23 in Rakai, and 23 in Sembabule were also assessed. Of the 222 facilities 177 were government aided, 30 were NGO-PNFP aided,

8 2.1 IPTp/ANC Assessment of at least two doses of IPT. In the malaria control strategic plan 2005/6-2009/10 IPTp was to be implemented using a Directly Observed Treatment (DOT) strategy. Pregnant Majority of HFs were found to be offering IPTp with exce women were to be targeted for the distribution with ITN/LLIN particularly Kiboga, 2 facilities in Masaka, 3 facilities in Mityana, 3 fac through ANC services. This was expected not only to increase the protection facilities in Sembabule of which 5 are HCIIs. of this vulnerable group but also help to improve the uptake of ANC services in general. Treatment of clinical malaria cases during pregnancy and SMP the intended to find out whether those that provide IPTp management of severe malaria were part of the general approaches using DOT. 20 facilities; 8 from Sembabule, 8 from Masaka towards case management. one from Nakaseke district indicated that they do not DOT. 12 facilities never gave their opinion and 13 facili Access to ANC Services on a daily basis ANC services at all 11 of which are HCIIs. However m In Kayunga district all facilities where found to be providing ANC services facilities and assessed indicated that they use directly observe most (169) facilities indicated that they provided it on a daily basis.in Kiboga ANC. district only 9 of the 14 health centers provided ANC services and in almost all these facilities that provided the services, ANC services are only provided SMP on also desired to find out whether facilities have reliab Wednesdays. In Masaka of the 25 HCIIIs visited 6 don t provide ANC services of water safe for drinking in the ANC clinic. Only 1 on a daily basis, of the 5 HC IVs supervised 2 do not provide services Sembabule, on a 2 from Rakai, 4 from Mityana, 3 from Masaka daily basis. Those that do not provide the services on a daily basis in Masaka one each from Mubende and Mukono Indicated that were found to provide the services on specific days of the week. In Mityana reliable safe water, other wise 191 facilities where found to district of the 20 health facilities visited 9 of them were found to provide the ANC ANC clinic. Majority of facilities that indicated that th services on weekly basis. Mpigi district had the highest number (29) of facilities were found to be using Aqua-safe tablets which were providing ANC services on a daily basis. Mubende district had 3 HC III and Jericans. 1 However there was a significant number of f HC II that indicated that they do not provide ANC services on a daily basis. water meant borehole water although there is no evide Nakaseke district also appeared with 10 of her 11 health facilities providing borehole water is safe for drinking. ANC services on a daily basis with only 1 indicating that they were running a weekly ANC clinic. Rakai and Sembabule had 7 and 5 health facilities respectively that do not provide ANC services on a daily basis. However, of the 5 from Sembabule 4 where HCIIs and only one was a HCIII. In Sembabule 5 HFs indicated that they do not provide ANC services, 4 of these were HCIIs and one was a HCIII Access to IPTp during ANC visists Objective 9 of the malaria control strategic plan 2005/6-2009/10 was to Increase coverage with at least two doses of intermittent preventive

9 HC IIIs respectively indicated that they do not provide folic acid to pregnant supervised lacking IEC Materials including 2 HC IVs a women, the rest of the facilities do routinely provide folic acid. Stock outs facilities of in Mityana and 3 in Mpigi exhibited absence of IE Folic Acid were recorded in almost all health facilities including those that that lacked IEC materials included 2 facilities in Kayung indicated that they provide it routinely. each from Mukono, Mubende and Nakaseke districts. Majority (130) of health facilities indicated that they provide de-worming It should be noted that even in facilities where posters/ie services to pregnant women except for only 2 facilities in Mukono, 2 in Mpigi there is a likelihood that they made negligible impact bec and 1 in Kayunga where de-worming services were not provided on a routine where in English henceforth clients who do not underst basis citing inconsistency in the supply of albendazole. However most of may them not comfortably understand them. IEC materials indicated that they sensitize pregnant women about the advantages of would deworming a pregnant woman. have impacted the minds of people more. Dispensation of Insecticide Treated Mosquito Nets: The im Availability of ANC materials a pregnant woman and her foetus differs with the i transmission but in any case represents a significant burd Cups for IPTp: only 24 facilities indicated that they had inadequate cups for mother and child. In order to reduce maternal morbidity administration of IPTp; 6 of the 24 where HC IIIs from Mityana, 6 HC IIIs improve from the newborn s chances of survival the malaria co Masaka and 6 HC IIs from Sembabule. Others included 1 HCIV and /6-2009/10 HCIII targeted pregnant women for the dist from Mubende and one HCIII from Mpigi, Mukono, Kiboga and Rakai. particularly through ANC services. This was expected not protection of this vulnerable group but also help to imp ANC/IPTp cards: In most facilities there was a general lack of ANC/IPTp cards. ANC services in general. 2 HC IVs and 6 HC IIIs in Kiboga didn t have IPTp/ANC cards, 1 hospital, 5 HC IVs and 13 HCIIIs in Masaka did not provide IPTp/ANC cards. Mubende district In the Assessment it was discovered that almost all facilitie had 2 HC IV and 11 HC III that had no cards. Rakai district had 6 HC III and dispense 2 ITN/LLIN with exception of 10 facilities, 3 from Mu HCII without cards. Sembabule had 2 HCIV, 2 HC III and 7 HC II without cards. Nakasongola Mpigi and Kayunga and one facility from It was only Mukono District that had all the 29 facilities visited having these facilities that indicated that they dispense mosquito IPTp/ANC cards followed by Nakaseke district with only 1 facility without the assessment, nets were out of stock. Facilities however cards. advise pregnant women to buy mosquito nets although complain about the cost being too high. In Kayunga d It was noted that in the absence of preprinted ANC/IPTp cards some facilities dispense mosquito nets indicated that priority is given to where found to be using exercise books which are purchased by clients with HIV. themselves. In Masaka some facilities requested clients to photocopy existing cards and all those that failed they resorted to exercise books Provision of Health Education Talks during ANC In all districts majority of health facilities (122) sensitize In most facilities that had cards it was observed that IPTp cards, were properly

10 the data that are submitted. From the assessment, only 3 It was however noted that education talks are not malaria Specific, pregnant and 1 from Kayunga had registers which are not up-to-d women were found to be sensitized about other topics such as nutrition, of 6 facilities in Mityana and 4 in Kiboga which never ga immunization, breast feeding, and proper hygiene. The challenge health client registers, the rest of the facilities indicated that the facilities get is difficulty in getting the pregnant women into group talks client since registers. The health facilities which did not provide assessment was because their records personnel were pr they don t all come in at the same time. Educational programs would have during the supervision exercise. been more effective if all women come together on a common day so that they could also share experience and provide a feedback on what is working Recording data and formulating reports for utilization are The checklist provided for whether information recorde for them and what is not working. transformed into reports for utilization by the facility. facilities indicated that they make monthly summary re 2.2 Health Management Information Systems facilities in Kiboga, 3 facilities in Mityana and Masaka eac Objective number 18 of the malaria control strategic plan 2005/6-2009/10 Mukono that indicated that they were not making month was to improve collection, quality and utilization of routine data to monitor should be noted that there was a significant number of the implementation of malaria related interventions through the Health to show whether they had summary reports. These inclu Management Information System (HMIS) and other sources including Malaria Masaka, 12 facilities in Rakai, and 9 facilities in Mityana, Indicator Surveys, Demographic Surveillance System (DSS), sentinel sites Kiboga and and Mubende, 3 facilities each Mukono, Nakase the private sector. and 2 facilities in Kayunga that had no responses on HMIS Information currently used from HMIS for informational markers include: o The number of outpatient clinical malaria cases o The number of malaria blood tests o The number of malaria-positive blood tests o The number of ANC first visits o The number of pregnant women with malaria o The number of pregnant women receiving IPTp-1 and IPTp-2 o Stock out of albedanzole and quinine at time of form s completion and duration of stock out. This assessment reviewed the existence of data registers at the facilities supervised, whether reports were made, quality of data collected, existence of personnel, a database and utilization of data. The assessment also reviewed support supervision done and activities of Health Unit Management Committees (HUMC).

11 staff, and those that didn t have indicated using records assistants for have data conducted self assessments. managment. A records officer is expected to facilitate proper and timely data recording, processing, utilization and storage. From the assessment In all these facilities, there was no evidence to show co Sembabule had the highest number (22) of facilities that have records/reports for at least 2 years. There was also no evid officers followed by Masaka (14), Mpigi (11), Kiboga (9) and Mubende assessment (9). reports are share/utilized. Others included Mityana (6), Rakai (3) and Nakaseke (2) Support supervision to lower health facilities SMP also wanted to find out whether records officers in different health Higher health facilities are mandated to supervise lower le facilities received any training. Although majority of facilities had 3 their HC III in Kiboga, 2 HC IV and 6 HC III in Masaka, 9 HC III i assistants trained, there were a significant number (65/221) of facilities Mubende, that 5 HCIII in Mukono and 6 HCIII in Rakai indicat indicated that their staff had never received training in HMIS. Majority (18) carry are out support supervision to lower level health facilities from Sembabule, 15 facilities from Mpigi, 10 facilities from Masaka and that 5 a significant number of health facilities (45/204) thou facilities from Mityana district. role to supervise lower level health facilities while 18 Among the facilities reporting conducting lower heal Existence of a Health Unit Data base majority of health facilities there was no evidence of p Modern day data management activities requires a database, however reports a for supervisors to see. Health facilities that big number (21) of health facilities in Masaka, 14 facilities in Sembabule, supervision 11 gave the excuse of lack of funds. facilities in Mukono and 8 facilities in Rakai had no database that could be used in management of health unit information. This implies that these Meetings of the Health Unit Management Committee facilities continue to rely on manual records management systems. The biggest number of health facilities in most districts with and Nakasongola indicated that their HUMCs met ever For an organization to run an electronic database there is need to have the a performance of respective health facilities. Rakai h computer. Majority of facilities did not have a computer on which Nakasongola an had 6/9 facilities, Mityana had 8/20 facilitie electronic database could be run. Only 1/10 facilities in Kayunga, and 7/14 Masaka had 7/35 facilities that indicated that their H facilities in Kiboga, 8/35 facilities in Masaka, 5/20 facilities in Mityana, previous 6/30 quarters to review the performance of the health facilities in Mpigi, 7/29 in Mukono, 3/11 in Nakaseke, 1/9 facilities in Nakasongola, 4/23 in Nakasongola, 1/23 indicated that they had In majority a of health facilities there was evidence of re computer. No facility in Mubende district had a data management prove the existence of these meetings. Some facilities w computer. Even facilities that indicated to have a computer in many meetings though not regularly. instances computers were found to be non functional either because they lacked maintenance. Some facilities lacked computers because they had no main grid electricity or solar power supply Proportion of facilities that conducted self assessment

12 prompt and highly effective anti-malarial combination therapy of their for staff trained in uncomplicated Malaria. Majority (12 uncomplicated malaria episodes to complement efforts of malaria Mpigi indicated that they had 4-6 staff trained followed by prevention by: indicated that they had 1-3 members trained in uncomplic Reducing the number of cases progressing to severe malaria facilities in Masaka indicated that they had 4-6 members o Preventing or at least delaying development of parasite strains indicated that they had 1-3 members who trained in unco resistant against used Anti-malaria combinations Kayunga, Masaka, Mpigi and Mukono district had 3 or mo Contribute to reductions of malaria transmission by reducing indicated the that they had more than 10 members of their sta reservoir of parasite stages transmissible by the mosquito vector training in uncomplicated Malaria (gametocytes) The focus of this strategy was to gradually phase out the availability and use of mono-therapies for uncomplicated malaria, while rapidly providing access to treatment with ACTs for all segments of the population Existence of staff trained in Management of Malaria Cases MOH statistics shows that Training on malaria case management, including severe malaria, and the provision of supportive supervision was provided to Table 1: Number of facilities with personnel trained in uncomplicated Malaria NR 1-3 staff 4-6 staff 7-9 staff 10+ staff KAYUNGA KIBOGA MASAKA MITYANA MPIGI MUBENDE MUKONO NAKASEKE NAKASONGOLA RAKAI SSEMBABULE Total facilities indicating that they had an average of 1-3 over 10,000 health workers, including almost 3,000 workers from the private Severe Malaria. Sembabule district had the highest numbe sector. In this Assessment only a few health facilities (17/220) indicated not to 3 members of staff trained in severe malaria. have received training in Case Management. It was only 2 HC III facilities in Kiboga, 5 HC III facilities in Mityana and 3 HC III facilities in Mukono that indicated that they did not have trained staff in management of both severe and uncomplicated malaria. Most facilities especially in Mpigi expressed the Table 2: Average number of personnel trained in Severe M Non Response 1-3 staff 4-6 staff 7-9 staf KAYUNGA KIBOGA MASAKA MITYANA MPIGI MUBENDE MUKONO NAKASEKE NAKASONGOLA RAKAI SSEMBABULE Total Mpigi district had the highest number (28) of facilities whether they had any training in severe Malaria h responded. The district had only 2 facility one indicating members and the other indicating 4-6 members who Malaria. Masaka district had 10 facilities indicating tha and 13 HF had 4-6 staff members who trained in severe Ma

13 uncomplicated malaria to complicated forms of the disease, severe malaria Appropriateness of Malaria Diagnosis will still occur. In the malaria Control Strategic plan, the case management With the introduction of ACTs the need is increasing to m strategy focuses at the management of all forms of severe malaria (cerebral treatment while at the same time providing maximu malaria as well as severe malarial anemia) through; treatment access. Coverage of high quality clinical a o Introduction of suitable and easily applicable pre-referral treatment malaria diagnosis was expected to increase. Parasitologic (e.g. rectal Artesunate) at peripheral health facilities (HC II) as well be as either through microscopy or rapid diagnostic tests (RD at community levels where this can be shown to be feasible and effective. A significant number of facilities that indicated that mala Improving availability of safe blood and blood products for transfusing based on laboratory diagnosis. 13/23 facilities in Sembab severely anaemic patients as well as other relevant IV fluids and Nakasongola, 15/30 facilities in Mpigi, 18/36 facilities in Ma ancillary treatments they carry out presumptive management of malaria ca Improvement of the management of severe disease at higher advanced level for lack of diagnosis based treatment are; health facilities (HC III & IV) and hospitals which not only involves laboratory facilities, stocks of lab reagents, and sometim availability of medicines and commodities but also skills and processes laboratory assistants/technicians to carry out the diagnosis including patient triage Access to Guidelines and Standards required Technical Appropriateness: from the assessment majority of health facilities Majority of facilities indicated that they have access to t indicated that they have the capacity to provide technically appropriate guidelines in OPD and IPN and only a few had access to treatment of malaria cases. It was only 3 facilities from Mpigi, 2 facilities each was only 3 facilities each in Kiboga, Mityana and Masaka from Kiboga, Masaka and Mukono that indicated they could not provide they had not had access to any type of guidelines. H appropriate treatment. However, it should be noted that a significant number Mityana, 4 in Kiboga and 3 in Masaka where not sure wh of health facilities 6 from Masaka, 5 from Sembabule, 4 from Kiboga and guidelines. 4 Some health facilities in Kayunga and Semb from Mityana never gave their opinion. charts. Most facilities (184/221) had access to malaria management guidelines as supplied by the ministry of health. A challenge of stock out of supplies and drugs was mentioned in Mukono and Masaka which sometimes hinder technical management of malaria cases. Timely Appropriateness; majority of assessed Health facilities indicated that that their health providers are available most of the time. It was only 5 facilities from Masaka, 2 facilities each from Sembabule and Kiboga, which indicated that their health providers are not at the facility all the time. In some facilities due to lack of duty rosters it was not possible to verify whether

14 plan while 2 facilities indicated not applicable. In Kiboga district majority uncomplicated of malaria and severe malaria where availa health facilities had a referral plan; it was only 2 facilities that indicated where to health workers could visibly see them. Its only 3/10 f Table3; Number of facilities with a Referral Mechanism for Emergency cases District NR Yes No NA Total KAYUNGA KIBOGA MASAKA MITYANA MPIGI MUBENDE MUKONO NAKASEKE NAKASONGOLA RAKAI SSEMBABULE Total have a referral mechanism to higher level health facilities. In Masaka district management of severe malaria in OPD. 3 facilities each 16 facilities indicated that they had a referral plan, although there was Mpigi, a 2 facilities each in Nakaseke, Kiboga and Masaka significant number of 16 facilities indicating that they had no consistent materials plan for severe malaria in IPN. on management of referral cases. It was 9/20 facilities in Mityana, only 7/30 facilities in Mpigi, 11/16 facilities 21/29 facilities in Mukono, 6/11 facilities It should in be noted that many of the facilities had outd Nakaseke, 3/9 facilities in Nakasongola, 8/23 facilities in Rakai and Many 3/23 of the facilities indicated the desire to have IEC ma facilities in Sembabule that indicated that they had a referral mechanism language. for complicated malaria cases. 4/14 facilities in Kiboga, and 3/36 in Masaka that indicate IEC materials on management of malaria. IEC on Uncomplicated malaria; It was only 2 facilities Mityana and Mpigi districts that lacked charts on uncomplicated malaria in the OPD section. 3 facilities e Mpigi, and Masaka, 2 facilities each in Kiboga and Nakas materials on uncomplicated malaria in IPN. IEC on Severe Malaria; Majority health facilities (39/221) this checklist, only 4 facilities in Mityana, 3 facilities in Mpig Kayunga and Mukono that indicated that they lacke It should be noted that some facilities especially hospitals and sometimes HC IVs had access to ambulance services. However, most of these facilities experienced continuous ambulance breakdown and fuel shortages. In many facilities where the assessment was done it was noted that it is the referred clients are required to pay for fuel for the ambulance.

15 laboratory space. Masaka and Sembabule districts that had the highest Techniques Used to Diagnose Malaria in Health Facili Table 4: Number of facilities with a functional Laboratory Space District Name NR YES NO NA Total KAYUNGA KIBOGA MASAKA MITYANA MPIGI MUBENDE MUKONO NAKASEKE NAKASONGOL RAKAI SSEMBABULE Total number 11 each of facilities indicating they did not have a functional laboratory space. Mpigi district had 8/30 facilities, Mubende 5/17 facilities, Nakaseke 4/11 facilities and Mukono with 3/29 facilities indicating they did not have a functional laboratory space. It was noted in Masaka that, some facilities had functional laboratory facilities but lacked technical personnel to run them. Some facilities lacked supplies of There are several techniques used in diagnosing mala facilities, these include microscopy, Rapid Diagno Quantitative Buffy Coat (QBC) among others. This assessm out the most common techniques used. From table 5; i most health facilities use microscopy techniques in all mentioned in 3 facilities in Masaka, 2 facilities each in M and 1 facility each in Kiboga, Mubende and Nakaseke. It Table 5: Types of Malaria Diagnosis Techniques used in health facilitie Microscopy RDTS QBC CLINCAL DIAGNOS KAYUNGA 9 3 KIBOGA 9 1 MASAKA MITYANA 16 MPIGI 21 2 MUBENDE 9 1 MUKONO NAKASEKE NAKASONGOLA 6 RAKAI 20 SSEMBABULE 8 1 Total reagents and other chemicals required to carry out the common diagnosis in Kayunga, 1 facility each Masaka, Nakaseke and Mas and on many cases experienced breakdown of microscopes and other clinical diagnosis. equipment Availability of skilled laboratory personnel SMP desired to find out the number of laboratory personne The biggest number (144) of health facilities indicated having trained in microscopy and /or RDT techniques of malaria diagnos personnel to run laboratory services. It was only 4 facilities each in Mubende, 1 person who received the training included 7 facilitie Sembabule and Nakaseke, 2 facilities in Masaka, 3 facilities each in Mityana indicated that they had 2 or more personnel trained in m and Mukono which indicated not to have personnel with capacity to run facilities a in Kiboga, 5 facilities in Masaka, 3 facilities in Mi laboratory. Mpigi, 8 facilities in Mukono, 5 in Nakasongola, 3 eac Rakai. The assessment desired to find out whether the mentioned laboratory staff are available at the health facility all the time when needed, ie a qualified The major challenge indicated by health facility in use of

16 microscopes. Though efforts have registered limited success, HMIS reports significant in number of facilities (47/127) indicated that th 2008 reported increased availability of functional microscopy services. established This system to carry out quality assurance. On was also revealed in the assessment, most of health facilities had Kiboga, their 7/36 facilities in Masaka, 5/20 facilities in Mityan microscopes in good condition although the assessment further desired Mpigi, to 12/29 facilities in Mukono indicated that they had find out the longevity in time the non functional microscopes spend at for the quality assurance. In Mubende only 7/17 facilities, 3/1 facility without maintenance. From the assessment it was one facility facilities in in Nakasongola and 4/23 facilities in Sembabule Mukono that mentioned that they had a microscope which had taken had 10 systems for quality assurance. Furthermore 13 fa years without maintenance, Kayunga had 2 facilities with microscopes which indicated that they didn t have systems for quality assuran had broken down in the last 6 months and 2 facilities that had their microscope broken down in the previous 3-5 years. Nakaseke also reported Note: 1 An insignificant number of facilities in Rakai indic facility that had its microscope which had broken down in the last 3-5years system slides from national laboratories for quality assuranc without maintenance Lab Records/data Management Availability of Job Aids at Laboratory All facilities in Kayunga, Kiboga, Mpigi and Masaka that From the assessment most facilities (118) had job aids displayed in facilities their where found to have a lab register. In Mityana respective laboratories. It was only 7 facilities in Mpigi, 6 facilities in Mityana, districts 3 only 1 facility each did not have a register, in Muk facilities each in Masaka and Mukono that had no job aids for laboratory only 2 facilities each, the assessment team was not a technicians. Furthermore 2 facilities each in Kayunga, Kiboga, Nakaseke registers. and Ssembabule also indicated that they had no access to job aids in the laboratory. It s mandatory for all health facilities to submit monthly re health office. This requirement has given a chance to ma Preparation of stains used in the laboratory compile, analyze and write monthly reports from labo Majority of health facilities indicated that stains used in their laboratories assessment, only 2 facilities each from Masaka, Mp come already prepared either from the district or from Joint Medical Stores indicated that they didn t prepare monthly reports from th (JMS). It was only 2 facilities each from Kayunga and Rakai that indicated that stains are prepared by laboratory assistants. Some facilities indicated It should however be noted that apart from preparing re that they purchase stains from pharmacies or from JMS already prepared. there was no mechanism for sharing data internally am departments. Almost all health facilities that had laboratory technicians indicated that they knew how to prepare standard stains used in laboratory. It was only 4 facilities Replenishment of Lab supplies each in Sembabule and Mpigi, 2 facilities each in Kiboga and Mukono The assessment desired to find out whether laboratories a districts that indicated that they lacked the capacity to prepare standard facilities experienced stock outs of laboratory supplies in th stains. In Kayunga district 5 facilities indicated that they experi Mpigi 11 facilities indicated the same, in Mukono 10 fa

17 malaria. It was only 4 facilities each in Mityana and Naka health center staff to monitor supply of selected essential malaria treatment in Nakaseke and 2 facilities in Kiboga that indicated supplies. In this assessment quantities on stock cards were compared with carrying out community sensitization activities on malaria actual physical count at facility stores. With exception of 9 facilities in and treatment. Masaka, 2 facilities in Rakai and 2 facilities in Sembabule majority of facilities had updated stock cards at the facility stores. It should however be noted that although facilities in conducted health education talks, supervisors failed to Although almost all facilities had updated stock cards, most facilities records/reports on attendance, response and achieveme indicated that they had stock outs of essential malaria drugs. 12 facilities been shared among staff or submitted to the district. It wa each in Rakai, Mukono and Mpigi districts and 8 facilities in Masaka indicated with only 9 facilities, Kayunga and Mukono with 6 facilities that they had stock out of IV quinine. Stock outs of Coartem for children with only 3 facilities reporting to have written health edu under-5 were reported from 21 facilities each in Rakai, and Mpigi, 10 facilities and submitted them to the district. Most of these fac each in Mubende and Mukono districts. Furthermore 16 facilities in Rakai, 14 opinion that they were not informed about the requireme facilities in Mukono and 14 facilities in Mpigi indicated that they experienced education talk reports to the district. stock outs of SP. Availability of Teaching Materials; SMP desired to find From general comments made by health facilities, most health centers facilities use charts, leaflets, posters, and flip charts du experienced continuous stock out of coatem. Some facilities indicated that conducting health education talks. Majority of facilities w coartem gets finished quickly, while others indicated that the district/nms these materials although not specifically as mentioned ab take long to restock coatem. indicated that they lacked materials for health educat included; Masaka had 8/37, Mityana 7/20 facilities, Mpig 2.6 IEC VERIFICATION facilities each. Others that did not have materials wer Mobilizing the communities, local, regional and national as well as political Nakasongola with 3 facilities each and Mubende with 2 fa and religious leaders to play an active role in malaria control and ensuring proper understanding of the core interventions by the population and Community Awareness Activities promoting positive change of behaviors is the major purpose of advocacy, The IEC strategy aims at supporting active community par IEC & social mobilization as part of the malaria control strategy. control activities. Majority of health facilities in the assessm they often sensitize communities on key malaria preve Objective 12 of the Malaria control strategic plan 2005/6-209/10 is to raise treatment. the Use of ITNs/LLINs was mentioned in almos profile of and demand for malaria control interventions through targeted, exception of 4 facilities in Mityana, 3 facilities in Sembab well designed advocacy and communication campaigns and activities each with in Kiboga, Nakaseke and Mukono districts. Sensitiz special emphasis on the biologically and economically vulnerable. IPTp and Malaria treatment was also mentioned in exception of 5 facilities in Mityana, 3 facilities in Semba Nakaseke, and 2 facilities in each of Kiboga, Mukono and

18 were also being used to promote malaria community awareness activities. Generally the results of the assessment vary across and fa for SMP technical staff to identify areas of strength, we 2.7 SUPPORT SUPERVISION tailored district needs for further on-the-job training and s The biggest number of facilities (197) assessed indicated that they received from this assessment should augment other routine field routine support supervision from upper levels. From Masaka, Mubende, better interventional planning. Mukono and Rakai only 2 facilities in each of these districts reported that they 3.1 Action Points for Further Assessment Activities did not receive support supervision. In addition, 1 facility each in Kiboga and The consultant proposes that further assessment requ Nakaseke reported the same. approach or methodology of gathering information. Usin to obtain assessment information will give SMP a more c Support supervision was found to be carried out as a mandate from the the issues related to malaria services. Relying on only the DHO s office or from the health sub district. It should be noted however that collection gave room for inconsistent reporting which may although some facilities could show supervision reports, many facilities could action plans. Methods like, group discussions, records not prove that supervision was done because they neither had minuted assessment, exit interviews and others may need to be con documents, nor reports to use as reference. A more specific data collection tool (s) which remain It should also be noted that not all facilities that received support supervision objectives should be developed to reduce on the ambig from upper levels extend supervision to lower level health facilities. It was only checklist used. Tools designed should be more diverse a Kayunga district which had 8 of her 10 facilities indicating that they carry out many fields were left blank due to the complexity of captu routine supervision to lower health facilities. In Kiboga none of the 14 facilities indicated that they carry out supervision to lower health facilities. In Masaka More time should be given to orienting people who are g only 14/36, in Mityana only 2/20, in Mpigi only 6/30, in Mubende only 4/17, in data so that they can understand properly the objective 16/28 facilities, in Nakaseke 6/11 facilities in Nakasongola 4/9 indicated that and the expected results. Selection of data collectors and they carry out supervision. Rakai had 11/23 facilities and Sembabule 7/21 given a lot of attention because in this assessment some q facilities that carry out routine support supervision. incomplete and logical checks were not adhered to. Dissemination of assessment findings is crucial before an conducted in the same districts. A 1 day workshop wit charges, and district supervisors can generate signific insight to interventional planning. 3.2 Conclusion The data in this assessment was collected in the last quart SMP staff working with district supervisors collected th

19 cases. The assessment desired to investigate issues related to availability MOH: of Malaria Control Strategic Plan 2005/6-209/2010 services, quality of services, and utilization of services MOH: Malaria Operation Plan WHO: World Malaria Report 2009 The assessment collected data in 12 districts of central Uganda, but data analysis captured information from 222 facilities from 11 districts with Luwero data missing. Masaka District had 36 facilities visited, Mpigi 30 and Mukono 29. Nakasongola 9, Kayunga 10 and Nakaseke HFs in Kiboga, 17 in Mubende, 20 in Mityana, 23 in Rakai, and 23 in Sembabule were also assessed. Assessment results were presented to SMP staff in a one-day workshop at which participants identified priority areas for improvement.