BACKGROUND TO ST.JOSEPH S HOSPITAL MARACHA Maracha hospital is a private Not For Profit hospital belong to Arua Catholic Diocese with a bed capacity of 200. The hospital is located in the Northern part of Arua District 33 km from Arua town on the Arua Koboko high way, in Maracha County, Nyadri Division in the proposed District of Maracha Terego. The hospital was started by the Comboni Missionary Sisters in 1953 as a Dispensary and Maternity Centre and the dynamic person to realize this was a lay missionary called Jokomina Pandolfi now in Italy. It became fully flagged hospital in 1973 and was handed to Arua catholic Church in 1974.During the years between 1980 to 1986 the hospital was looted and closed and the few staff and Doctors took refuge to the Republic of Congo where it was operating as a health center to serve the Ugandans who were there. When the situation calmed the German Emergency doctors took over the running of the hospital and putting some staff house for the staff and equipping it for operation and this only lasted for two and half years. Thereafter CUAMM the doctors working for Africa came and renovated the hospital and managed it up to 1992 when they finally gave the management to the local people. The hospital was established by the church to imitate the Mission of Jesus Christ of healing the sick. Its Mission is to continue the healing Ministry work left by Christ Jesus to save and provide holistic health care to the people of Maracha and the neighbors and to fight diseases and poverty thus witnessing the maternal concern of the church for every sick person regardless of the ethnic origin, social status religious or political affiliation with emphasis for preferential option to the less privileged. This mission is based on the moral teaching of the Roman catholic church. The aim of the hospital is further to promote access to health care for the less-privileged and the vulnerable social groups women, children the financial destitute and the chronically ill. To this mission the hospital is anon profit making Institution of the church. Since the person is at the centre of the activities of the hospital the basic attitude of the respect for human dignity is the guiding principle in executing the mission. The Core value of the hospital stands for are: humanity equity, equality, justice, universality, access and transparency, quality, non-discrimination access and sustainability. In the years 1997/1998 the ministry of health came up with the Policy of Health Su-district and Maracha hospital was given the responsibility to head the Maracha health sub-district as ahead the neighboring sub-districts, Ayivu, Terego Koboko and the neighboring countries of Congo and Sudan as a matter of fact the hospital suffers epidemics due to border influence. In promotion of heath provides the following services: curative, preventive, Promotive, rehabilitative and spiritual care through Pastoral gents. Apart from these services the hospital also acts as a referral for the 11 lower level units. In the area of HIV/AIDS the hospital provides voluntary counseling, and testing (VCT) prevention of mother to child transmission (PMTCT), home based care Palliative care to terminal ill patients or clients, TB BOTS Psychosocial support to the families affected and infected by the HIV /AIDS. Recently through a six month programme under UPHOLD on small scale the hospital has is implementing AB (Abstain and Be faithful programme) through model couple which is doing well it may meet a stand still because it will end soon and continuity without support may be a problem. The hospital in further promotion of HIV/AIDS has been in collaboration with the net work of Community based associations and clubs that support sensitization activities within its catchment area. The management of the hospital is at two levels : The Board of governors who are mandated by the Board of Trustees who holds the power of Ownership. The management team of the hospital comprising of the medical superintendent, the Administrator, the Senior Nursing Officer and the Community health Officer. These 4 form the Core management Team for the day to day running of the hospital. Apart from the Core management team there id the Extended management team comprising of the Departmental heads and the Incharges of the Lower Level units. Each department runs its activities according to its setting levels. The management is guided by the Charter, employment Manual, Finance and material resource manual, the Ethical Code of conduct. This Police documents help a lot in execution of duties and relationship. The hospital has in the net work collaborated with a number of partners in the recent past among whom were the following: 1. HIV/AIDS and TB Collaborations initiative projects worth USH 12,000,000/= funded by CUAMM an Italian NGO known as Drs for Africa working in West Nile in late 1980s and 1990s and they renovated the hospital after the war and have been providing technical advise for the hospital through the District and the Diocesan office.
2. Ecological water and Sanitation project worth 1,600,000,000/= funded by BBM MIVA, DKA and Austrian organisation between 2000 and 2004. 3. Primary Heal project (Establishing a local decentralized health system) worth USH 420,000,000/= FUNDED by Medicus Mundi Navarra Spain. These mostly worked in the Community within the catchment area to rehabilitate the infrastructure in the 1998 to 2003. 4. VCT and Community based out reach HIV/AIDS sensitization campaign programme worth USH 14,000,000= funded by PIS (Population services international ) 2004/5 These were the recent projects we had for various activities in the hospital TOP TEN (10) DISEASES COMMONLY FOUND ARE: The commonly diagnosed disease in these place for under 5 are the following: Malaria URAT (Upper respiratory tract infections) Diarrhea Pneumonia Intestinal worms Anemia Skin disease UTI (upper tract infection) Trauma Malnutrion The common diseases among the adults are the following in the order of commonality : Malaria Intestinal worms URTI Trauma UTI Hypertension Diabetes Eye disease Asthma Diarrheal disease SUMMARY UTILISATION OF OPD (OUT PATIENT DEPARTMNT) Out patient attendants by age group in a period of two years Sex Attendance Age range 2005/6 2006/7 Female New attendance 0-4yrs 6191 4989 5rsand over 9158 9393 Re-attendance 0-4yrs 877 526 5yrs and over 894 1190 Male New attendance 0-4yrs 6498 5991 5yrs and above 6886 7117 Re-attendance 0-4 yrs 1,112 777 The OPD Catchment area is not geographically well defined and the population s seeking for Primary Health Care services belong to different Sub- Counties. The total work load during the year reduced by 6.7 of the 31.00 of total patients 221 0.7% were referrals out side Maracha Health Sub- District in to the hospital while 147 cases 0.5 were referred out for specialist care in regional hospital Arua. Problem Statement Maracha Hospital like any other Private Not for profit hospital in Uganda Catholic health Net work were all stated by the Missionaries to help all, but with preference to the most needy and as such they were mostly located in rural areas were the population could not afford The finance to run these hospitals were donation from the relatives and other donors from abroad.
The years between 1980s and 1990s and the following have not been easy for these hospitals, due to donor fatigue, self reliance policy created by big financial Institutions like world bank to mention but few. These hospitals have suffered because the user fee they charged only coved 15-20% of the total cost while 80% was covered by donations. In the late 1997/8 the government started to support part of the recurrent cost but for the last 3 years it has been reducing drastically, that means these rural church hospital including Maracha hospital s future is questionable and yet they provide 45% of health care service to the population of Uganda. Specifically, to Maracha, the following are some of the problems: 1. The Cost of employment: This takes a larger part of the 42% followed by medical goods and services (drugs and supplies) 36% and the rest 22% is for other expenditure lines such fuel, transport and so on. The present salary the hospital is paying is USH 305,653,024 as compared to what the government unit is paying if they use our staff establishment is about 450,000,000/= but the general hospital of government will have more staff done what we have and that means the salary would be more that 500,000,000/= annually. The difference of 144,346,976 for the same number has caused high staff turn over leading work over load and compromise on the quality of services. 2. The hospital lacks some Equipments that could be used for income generating services such as Ultra- Sound, X-ray we have a small x-ray and is faulty now and then we have failed to acquire a new one. Other equipments that could be of income generation for the hospital are the following (a) ECHOGRAM (ECG) (b) ELECTRO CARDIOGRAM (c) BARIUM MEAL machine (d) HYSTROGRAM Other equipment sets that we have been using and are in bad shape and need replacements are the following: a) APENDICECTOMY b) CEASARIAN SECTION c) SET OF DELIVERY EQUIPMENTS d) SET OF LABORATORY EQUIPMENT e) THYRODECTOMY f) AMPUTATION SET g) HERNIOTOMY SET h) HYDROSECTOMY SET i) MASTERACTOMY SET j) HISTERACTOMY SET k) BURCHOLE l) EVACUATION SET m) SURGICAL TOILET SKIN GRAFTING SET. 3. Human Resource is another problem in terms of high turn over due to little salary and heavy work load and accommodation. More so we have failed to recruit permanent staff for auxiliary services such as anaestatic officers, radiographer, laboratory Technicians most of them are trained on job and others are part timers and can leave any time. The following table gives the picture of the gap Details Hospital norms Actual Gap Doctors 6 4 2 Qualified staff 143 41 102 Administrative staff 15 8 7 Nursing Assistants 15 29 (14) Supportive staff 27 48 (21) Total The table above shows that, the untrained staff are many to fill the gap created. And we have come up with the strategies in our strategic plan as below:
Suggestions: (a) According to our strategic plan we want to train the above cadres so that we can retain them. (b) We have land for developing a nursing school and if that is done the chronic problems of the hospital will reduce because we shall use students and employee few staffs especially Nursing staff. (c) The hospital still has land that that can be developed to put up accommodation for staff to solve the problems of accommodation. All these plans enumerated above can only be done if we get donations and well-wishers to offer training funds for the cadres we needed to train. 4. Financial constraints: as earlier on stated in the background, the hospital s source of income are: User fee that represents 25% of the budget, Government grants that has been reducing in the last successive years and its makes 40% of the recurrent cost, while the rest 35% is donation. This picture defiantly shows that without donations and government grants the sustainability of hospital is questionable. When the donor funds dropped between 1992 and 1997/8 the hospital almost closed but thank God the government came in with some few aids and some donations came in but as per now the government is reducing its aid and that sounds bell of discomfort for the management and the owner who depended so much in the donations from abroad. To make matters worst its located in the rural area, where most of the patients are poor. Our appeal as managers to the donors out side there are the following as regards financial constrains: To have if possible some organizations that can support us with some amounts of money to buy drugs monthly if we can receive some UGH 15,000,000/= (Fifteen million only) this will add to what we have as a backup. To support our income generating activities. The management has come up with some income generation activities, say we acquired land to build Petrol station. Secondly we have prepared business plan to provide drugs to units in Arua with the help of Joint Medical stores, this need us to have funds to carry out the business. Thirdly we have carpentry workshop that we needed to improve to make furniture for commercial purposes to raise funds. The ideas are so good but funds are not forth coming. We request for personnel, equipments especially for the carpentry to kick start and the funds needed. 5. HIV/AIDS and TB: This has come with a lot of demands on the hospital. At the begging as reflected in the background we had some none governmental organizations, that came to aide this activities, and soon after they left and the burden has remained on the hospital, in terms of personnel, consumables and drugs that are used without pay buy the HIV /AIDS and TB patients. We actual need help in terms of drugs, and personnel to reduce the work load and high expenditure on drugs unpaid for. Finally, the list of problems, would be long but few of these are representative enough. Justifications: The Mission of the church is to provide services to all but with the preference to the most needy. Therefore, inorder for the hospital to achieve this mission it has to work hard to provide quality services to the people, and at the same time get the support of well-wishers inform of donations and also through engaging in other commercial activities in order to survive in health service provision. INTRODUCTION The period covered by the report varied from 2001 to 2006 June. And the sources of data used for this report comes from the activities done over these years for comparison purposes. The dates collected were analyzed by use of Tables, graphs, and figures respectively. Generally, as far as income is concerned, there has been general decrease in income for the hospital and there were slight increments in user fees income in user fee over the years. On the other hand the expenditure side also showed a remarkable increase in all expenditure line of the hospital, which is an issue to pay attention to. The compliance to the faithfulness to the mission is seen in the accessibility of services and predictability of cost of services by the patients, and efficiency in services provided. The problems faced during the report writing were many among are the following: Time was not enough to analyze the information. The report writing was hampered with other programmes like meetings and other activities.
So many details were needed which was so tiring to analyze the data. Some of the information and date needed for this report in the previous years could not be captures readily by the new HMIS, hence were difficulties to obtain them. We request the readers to give us feedback on the performance in the report writing so as to improve on the areas that need correction and appreciate when due for encouragement. The Hospital and its Environment St. Joseph s Hospital Maracha started as a maternity unit in 1953 by the Comboni missionaries in the persons of Jocomina, a lay missionary sister. The hospital was named St. Joseph because Joseph was a worker. Due to the continued demand of the health services for the community, it expanded to include other clinical services. In 1973 the unit was licensed and became a fully-fledged hospital run with the help of Italian organization CUAMM and later by the Germany team of Emergency Doctors after the civil war of 1983-1985. The hospital was handed over to the Little Sisters of Mary Immaculate of Gulu in 1986 after departure of the Comboni sisters from Maracha parish. The sisters managed the hospital with financial assistance from CUAMM and other small projects supported by friends from Europe. In the 1990s as Uganda began to stabilize politically, the hospital yet again began to experience a new challenge, of donor fatigue, as the financial support from out side reduced significantly more so when donor funds were centralized through government ministries. The hospital to cope up with challenge took a risky position to generate local revenue in order to off set this imbalance by increasing the user fees without technical guidance. Since the catchment population mainly depended on subsistence economy with low income, the result was that, attendance reduced dramatically. With low attendance, low revenue was collected and therefore, no capacity to finance the needs of the Hospital particularly in infrastructure and above all difficult to pay the Human resource, whose function is pivotal in health services. All this made the hospital to lose its mandate to serve the poor and the disadvantaged as enshrined in the mission statement of the hospital and the Roman Catholic Church in general. These situations almost drag the Hospital to a closure. But around 1997/8 the situation started improving when the UCMB started giving technical guidance on how best to manage the hospital s meagre resources as mandated by Uganda Episcopal conference and when the new Uganda government health policy (1992) recognised the role-played by the private sector there by providing direct financial assistance. From 1994-2001, the hospital received support from Medicus Mundi Navarra to strengthen the Primary Health Care and reorganization of the local health system of the Health Sub-District. This programme coincided timely with the decentralization of health system (Uganda Health Sub-District Concept) and Local government decentralization policy. The impact of this programme is that all the lower level units in the HSD were rehabilitated, equipt and stocked with drugs. This made service utilization at periphery to increase dramatically with consequent increase in referral to the Hospital. The infrastructural development and rehabilitation was undertaken by DKA/BBM (HORIZONT 3000) an Austrian organization that electrified the hospital and overhauled the sewage and water systems for the hospital. New staff houses were constructed and this increased the staff accommodation in the hospital and reduced the rent expenditure for the hospital to some extent. St. Joseph s Hospital Maracha is legally owned by Catholic diocese of Arua. It is managed by a team of managers appointed and answerable to the board of governors who in turn answers to the diocesan health board. The Hospital is a general Private Not for Profit hospital in the network of Uganda Catholic Medical Bureau (UCMB) and has the same status of a district hospital (200 bed capacities). It is the head quarters of Maracha HSD supervising ten lower level health units on behalf of Arua District local government- this has made it fit well within the national health system. The Hospital is located in Maracha county, Nyadri sub county, Pabura parish and Lurua village. Maracha County is located to the western side of Arua district bordering DR Congo to the west, Koboko to the north, Yumbe and Terego to the East, and Ayivu to the south. The terrain in the county is made up of low flat lands and undulating land surface. There is a network of rivers and streams draining the area. The land is devoid of most of its natural forests. It has a good network of roads originally meant to transport wood fuel for curing tobacco. The trunk road to the Sudan, feeder roads and village roads are present and are motorable by high vehicles. The county is well served by all the local FM
radio stations in the West Nile region. Although networked by the main communication companies, the reception in many parts of the county is good thus enhancing fast communication of emergency cases or out brake of epidemics. The county is well networked by 10 health units located at least 2-5km from each other and 1-19km for the hospital. All the 7 sub-counties have at least one or two health centres. The only sub-counties that are not served well by the existing health centres were a 5 km radius to the nearest health units are Kijomoro and Oleba sub-counties. The details of the hospital location in relation to the environment is shown in Annex 2 In the HSD, there is a network of radio communication in all the health units except Loinya health centre II. This has been possible through the UNFPA and HSSP II project. This has enabled easy communication within the HSD in areas of disease surveillance and referral of emergencies especially the mothers in labour from peripheral units. Two health centres (Tara HCII and Loinya HCII) were established without provision of basic equipments- in addition to equipments as major tool for service delivery; the accommodations for the staffs in all the 11 health units in the HSD are inadequate to meet the settlement need of the facility for easy attention of patients by health workers The following are key recommendation for the future of the hospital and its environment: The new district of Maracha Terego has to enter into agreement with the Hospital to easy co-operation in private public partnership for effective service delivery. Some lower level health units have to be operational in the HSD especially Ajikoro health centre in Oleba sub-county to increase service accessibility to the population of the sub-county. The investments made in the hospital and HSD like the solar system installation, equipment and buildings are the responsibility of the sub-county local governments and the diocese to ensure security and rehabilitation and maintenance. The community and health status SOCIO-ECONOMIC ARRANGEMENT / LIFE STYLE OF THE PEOPLE/BELIEFS The HSD population is more rural with some potential to urbanise particularly the trading centres that has attracted several rural people to settle in. The county has a high population density of 234 people per square kilometer which translates into serious population pressure on limited resources hence eminent poverty. The county used to be the food basket for Arua District but now with this high population pressure, there are frequent periods of food shortage and hunger leading to increased malnutrition cases in the HSD The people in the HSD are Lugbari speaking; the Maracha dialect. There are no unique characteristics to Maracha from Arua district. Some migratory populations due to business venture have infiltrated the trading centres particularly the Banyoro and Baganda people. Some migratory behaviour exists among the people of Maracha in search of farmland during the rain season. Due to the population pressure there is not enough arable land. Families move to Madi, areas along the River Nile, and come back during the dry season The Maracha people have strong beliefs and culture as concerns the causes of sickness and death in their community. Conditions which are thought to have known causes end up being delayed at homes. Difficulties and complications in deliveries are attributed mainly to bride wealth and delivery in health units is said to be a form of cowardice for women as child birth pains are associated to testing of womanhood. Traditional healers and herbalists are the first health care points for many in the rural and much money is spent at that point before coming to the formal health systems. Other beliefs including these beliefs compromise early health seeking behavior of the people for primary health care. Due to low income, most people do not have budget for health care services hence health spending at community levels are based on the occurrence of illnesses The main economic activities in the county are subsistence agriculture at household levels, trading in essential commodities, selling of fish from Panyimur and Rhino camp along Lake Albert and River Nile edges. Most of these activities are done by women who come from rural parts of the county. Tobacco is the main cash crop grown in the county with no alternative to the population. Tobacco growing is a labour intensive activity that robes the population of time to do other activities in the families. It is being sighted as the major cause of deforestation and hunger in the HSD. The main food crops grown are cassava, millet, sorghum, ground nuts, beans and sweat potatoes that form the basic daily food package in families. Other activities include raring of chicken, goats, sheep and cattle to solve domestic problems of marriage and food.
The population is predominantly Christian-Anglicans and Catholics (64%) with some Moslems (15%) in few places in the trading centres. The catholic belief is strong in the county about the use of contraceptives and this is one of the factors contributing to low family planning services utilization in the HSD. The demographic data of the catchment population of the hospital OPD (HC II) is shown in Annex 3. The hospital OPD has responsibility to provide services to the catchment population of 23,236 people. This required the hospital OPD (HC II) to take care of 2.9% of the district population, 13.7% of the HSD population and 0.094% of the national population in order to contribute effectively to national responsibility. TABLE 1: HEALTH STATUS AND RELATED INDICATORS OF THE MARACHA HSD, ARUA DISTRICT AND UGANDA INDICATOR MARACHA HSD ARUA DISTRICT UGANDA Total Population 169,629 804,290 24,834,000 88/1000 live IMR 88/1,000 live births 88/1,000 live births births < 5 MR 152/1,000 152/1,000 152/1,000 MMR 505/100,000 505/100,000 505/100,000 Rate of Stunting x x 38.50% HIV Prevalence 2.30% 2.30% 6.40% % of Supervised deliveries 25% 25% 25% Total Govt. & PNFP OPD Utilisation 1.02 0.9 0.9 % of children < 1 year fully immunized 74.9% 70% X Source: Arua district annual report 2005/06, Uganda HIV/AIDS sero-survey report 2006, The Annual health sector performance report FY 2004/05, Maracha HSD data base 2005/06, HSSP II volume I and Maracha HSD Annual performance report 2005/06 Maracha HSD population constitutes 21.1% of the entire district population. This meant that the HSD takes care of about 1/5 of the entire population in terms of health care need. The population growth rate of Arua District is 3.8% higher than that of Uganda. The health outcome for Uganda are poor and consequently the health out comes for Arua may be worse as its population growth rate is more than the national growth rate. In order to raise the HSD, District and national averages for health outcomes, there is need to specifically encourage preferential option to poor particularly the less-privileged and improve the situation for many of the disadvantaged group in the rural population. The Child mortality, MMR and IMR of the health sub-district is the same as that of the entire district since the HSD population characteristics are the same to that of the entire district. The HIV prevalence of the district is at 3.5% as per the HIV Sero-survey of 2005. But the prevalence of the HSD could be slightly below that of the district because the HIV prevalence rate through VCT and PMTCT as (proxy) are 4.9 % and 1.6% by PMTCT respectively. This figure could suggest an agreement with the national sero-survey of 2005. More resources are needed to continue to fight the scourge paused by the HIV/AIDS in our HSD, District and the nation. HIV/AID has far reaching socio-economic consequences including a decline in life expectancy (UDHS 2000)
The percentage of supervised deliveries in the HSD is 25% as that of the District. This meant that the HSD performed within the national target set for the year. How ever the coverage varied from 4.7% in Tara sub-county to 55.6% in Oluvu sub-county. There is room to improve this service delivery. Emphasis should be put on staff attitude and political will to improve on the rate of deliveries in health units. Most of the health units are accessible in the HSD with exception of Tara, Oleba and Kijomoro sub-county. The total OPD utilization rate of the HSD is 1.02 more than the district and the national rates. Health Policy and District health services The national health policy of 1992 and Health Sector Strategic Plan II are the routine guiding frame work for delivery of health services in the Hospital and the HSD. The key HSSP II indicators are used to develop the annual targets for the Hospital and the HSD In the process of developing annual plans, a number of national and institutional guidelines and policies and manuals were used and referred. For the issues raised in MDG, the Hospital refers to three agenda: Reduction mortality due to communicable diseases (malaria, tuberculosis and HIV), water and sanitation and Partnership in resource mobilization for development. PEAP of Uganda plays a crucial role in all health planning issues of the hospital and the HSD in general. The PEAP outcome Indicators considered are: Reduction of both IMR, <5 MR and MMR and Stunting (Malnutrition). The hospital fits into this implementation and achievements from planning, implementation, monitoring of activities that are in line with the national objectives laid in the PEAP, HSSP II through work plans with achievable set objectives and targets. Increasing access to the all the Public and PNFP health units by assessing the OPD Utilizations per health unit in the HSD Immunization coverage in the HSD with emphasis on DPT3 and Measles in routine and accelerated immunization sessions -these contribute in reduction of morbidity and mortality due to preventable communicable diseases that accounts for 75% of life years lost in premature deaths. Increasing the percentage of supervised deliveries in health units to reduce MMR at homes Malnutrition outreaches and case management by the hospital there by averting death. TABLE 2: ACHIVEMENTS IN PEAP INDICATORS HOSPITAL HEALTH SUB-DISTRICT INDICATORS 2004/05 2005/06 2004/05 2005/06 OPD utilization per capita 2.2 2.3 1.10 1.09 DPT3 Coverage 90% 95% 92% 86% Measles Coverage 83% 86% 92% 76% % Supervised unit deliveries 72% 76% 23% 25% District Health Services The HSSP II and PEAP documents formed the basis of developing the district strategic (Arua District Development Plans 2005-2010). Annual district plans are developed within the frame work of this development plan. Similarly the HSD, the Hospital and the lower level units use the requirements in the HSSP to make their work plans and forward the to the district. This bottom up planning fine-tunes the plans to suit the specific peculiarities at the different levels of implementation in the National health system i.e. District, HSD, Lower Level health units and the community level. These plans are set against clearly identified objectives and targets. The constitution and the local government act of 1997 amended in 2001 defined the legal mandate of the local government (DLG) in health services delivery. In health sector, they are responsible for; Hospitals, all health centres, maternity and child welfare services, communicable disease control, especially Malaria, HIV/AIDS, TB and Leprosy, control of other diseases. Rural ambulance services, PHC, Vector control, Environmental sanitation, Health Education, Provision and maintenance of water supplies.
These activities are the responsibilities carried by the District Directorate of health services. Under the decentralized health system (HSD concept) the mentioned responsibilities are implemented at different levels e.g. District, HSD, Lower level unit, or the community level. To avoid duplication and confusion the mandates of the various levels are clearly stipulated in the HSD structure. Maracha hospital as one of the units in the HSD has been vested with the mandate to head the HSD and carries out these policy programmes. According to the HSD concept the Medical superintendent is the DDDHS to the DDHS and is supposed to be a member of the District Health Team. Participation in this forum has been limited due to the various commitments on the hospital management. The health Sub-district has 11 health units that are networked for appropriate service delivery for the HSD. Out of the seven sub-counties five exhibit the 5Km radius to the nearest health unit for their population except Oleba and Kijomoro sub-counties. TABLE 3: Distribution of Health Service Points by Sub-County in Maracha HSD TABLE 4: Ratio of population to health facilities and immunization points by Sub-county in HSD Sub- Counties Total Pop. No of Hosp. No of HC IV No of HC III No of HC II Total imm. static stations Nyadri 24,473 1 0 1 0 2 Oleba 26,029 0 0 1 0 1 Oluvu 27,989 0 0 2 0 2 Oluffe 19,414 0 0 1 1 2 Kijomoro 31,760 0 0 1 0 1 Tara 17,166 0 0 0 1 1 Yivu 22,415 0 0 1 1 1 Total HSD 169,246 1 0 7 3 10 Sub- Counties Total immunization outreach stations Population per HF Infants (< 1 year) per immunization post Nyadri 09 12,237 117 Oleba 08 26,029 140 Oluvu 10 13,996 120 Oluffe 10 9,707 83 Kijomoro 09 31,760 152 Tara 06 17,166 122 Yivu 11 11,208 88 Total HSD 63 15,386 116 The sub-counties of Oleba, Kijomoro and Tara have only one health in their areas. It is noted that these sub-counties have the lowest immunization coverage in FY 2005/06 as shown in table 6 below. It is the same sub-counties with difficult to reach areas by their respective health units. These sub-counties have the highest ratios of infant and post than other sub- counties. TABLE 5: IMMUNISATION COVERAGE BY HEALTH UNIT CATCHMENT AREA Sub-Counties DPT3 COVERAGE Measles coverage Infants (< 1 year) per immunization post Nyadri 124% 104% 117 Oleba 75% 65% 140 Oluvu 81% 79% 120 Oluffe 84% 80% 83 Kijomoro 63% 57% 152 Tara 70% 70% 122 Yivu 67% 69% 88 Total HSD 86% 76% 116
Basing on the above arguments and sub-county performances; Oleba, Kijomoro and Tara Sub-counties deserve additional posts to reduce infant/post ratio for effective utilization of services. MANAGEMENT The hospital has a Charter that spells out the composition, the roles, and methods of work of Board of Governors and its committees, the HMT and Core management Team. The Hospital has the Congregation of Little Sisters of Mary Immaculate working. Their relationship with the hospital is spelt out at two levels. First at Diocesan level, then in the hospital the Management also signs Contract with the Religious sisters who work like any other employee. The modus operandi was not included in our Chapter and its one of the Items we have in plan to included during the review of the charter and its signed between the Diocese and the Congregations. The list of the Members of the BOG is attached in the (annexes.1) The Board Committees that have been functional were three, the finance Committee that meets monthly and their responsibility is to assist the management team with developing sound financial policies and plans, monitoring and adapting implementation. On the other hand, Quality Assurance, discipline and grievance Committee meets after every two months, according to the charter. The function of this committee is to advise the staff departmental heads, HMT and BOG with respect to all matters pertaining to quality improvement, handling of complaints and grievances of patients and their attendants, staff members and other stakeholders. While the Recruitment and training Committee meets quarterly and it was important this year because of high attrition rate. Their work in the year of repot was mainly advisory to HMT, Cost Centre in charges, and BOG with the respect to general and individual principles and procedures for staff recruitment and training. It also acted as sponsorship award committee for those who went to school. The HMT meets daily to address day to day running of the hospital, while the extended management that comprises of departmental heads meets monthly to review month s activities including the progress in undertakings and planed activities to be achieved. The extended management also participates in giving inputs for hospital and HSD budget planning. Its important also to note that during the year under review the hospital fulfilled all the statuary requirements such as NSSF, PAYE, License of the hospital with the Ministry through UCMB, submission of report to the Ministry of health, UCMB the district and other stakeholders., as well as the subscription to UCMB and Diocesan health Offices. However last year the hospital was accredited late for not submitting the reports on the undertaking as required. This was because of the transition in management otherwise all the undertakings were done and some reported submitted to UCMB. We would like to inform the BOG that in the year we are reporting the entire requirement were submitted and the hospital was accredited. At this point we would like to thank the BOG Committees who remained with us in executing other activities during the year. The management of the hospital was further made easier by use of three documents that are guides for the management. These are the hospital Chapter that spells out all the responsibilities of actors in the management of the hospital, secondly the Employment manual helps in the issues pertaining staff and Resource and Material management manual. However we did realize that there is need to change some of the policy issues that have negative effect on the institution. Eg. Free treatment scheme for the staff as shown by the table bellow. TABLE 6: SHOWING FREE TREATMENT TO THE STAFF OVER THE YEARS No Financial Years Amount Ug. Shs. 1 2001/2002 1,000,000 2 2002/2003 1,200,000 3 2003/2004 1,800,000 4 2004/2005 6,850,000 5 2005/2006 7,156,000 The table 6 shows that there are high increments in free treatment to the staff due to change in policy and relaxation in the monitoring of user fee tracking. The management has at their Extended management meeting resolved to revise the policy to cover only the nuclear and children up to 18 years not marries and singles to present only two names of their parents or persons of their choice. The nuclear family meant here is the first year if you have more; you bear the responsibility and having dependant id ones responsibility. The management has realized the need to have a process Auditor to and it is also one of the requirements of UCMB to have this person. This person will get acquainted with
the management style of the Institution and the guiding documents like the Charter and the various undertakings and statutory requirements, which he will use as a checklist to help the management where they have not perform. We therefore request the BOG to second one among them to do this work or give us the permission to get some body. Finally, the Team spirit helped the management so much, especially where most of the managers where new for example, the M/S the Public health In charge, and Ag. SNO However e-mail was our major problem, where we spent a lot of money to repair with functionality of one or two days and the problem recur. HUMAN RESOURCE (STAFF) The HRM in the hospital is characterized by uncertainty. The carrier path for the staff is not so clear though the hospital has Human resource plan for development, it all depends on the availability of donation or UCMB sponsorship. The years before FY 2002/3 are not shown but the staff was stable, however from FY 2002/3 when the Public Service commission advertised the hospital stated losing staff as shown in the table7 below. TABLE 7: SHOWING STAFFING STATE IN THE LAST THREE YEARS Particulars 2002/3 2003/04 2004/5 2005/06 Doctors 4 3 4 4 Other trained Medical staff 36 38 40 43 Unqualified medical staff 34 34 34 29 Administrative staff 10 10 8 9 Other supportive staff 58 58 58 48 Government second staff 11 11 9 14 Medical staff attrition 11 4 8 14 Administrative staff loss 0 0 1 2 Medical new recruits 6 11 5 14 Administrative and other staff employed 0 1 1 1 Administrative staff loss 0 0 1 1 Total Number at the end of the FY 137 145 144 133 The table7 shows that the number of qualified staff has been increasing; this was to provide more efficient services to the patients. The number of unqualified staff has almost remained stable. The plan to develop them failed due to the fact that they cannot be trained. The management has reduced the number of supportive staff by 14 at the end of the financial year. The purpose was to cut on the cost on employment especially on the supportive staff. The carpentry will be re- opened after a clear business plan is in place as income generating activity. TABLE 8: SHOWING GAP IN STAFF ESTABLISHMENT Details Hospital Norms LG Staffing Norms Status Gap LG Gap Hospital Doctors 4 7 4 3 0 Qualified Staff 118 143 43 100 75 Administrative Staff 15 14 9 5 6 Nursing Assistants 15 15 29 (14) (14) Supportive Staff 27 13 48 (35) (21) Total 179 185 133 108 81 Find details of staff attached in the annex (ii) the two staffing norms compared shows gap in staff establishment of 108 for LG and 81 for the hospital respectively. On the other hand the working hours has remained not streamlined to 8 hours as stated in the employment manual with exception of night shift The responsibility of HRM in the hospital is in the hands of the hospital Administrator with the help of SNO and guided by Recruitment Committee. This Committee has also been responsible for human resource development plans. Staff development At the moment we have 5 staff for training of the five 3 are medical staff and two are Administrative related and the hospital is planning to send 2 staff for laboratory Assistance course which department has had problems. The Medical Superintendent is also going for Certificate course in Health services management from December 2006.
However, the hospital continues to search for the scholarships for upgrading and short course for the staff. Nevertheless, what still remains a problems is to determine who should go and when has not been documented. Please advise. Major experiences of disciplinary were not realized. Some few issues of disciplinary in nature if at all were handled at departmental levels, as they did not qualify appearing before the Committee. The hospital continues to give staff fringe benefits like water, electricity, and free treatment which value is reflected in their contract as remuneration. Seconded staff Some few Seconded staff deployed to the hospital from other facilities continue to be unsatisfied with workload of the hospital and conditions of work which has given dissatisfaction to the departments where they work. While those who have been re-deployed to remain in the hospital have been doing very well. However the Policy of UCMB on secondment of staff is that, the hospital should not on their own negotiate for it but if given, a clear Memorandum of understanding is reached between the posting authority and the Institution. Emerging and Lawful issues on Human Resource The Parliament has declared 60 days for maternity leave with full pay for women and Paternal leave of 4 days for men to care for their women. These take effect from the day it was announced. Therefore, we have a responsibility to change the same in our employment manuals. This further means that, the hospital should peruse the 8 hours work in order to cover the gaps that will be created by those who go for maternity leave. The history has it that, especially in the maternity ward yearly two or three go for maternity which situation creates undesirable situation of work load.. PLANS FOR HUMAN RESOURCE 5. To harmonize the working hours for the staff. 6. Train new Nursing Assistants to replace the current Assistant most of whom are old now and cannot be redeveloped. 7. Appraise and promote some, especially those who have worked for long and have no hope of training any more. 8. To calculate and educate the staff on the need to work according to established working hours and workload. 9. To adjust the Employment manual to take care of the adjustment in the law. FINANCES The hospital uses the cost based accounting procedures; where cost is recognized at the consumption point rather than at purchase point or where cost is not recognized as expenditure but is made when using the resources. TABLE 9: SHOWING INCOME AND EXPENDITURE FOR THE YEAR ENDED 2005/2006 User fee 135,656,700 PHC Conditional grants 251,420,239 PHC Conditional for HSD 85,307,052 Donations for funds for recurrent cost 61,606,895 Value of drugs received through EDP 44,257,092 Global fund 43,203,328 Value of drugs from NMS and PFP 20,147,867 Rotary (water project) 30,000,000 UCMB Training 1,200,000 Other Income 50,021,328 Total income 722,820,501 EXPENDITURE Employment cost 323,754,139 Hospital BOG cost 825,000 Administration cost 14,546,942 Property cost 12,356,709 Transport and Plant cost 61,362,591 Supplies and Services 25,383,200 Medical goods and Services 68,614,023 Hospital based PHC 7,976,700 PHC for HSD activities 83,956,734 Capital Development 30,000,000
Staff development cost 1,662,000 Drugs received through EDP 44,257,092 Drugs from NMS and PFP 20,147,867 Global funds 43,112,480 Total Expenditure 737,955,477 The table 9 above reveals that the expenditure is more by 15million this is due to the fact that, during the year the hospital spent more on fuel coupled with the increase of price of fuel. Also one of our vehicles (Mazder drifter) got accident and money was spent for its repair (about 5 million). The excess expenditure was met from the reserves saved in the previous years. TABLE 10: INCOME AND EXPENDITURE PERFORMANCES FY 2005/06 DETAILS BUDGET ACTUAL BUDGET PERFORMANCE INCOME User fee 140,000,000 135,000,000 96.4% PHC Conditional grant Hospital 266,891,350 251,420,239 94.2% PHC Conditional grant HSD 116,270,000 85,307,052 73.4% Donation for recurrent costs 43,635,500 61,606,895 141.2% Value of EDP Drugs received 45,000,000 44,257,092 98.3% Global Fund 63,000,000 43,203,325 68.6% Value of Drugs from NMS 0 20,147,867 0 Other incomes 40,488,108 50,021,328 123.5% Rotary club (productive water 100,000,000 30,000,000 30.0% project) UCMB 3,200,000 1,200,000 37.5% TOTAL INCOME 818,484,958 722,163,798 88.2% EXPENDITURE Employment costs 325,538,548 323,754,139 99.5% Hospital board costs 1,000,000 825,000 82.5% Administration costs 14,000,000 14,546,942 103.9% Property costs 12,534,000 12,356,709 98.6% Transport and plant costs 45,419,000 61,362,591 135.1% Supplies and Services 27,417,200 25,383,200 92.6% Medical goods and Services 60,990,834 68,614,023 112.5% Hospital based PHC activities 9,000,000 7,976,700 88.6% PHC for HSD Activities 116,270,000 83,956,734 72.2% Capital Development 100,000,000 30,000,000 30.0% Staff Development 3,200,000 1,662,000 51.9% TOTAL EXPENDITURE 715,369,582 630,438,038 88.1%
FIG1: DISTRIBUTION OF INCOME FY 2005/06 INCOME FY 2005/06 0.20% User fee 2.80% 6.90% 4.20% 18.80% PHC Conditional grants 6.00% PHC Conditional for HSD 6.10% Donations for funds for recurrent cost 8.50% 11.80% 34.80% Value of drugs received through EDP Global fund Value of drugs from NMS and PFP Other Incom e FIG 2: DISTRIBUTION OF EXPENDITURE FY 2005/06 EXPENDITURE FY 2005/06 2.7% 5.8% 0.2% 6.0% 4.1% 11.4% 43.9% 1.1% 9.3% 3.4% 8.3% 1.7% 0.1% 2.0% Employment cost Hospital Board cost Administration cost Property cost Transport and Plant cost Supplies and Services Medical goods and Services Hospital based PHC PHC for HSD activities Capital Development Staff development cost Drugs received through EDP In Table 10, FIG 1 and 2, it can be noted that the top 5 sources of income are: The PHC Conditional grant still dominates the income (34.8%) with budget performance of 94.2% - this is a source of revenue from government The user fee is the second source of income (18.8%) with budget performance of 96.9% - this is a major source of revenue internally generated by the hospital. The PHC for HSD is the third source of income (11.8%) with budget performance of 72.3% - this is a second major source of revenue from the government. Donation of funds for recurrent costs is fourth income (8.5%) with budget performance of 141.2% - this is the first major source of revenue from donors (external support) The last fifth source of income is other incomes (6.8%) with budget performance of 123.5%- this is the second source of revenue generated internally by hospital from IGA and savings. In figure 2 above, the top four line expenditure points that consumes about 73% of the total expenditure are:
SHILINGS Employment cost consumed 43.9% of the total expenditure of the hospital. This is mainly the staff salaries and other emoluments. HSD PHC activity is the second line expenditure point consuming 11.4% of the total expenditure. This is mostly for outreaches and running HSD administration. Medical goods and services is the third line expenditure item that consumed 9.3% of the total expenditure- this is mostly construed by medicines and medical supplies Transport and plant cost is the fourth line expenditure point that consumed 8.3% of the total expenditure of which fuel and vehicle maintenance are the major areas of this expenditure. TABLE 11: COMPARING INCOME AND EXPENDITURE FOR THE LAST FOUR YEARS DETAILS 2002/2003 2003/2004 2004/2005 2005/2006 INCOME 621,969,962 651,338,002 641,551,000 722,820,501 EXPENDITURE 570,084,165 671,390,410 460,004,000 737,955,477 FIG3. TREND OF INCOME AND EXPENDITURE OVER THE 4 F/Y INCOME AND EXPENDITURE TREND 2002-2006 900,000,000 800,000,000 700,000,000 600,000,000 500,000,000 400,000,000 INCOME EXPENDITURE 300,000,000 200,000,000 100,000,000 0 2002/2003 2003/2004 2004/2005 2005/2006 FINANCIAL YEARS The figure 3 above shows that there has been some increase in user few collection since 2002/3 though not so remarkable due to the effect of user fee flattening because the hospital last reduced free in 1996 to 1998 hence what was done in 2002/3 was flattening dawn trend because of capital development around 2001 to 2004. After that the expenditure dropped because there was no major work of capital in nature until 2005/6 when the project of New OPD in progress. Last FY we also had expenditure on vehicles repair and high cost of fuel and medical goods and services. TABLE 12: SHOWING TREND OF INCOME BY SOURCE OVER THE LAST 5 YEARS 2001 TO 2006 YEARS 2001/2 2002/3 2003/4 2004/5 2005/6 User fee 100,518,976 112,481,625 114,056,000 134,220,000 135,656,700 PHC CG 203,806,215 267,243,002 295,974,110 286,877,000 251,420,239 Hospital PHC for HSD 90,839,569 133,165,700 133,165,700 85,307,052 Donations in cash 411,186,430 0 47,799,000 140,181,000 61,606,895 Donations of 0 0 45,798,000 43,924,000 44,257,092 goods in kind EDP Donations of 3,000,000 36,000,000 36,000,000 36,000,000 6,000,000 services Drugs from NMS 0 0 3,500,000 6,200,000 20,147,867 and PFP Income 26,581,382 103,831,966 22,029,000 5,423,000 50,021,328