Assessing Malaria Treatment and Control in Selected Health Facilities. October 2010

Assessing Malaria Treatment and Control in Selected Health Facilities October 2010

Plot 2 Sturrock Road, Kololo Opposite Lohana Academy P.O.box 8045 Kampala, Uganda Tel: +256 (0) 312 300450 Tel: +256 (0) 312 300421 Fax: +256 (0) 312 300425 Stop Malaria Project is a five-year program (2008-2013) of development assistance funded by the Presidential Malaria Initiative and United States Agency for International Development (USAID) The Project is managed by Johns Hopkins University Bloomberg School of public health Center for Communication programs (JHU/CCP), Malaria Consortium, the Infectious Disease Institute, Communication for development foundation and the Uganda Health Marketing Group. Assessing Malaria Treatment and Control in selected Health Facilities ii

Acknowledgements Stop Malaria Project with support from Focus Development Associates performed the activities that led to the compilation of this report. The report is based on information collected by Stop Malaria Project, analyzed and reported by Focus Development Associates a management and Development Consultancy Firm. The consultancy team comprised of Patrick Nsamba Oshabe, Prosper Behumbize and Dr. Kayita Godfrey. Special Thanks goes to Dr. William Katamba, Dr. Sam Guidoi, and Flora Gombe from SMP who aided the smooth completion of all exercises that led to the completion of this report. In addition we appreciate the efforts of supervisors, District Health Officers and health facility staff of visited centers that fully supported the assessment activities and cooperated with the supervisors Assessing Malaria Treatment and Control in selected Health Facilities iii

Assessing Malaria Treatment and Control in selected Health Facilities iv

Table of Contents 1.0 BACKGROUND TO MALARIA IN UGANDA... 1 1.2 THE STOP MALARIA PROJECT... 2 1.3 SUPPORT SUPERVISION... 2 2.0 METHODOLOGY AND CHARACTERISTICS OF THE SUPERVISED FACILITIES... 3 3.0 SUPERVISION FINDINGS... 5 3.1 MALARIA DURING PREGNANCY... 5 3.1.1 Provision of ANC Services... 5 3.1.2 IPTp during ANC Visits.... 6 3.1.3 IPTp under DOTs... 7 3.1.4 Routine provision of Folic Acid and De-worming of Pregnant Women... 8 3.1.5 Availability of Supply of Clean and Safe water to administer IPT under DOT... 9 3.1.6 Availability of ANC Cards... 10 3.1.8 Utilization of ANC IEC Materials... 12 3.1.8 Utilization of ANC IEC Materials... 12 3.1.9 Dispensation of LLIN through ANC... 13 3.1.10 Provision of Health Education Talks during ANC... 14 3.2 HEALTH MANAGEMENT INFORMATION SYSTEM... 15 3.2.1 Existence of up to date HMIS registers... 15 3.2.2 Completing HMIS Reports Appropriately... 16 3.2.3 Availability of trained HMIS officers... 17 3.2.4 Availability of data management computer... 18 3.2.5 Availability of Health Unit Management Committees... 19 3.3 CASE MANAGEMENT... 20 3.3.1 Availability of trained Staff to Manage Malaria... 20 3.3.2 Utilization of treatment guidelines in treatment of malaria... 21 Assessing Malaria Treatment and Control in selected Health Facilities v

3.3.3 Malaria Treatment based on Laboratory Diagnosis... 22 3.3.4 Referral of Emergency Cases... 23 3.3.5 Facility Clinical Audit... 24 3.3.6 Monthly Malaria Case Management... 25 3.4 LABARATORY MANAGEMENT... 26 3.4.1 Availability of Functional Laboratory at the Facility... 26 3.4.2 Availability of Skilled Human Resources... 27 3.4.3 Techniques used in Diagnosis of Malaria... 28 3.4.4 Maintenance of Laboratory Equipment... 29 3.4.5 Preparation of Stains used in Laboratory... 29 3.4.6 Management of Laboratory Data... 30 3.4.7 Availability of Staff Trained in Logistics Management... 31 3.5 DRUG VERIFICATION... 32 3.6 IEC VERIFICATION... 33 3.6.1Availability of Malaria Specific Health Education Talks... 33 3.6.2 Community Awareness activities about Malaria... 34 3.7 SUPPORT SUPERVISION... 35 4.0 RECOMMENDED ACTION POINTS... 36 5.0 APPENDICES... 37 Assessing Malaria Treatment and Control in selected Health Facilities vi

1.0 BACKGROUND TO MALARIA IN UGANDA In Uganda, malaria is the most commonly reported disease by both public and private health facilities. Clinicallydiagnosed malaria is the leading cause of morbidity and mortality, accounting for 25 to 40 percent of outpatient visits at health facilities, 15 to 20 percent of all hospital admissions, and 9 to 14 percent of all hospital deaths. The overall malaria specific mortality is estimated to be between 70000 and 100000 child deaths annually a death toll that exceeds that of HIV/AIDs. Nearly half of in-patient deaths among children under the age of five are attributed to clinical malaria. According to Ministry of Health, Malaria impacts negatively on the household, community incomes and the national economy, thus keeping the affected communities trapped in perpetual poverty. Available statistics show that families spend 25% of their income on malaria. Poor school performance and absenteeism due to malaria reduce chances of escaping from poverty. Poor people tend to live in environments conducive to mosquito breeding and malaria transmission. Thus malaria enhances poverty, which in turn causes poor disease management, locking people in a malaria-poverty trap. Despite the overwhelming burden imposed by malaria in Uganda, there is increasing optimism that the tide can be turned through the establishment of several initiatives. The United States government launched the President s Malaria Initiative (PMI), with the goal of reducing malaria-related deaths in selected countries, including Uganda, by 50% within five years. Through PMI and other large funding sources, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, Uganda have an unprecedented opportunity to reduce malaria associated morbidity and mortality on a national scale. Several Policies, strategies and Innovative approaches to malaria control targeting high-risk populations have been initiated by Ministry of Health and development partners, among which have included; the Malaria Control program, malaria control policy, malaria strategic plan and a fully fledged malaria consortium to coordinate all these efforts. Assessing Malaria Treatment and Control in selected Health Facilities 1

1.2 The Stop Malaria Project The Stop Malaria Project is a five-year program (2008-2013) of development assistance funded by the Presidential Malaria Initiative and United States Agency for International Development (USAID). The project is designed to contribute to USAID Uganda s Strategic Objective of improving human capacity through improved human health. Specifically the project contributes to program by assisting the government of Uganda to reach the PMI and Roll Back Malaria (RBM) goal of reducing malaria related mortality by 50%. To help achieve this goal, SMP uses an integrated set of approaches that reach recipients at multiple levels, including behavioral change interventions at the individual, household, and community levels, service delivery strengthening at the health facility level, and institutional capacity building at the district and national levels. 1.3 Support Supervision As a way of monitoring and evaluating project activities SMP collects data on a number of interventions including rapid district assessments, support supervision and facility assessment. In months of August and September, 2009 SMP carried out a support supervision exercise in 14 districts The purpose of the support supervision was to assess the capacity and gaps of selected health facilities in controlling and treatment of malaria related cases. The assessment investigated 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, 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, HCIVs, and HCIIIs. Assessing Malaria Treatment and Control in selected Health Facilities 2

2.0 METHODOLOGY AND CHARACTERISTICS OF THE SUPERVISED FACILITIES 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 who could be joined with other members who where previously trained as facilitators in IPTp. Number of Supervised Facilities by Ownership District Name Govt NGO-PNFP Private Total AMURIA 9 4 13 BUKEDEA 8 3 11 BULIISA 8 1 1 10 HOIMA 33 6 2 41 KABERAMAIDO 10 2 2 14 KATAKWI 8 2 10 KIBAALE 18 6 24 KIBOGA 18 1 1 20 KUMI 13 2 15 LUWERO 32 15 6 53 MASINDI 28 5 33 MPIGI 34 9 1 44 MUKONO 40 14 1 55 NAKASEKE 11 2 13 NAKASONGOLA 18 2 20 RAKAI 24 3 27 SOROTI 26 6 2 34 WAKISO 38 7 45 A total of 482 facilities from 18 districts 1 where supervised in the fourth quarter; Majority (55) of them where from Mukono District followed by Luwero (53), Wakiso (45), Mpigi (44), Hoima (41) Soroti (34) and Masindi (33). Others included 27 facilities from Rakai, 24 facilities from Kibaale, 20 facilities from Kiboga and Nakasongola. Katakwi (10), Buliisa (10), Bukedea (11), Nakaseke and Amuria 13 facilities where among the districts with fewest number of facilities supervised. Out of the 482 facilities supervised in the quarter majority (376) were Government aided, 90 were aided by NGOs or faith based organisations or churches and 16 were privately owned. Of the 482 facilities supervised 274 were HCIIIs, 133 were HCIIs 43 HCIVs and 22 Hospitals. In some instances supervisors failed to categorize health facilities especially those that are privately owned. 2 were from Kaberamaido, 3 from Luwero, 2 from Mukono and 2 from Rakai District Total 376 90 16 482 The supervisory activities where undertaken in the months of July, August and completed in September 2010. And data analysis and report production commissioned and completed in October 2010. 1 At the time of collecting this data some districts had been partitioned by government of Uganda, e.g Mukono now comprises of Buvuma and Buikwe, Mpigi comprises of Gomba and Butambala, Masindi comprises of Kiryandongo etc. For the sake of this report Buvuma and Buikwe where taken as Mukono, Gomba and Butambala as Mpigi, and Kiryandongo as Masindi. Assessing Malaria Treatment and Control in selected Health Facilities 3

At the time of the supervision of the 133 HCIIs supervised; 91 indicated that they had 3-6 members of staff, 29 facilities indicated that they had less than 2 members of staff. It was only 8 and 3 facilities that indicated that they had a staff team of 7-10 members and 11-20 members respectively. Number of Health Workers at the Facility Level No Response Less than 2 3-6 staff 7-10staff 11-20Staff 21+ Total HC II 2 29 91 8 3 133 HC III 5 5 97 115 47 5 274 HC IV 1 1 3 18 20 43 Hospital 3 19 22 Number of health workers Present at the facility during HC II 1 90 40 2 0 0 133 HC III 10 55 172 33 4 0 274 HC IV 5 0 14 19 5 0 43 Hospital 3 3 16 22 members of staff, while 18 facilities indicate that they had 11-20 members of staff. Out of the 274 HCIIIs supervised 115 facilities indicated that they had a staff team composing of 7-10 members, 97 facilities indicated that they had 3-6 staff members and only 5 facilities indicated that they had less than two members of staff. Most (20) HCIVs had more than 20 It should be noted however that although a significant number of facilities indicated that they had higher numbers of staff members, the data-set points out to the fact that a significant number of health workers were off duty during support supervision. Although most (91) HCIIs had 3-6 staff members and only 29 facilities had less than 2 staff members, 90 facilities indicated that they had less than 2 members of staff on duty, only 40 facilities had 3-6 members present. The same scenario can be seen with HCIIIs. Although there only 5 HCIIIs that reported to have less than 2 staff members, 55 HCIIIs had less than 2 staff members at the time of the assignment. When it came to specific health worker staffing 2 at facility level; o of the 133 HCIIs only 3 indicated that they can access services of a Doctor, only 18 facilities indicated that they had one or more clinical officer(s), 71 had one or more Nurses, 63 had one or more laboratory personnel, and only 7 had one or more HMIS officer(s) o Of the 274 HCIII supervised, only 7 facilities indicated that they had one or more Doctors, 155 had one more clinical officers, 196 had one or more nurses, 188 facilities had one or more laboratory personnel, and 110 indicated that they had one or more HMIS officer(s). o Of the 43 HCIVs supervised in this quarter, only 15 had one or more doctors, 29 had one or more clinical officers, 38 facilities indicated that they one or more nurses, 39 facilities had laboratory personnel and 28 facilities had one or more HMIS officer(s). o Of the 22 Hospitals supervised, 10 hospitals indicated that they lacked services of a Doctor, 3 did not give their opinion on whether they had clinical officers, 2 hospitals expressed the desire for Nurses, 3 hospitals did not have a laboratory personnel and 2 had no HMIS officers at the time of this assignment. 2 For details on staffing go to appendix???? Assessing Malaria Treatment and Control in selected Health Facilities 4

3.0 SUPERVISION FINDINGS The section provides information on key supervisory areas which included, management of malaria among expecting mothers, health information management system for malaria, management of malaria case, laboratory management, IEC information, support supervision and drug management. 3.1 MALARIA DURING PREGNANCY Malaria during pregnancy is associated with poor maternal, obstetrical and infant outcomes. Malaria affects pregnant women living in both low and high transmission areas. In pregnant women living in high transmission areas, malaria magnifies the risk of anemia, contributing indirectly or directly to significant morbidity and mortality. In the malaria control strategic plan 2005/6-2009/10, pregnant women were to be targeted for the distribution with ITN/LLIN particularly through ANC services. This was expected not only to increase the protection of this vulnerable group but also help to improve the uptake of ANC services in general. To increase the proportion of pregnant women receiving two doses of IPTp, SMP distributed malaria in pregnancy wall charts and gestational wheels to health centers as job-aids. Health workers were trained in IPTp and received regular supportive supervision. SMP also provided cups and safe drinking water to ensure that directly observed treatment of IPTp dosing was possible at both public and private ANC clinics. 3.1.1 Provision of ANC Services SMP intended to find out whether the supervised facilities provided antenatal care on a daily basis to help protect pregnant women from dangers associated with malaria. From the data-set 135 (28%) facilities indicated that they do not provide ANC on a daily basis. 3%(15) of the facilities indicated that they do not provide ANC services at all and 8 (2%) facilities did not give their opinion about this ANC query. Katakwi district has the highest percentage (80%) of her facilities not providing ANC on a daily basis, followed by Kiboga with 45% of her facilities indicating the same. Wakiso (38%), Soroti (38%), Nakaseke (38%), Amuria (38%), Mukono (33%) and Kibaale (33%) are other districts with a significant percentage of their respective facilities indicating that they do not provide ANC on a daily basis. Kumi District (93%), Luwero (87%), Buliisa (80%) and Mpigi (80%) had the highest coverage of facilities indicating that they provided ANC on a daily basis. Although most facilities indicated that they provided ANC on a daily basis, it was discovered that although services can be accessed on all days of the week, there are specific days in almost all health facilities designated for ANC clinic and most mothers are used to this system. However there health facilities where services cannot Assessing Malaria Treatment and Control in selected Health Facilities 5

be accessed unless on the designated days of the week 3 and facilities where ANC cannot be accessed at all because they do not have midwives to attend to mothers. 3.1.2 IPTp during ANC Visits. District Name Proportion of facilities providing Intermittent Preventive Treatment Facilities Facilities Facilities that do Facilities that do without opinion providing IPTp not provide IPTp not provide ANC AMURIA 62% 38% BUKEDEA 73% 18% 9% BULIISA 10% 90% HOIMA 5% 85% 2% 7% KABERAMAIDO 64% 21% 14% KATAKWI 100% KIBAALE 100% KIBOGA 10% 80% 10% KUMI 93% 7% LUWERO 2% 98% MASINDI 85% 12% 3% MPIGI 2% 89% 9% MUKONO 4% 87% 4% 5% NAKASEKE 23% 69% 8% NAKASONGOLA 90% 5% 5% RAKAI 4% 89% 4% 4% SOROTI 71% 26% 3% WAKISO 91% 4% 4% Total 3% 86% 7% 4% The current MOH Intermittent Preventive Treatment (IPT) policy states that; all pregnant women - even if they do not have fever or other signs of malaria- should take 3 tablets of Sulfadoxine-Pyramethamine (SP) once between 4 and 6 months of pregnancy and 3 SP tablets between 7 and 9 months. Pregnant women infected with HIV should take 3 doses of SP 1 month apart or stay on cotrimoxazol (e.g. Septrin). From table 3 above Amuria (38%) and Soroti (26%) Districts had the highest proportion of health facilities that do not provide IPT during ANC visits. Katakwi and Kibaale had all their facilities reporting that they provide IPT during ANC. Generally most districts had majority of their facilities reporting that they provided IPT. If the trend continues its anticipated that the serious health risk for pregnant women posed by malaria in Uganda will reduce. 3 Most facilities have ANC clinics run twice a week on specific days agreed upon by the health facility and expecting mothers. Assessing Malaria Treatment and Control in selected Health Facilities 6

3.1.3 IPTp under DOTs Using Directly Observed Treatment (DOT), among pregnant women attending public as well as private sector health services is part of a comprehensive reproductive health package recommended during focused ANC services by MOH. Proportion of facilities providing IPT under DOT District Name Without Opinion IPT under DOT IPT not under DOT No ANC services AMURIA 8% 77% 8% 8% BUKEDEA 9% 55% 27% 9% BULIISA 10% 80% 10% HOIMA 2% 78% 10% 10% KABERAMAIDO 57% 29% 14% KATAKWI 30% 70% KIBAALE 79% 21% KIBOGA 5% 75% 5% 15% KUMI 13% 80% 7% LUWERO 4% 79% 17% MASINDI 76% 12% 12% MPIGI 7% 68% 11% 14% MUKONO 2% 78% 13% 7% NAKASEKE 15% 77% 8% NAKASONGOLA 5% 80% 5% 10% RAKAI 4% 70% 19% 7% SOROTI 6% 65% 24% 6% WAKISO 69% 24% 7% Total 5% 74% 15% 7% From table 4; it can be noted that majority (74%) of health facilities indicated that they provided IPTp under DOT. However some Districts like Bukedea (27%), Kaberamaido (29%), Soroti (24%) and Wakiso (24%) had significant proportions of facilities that indicated that they do not provide IPT under directly observed treatment as recommended by MOH. Katakwi (30%), Nakaseke (15%) and Kumi (13%) hardly gave their opinion about the question at hand. Most health facilities including those that indicated to provide IPT under DOT, faced challenges related to lack of consistent supply of clean water and disposable drinking cups. Nakasongola district had 55% of her facilities indicating that they lacked adequate cups, 49% of facilities in Wakiso reported the same and 39% of facilities in Masindi 4. Those that insist on using non disposable cups face another challenge of hygiene and sanitation since it was uncommon to prove rewashing of already used cups. Health workers also indicated that they sometimes get resistance from mothers who prefer taking medicine home to take it after they ve had a meal. 4 Go to appendix for detailed table about adequacy of cups for drinking water. Assessing Malaria Treatment and Control in selected Health Facilities 7

3.1.4 Routine provision of Folic Acid and De-worming of Pregnant Women Proportion of facilities that provide Folic acid for pregnant women District Name Without opinion Folic acid provided No folic acid No services Proportion of facilities that routinely de-worm pregnant women Without opinion De-worming provided No de-worming services Not Applicable AMURIA 8% 85% 8% 23% 69% 8% BUKEDEA 9% 73% 9% 9% 18% 73% 9% BULIISA 10% 90% 10% 90% HOIMA 2% 81% 12% 5% 7% 78% 10% 5% KABERAMAIDO 86% 14% 86% 14% KATAKWI 90% 10% 90% 10% KIBAALE 4% 92% 4% 4% 96% KIBOGA 5% 85% 10% 5% 85% 10% KUMI 100% 100% LUWERO 4% 91% 6% 9% 89% 2% MASINDI 88% 9% 3% 91% 6% 3% MPIGI 2% 80% 11% 7% 2% 82% 9% 7% MUKONO 91% 4% 6% 4% 89% 2% 6% NAKASEKE 8% 92% 8% 85% 8% NAKASONGOLA 85% 10% 5% 5% 90% 5% RAKAI 4% 78% 15% 4% 4% 89% 4% 4% SOROTI 3% 74% 21% 3% 3% 88% 6% 3% WAKISO 93% 4% 2% 4% 82% 11% 2% Total 3% 86% 8% 4% 5% 86% 5% 4% Most facilities in all districts were found to be providing de-worming services to pregnant women. However routine Stock outs of Folic Acid were recorded in almost all health facilities including those that indicated that they provide it routinely. They indicated that an inconsistency in the supply of albendazole causes failure to routinely de-worm pregnant women in some facilities. However most health workers indicated that they sensitize pregnant women about the advantages of de-worming to pregnant mothers. Assessing Malaria Treatment and Control in selected Health Facilities 8

3.1.5 Availability of Supply of Clean and Safe water to administer IPT under DOT During support supervision SMP desired to find out whether facilities have reliable supply of water safe for drinking 5 in the ANC clinic. Most facilities in all districts indicated that they had safe water (treated or boiled) for drinking and use in the ANC clinic. Proportion of facilities with safe water by district Safe Water No safe District Name No Opinion available water AMURIA 8% 77% 15% BUKEDEA 9% 64% 27% BULIISA 10% 90% HOIMA 7% 73% 20% KABERAMAIDO 14% 57% 29% KATAKWI 90% 10% KIBAALE 83% 17% KIBOGA 15% 75% 10% KUMI 73% 27% LUWERO 2% 87% 11% MASINDI 76% 24% MPIGI 5% 77% 18% MUKONO 9% 76% 15% NAKASEKE 69% 31% NAKASONGOLA 90% 10% RAKAI 78% 22% SOROTI 85% 15% WAKISO 4% 82% 13% Total 4% 79% 17% buckets, water jugs among others. It was only Buliisa district that had no facilities indicating that they had no safe water. Nakaseke (31%), Kaberamaido (29%) and Bukedea (27%) had the highest proportion of facilities indicating that they do have clean water. Nakaseke district should be a point of concern because in table 4 above it had 77% of her facilities indicating that they provide IPT under DOT. This may imply that they could be using untreated water to administer the drugs. Most facilities were found to use Aqua safe and water guard tablets to treat water used in the ANC clinic. In times of stockut of drugs a few health facilities where found with mechanisms of boiling water. Some facilities sometimes improvise and use other water containers like Supervision team intended to establish the source of clean water for the facilities. Apart from Kumi, Wakiso and Mukono that had a significant number of facilities using tap water, majority depended on ordinary/shallow wells and boreholes for water. Nakaseke, Bukedea and Kibaale districts had the biggest proportion of facilities depending on wells for water. Some facilities had water tanks installed or other containers used to harvest rain water. 5 Water safe for drinking is either treated or boiled as opposed to many facilities that equated safe water to clean water e.g. rain water and borehole water even when its not treated or boiled. Assessing Malaria Treatment and Control in selected Health Facilities 9

3.1.6 Availability of ANC Cards Proportion of facilities providing ANC services and ANC Cards during visits District Name ANC Daily? No Response Anc Cards Provided No Cards Provides No ANC at all AMURIA Yes 86% 14% No 40% 60% BUKEDEA Yes 100% No 33% 67% HOIMA Yes 50% 50% No 100% KABERAMAIDO Yes 50% 50% No 33% 67% KATAKWI Yes 100% No 38% 63% KIBAALE Yes 50% 50% KIBOGA Yes 89% 11% No 44% 44% 11% KUMI Yes 93% 7% LUWERO Yes 2% 83% 15% No 71% 29% MASINDI No 100% MPIGI Yes 83% 17% MUKONO Yes 94% 6% No 78% 17% 6% NAKASEKE Yes 86% 14% No 60% 40% NAKASONGOLA Yes 71% 29% No 33% 33% 33% RAKAI Yes 44% 56% No 44% 44% 11% SOROTI Yes 45% 55% No 33% 67% WAKISO Yes 52% 48% No 47% 53% The table below provides information on a cross tabulation of all facilities that indicated that they provided ANC services on a daily basis and those that indicated that ANC is not 6 daily against whether they provided ANC cards during ANC visits. In Amuria district 86% of facilities providing Anc on a daily basis indicated that they provided ANC cards while 14% of them do not provide ANC cards. Only 40% of facilities without daily ANC provided cards with 60% of them indicating that they do not provide cards. Wakiso district had 52% of her facilities that provide ANC on a daily basis providing cards while 48% indicating that they do not provide cards. 47% of Wakiso s facilities that do not run daily ANC clinics provides cards while 53% of them don t provide cards. All facilities in Masindi that don t run daily ANC clinics indicated that they provided cards, while almost all facilities in Kibaale though they indicated that they run daily ANC clinics, 50% of them did not provide cards while 50% did not respond the query. From the dataset in the above table, one can conclude that facilities that provide daily ANC services where found to provide Cards more than their counterparts that do not run a daily clinic. 6 Some facilities may not be providing services daily but provides it say twice a week. Assessing Malaria Treatment and Control in selected Health Facilities 10

3.1.7 Record Management of IPTp activities Proportion of facilities that recorded IPT correctly in the ANC register per district District Name ANC daily? Without Opinion IPTp recorded well IPTp poorly recorded NO ANC services AMURIA Yes 100% No 20% 80% BUKEDEA Yes 100% No 33% 67% BULIISA Yes 87% 13% No 100% HOIMA Yes 96 % 4% No 78% 22% KABERAMAIDO Yes 11% 78% 12% No 67% 33% KATAKWI Yes 100% No 75% 25% KIBAALE Yes 87% 13% No 13% 62% 25% KIBOGA Yes 12% 56% 33% No 89% 12% KUMI Yes 7% 93% Proportion of facilities that recorded IPT correctly in the ANC register per district District Name ANC daily? Without Opinion IPTp recorded well IPTp poorly recorded NO ANC services LUWERO Yes 6% 77% 13.00% 4 % No 57% 43% MASINDI Yes 95% 4.80% No 78% 27% MPIGI Yes 89% 11 % No 33% 33% 34% MUKONO Yes 5.90% 82% 12% No 5% 72% 16% 6% NAKASEKE Yes 100% No 20.00% 80.00% NAKASONGOLA Yes 88.20% 11.80% No 66.70% 33.30% RAKAI Yes 83.30% 16.70% No 66.70% 22.20% 11.10% SOROTI Yes 80.00% 20.00% No 7.70% 61.50% 30.80% WAKISO Yes 7.40% 85.20% 7.40% No 88.20% 5.90% 5.90% Amuria district recorded the highest proportion (80%) of facilities that do not record IPTp properly and all of them were facilities that indicated that their ANC clinic is not open daily. Bukedea district followed the same situation with majority (67%) of facilities found with poorly recorded IPTp being those that never provides it on a daily basis. This was the same story in many districts with exception Buliisa, Kiboga Nakaseke and Nakasongola. From the records most facilities had recorded IPTp properly with exception of few cases where the column for IPT3 was found missing. Supervisors also observed lack of consistency in recording since registers are not managed by one person. For example in some facilities IPTp was not recorded immediately and health workers indicated that they fill in the gaps later on when they get time. Most facilities also experience regular stock out of ANC cards, and they indicated that under such circumstances they request mothers to buy exercise books. Assessing Malaria Treatment and Control in selected Health Facilities 11

3.1.8 Utilization of ANC IEC Materials Generally most facilities had pregnancy posters Proportion of facilities with IEC materials displayed in the ANC clinic displayed in the waiting area for patients to see. It was No IEC materials No IEC No District Name Response displayed materials Services rather unfortunate that most of the facilities had no AMURIA 8% 77% 15% posters displayed in local language; most of them were BUKEDEA 64% 27% 9% found to be in English. Given the fact that most of these BULIISA 10% 60% 30% HOIMA 10% 59% 29% 2% facilities are rural based, local language based IEC KABERAMAIDO 29% 57% 14% materials would create more impact since people can KATAKWI 80% 20% carry the message they carry with them instead of just KIBAALE 8% 38% 54% KIBOGA 5% 65% 20% 10% looking at pictures. They stand a chance of KUMI 7% 87% 7% misinterpreting which may be fatal to their lives. LUWERO 6% 64% 30% MASINDI 6% 52% 39% 3% MPIGI 7% 64% 25% 5% From the table it can be observed that Kaberamaido MUKONO 6% 38% 51% 6% (57%), Kibaale (54%), Mukono (51%), Nakasongola (45%), NAKASEKE 8% 77% 15% Wakiso (44%) and Soroti (35%) districts had the highest NAKASONGOLA 50% 45% 5% RAKAI 11% 67% 22% proportion of facilities which did not have IEC materials SOROTI 6% 56% 35% 3% displayed. WAKISO 2% 49% 44% 4% Total 6% 57% 34% 3% Kumi (87%), Katakwi (80%), Amuria (77%), Nakaseke (77%) Districts had the highest proportion of districts that had facilities with IEC materials with information focusing on mothers displayed. It was rather unfortunate that most of these facilities had English based posters or IEC materials. Other districts which significantly need to be supplied with adequate IEC materials are: Masindi, Buliisa, Luwero, Bukedea, Mpigi, Rakai, Katakwi and Kiboga. Supervisors also observed outdated posters in some facilities hence those supplying ought to replace them with update posters as recommended by ministry of health. These posters ought to be well hoisted and stacked on facility walls or notice boards. Assessing Malaria Treatment and Control in selected Health Facilities 12

3.1.9 Dispensation of LLIN through ANC The malaria control strategic plan 2005/6-2009/10 targeted pregnant women for the distribution of ITN/LLIN particularly through ANC services. This was expected not only to increase the protection of this vulnerable group but also help improve the uptake of ANC services in general. Proportion of Facilities distributing LLNs through ANC District Name Without opinion LLNs distributed No LLNs distributed No services AMURIA 8% 92% BUKEDEA 9% 9% 73% 9% BULIISA 20% 60% 20% HOIMA 5% 10% 78% 7% KABERAMAIDO 8% 8% 69% 15% KATAKWI 100% KIBAALE 4% 4% 92% KIBOGA 10% 85% 5% KUMI 20% 80% LUWERO 2% 98% MASINDI 6% 6% 85% 3% MPIGI 2% 82% 16% MUKONO 6% 9% 78% 7% NAKASEKE 8% 8% 85% NAKASONGOLA 95% 5% RAKAI 7% 4% 82% 7% SOROTI 3% 9% 85% 3% WAKISO 4% 11% 82% 2% Total 4% 6% 84% 5% The support supervision carried in the 4 th quarter as represented in the table below shows that only 6% of all the facilities supervised distributed nets through ANC and 4% were not sure or never gave their opinion. It was only Buliisa (20%) Kumi (20%), Wakiso (11%) with significant number of facilities indicating that they provide LLNs through ANC. Most facilities indicated that the government has not previously supplied facilities with free nets to distribute to pregnant mothers on a routine basis apart from those that were distributed sometime back as one off activity. Most facilities indicated that their patients have previously benefited from in mass distribution of nets at community level through local governments and local community leaders and during child days plus at the health facility. Other distributions are done occasionally by NGOs and other Programs mentioned among them were Malaria Consortium, Pace and Hunger project. This partly explain why almost all facilities experienced stock out of LLNs. Health workers though indicated that they continue to sensitize mothers about the importance sleeping under an insecticide treated mosquito net. However they faced a challenge of prescribing the best quality nets especially when they send mothers to shops and the fact that most mothers are poor. Nets that are permanently treated are very expensive and the ones in shops that are affordable are either not treated or poorly treated and are of low quality. Assessing Malaria Treatment and Control in selected Health Facilities 13

3.1.10 Provision of Health Education Talks during ANC Majority of health facilities supervised in the 4 th quarter were found to be providing educational talks about malaria during ANC visits. Proportion of facilities that provided educational talks about malaria during ANC Without Educational No Educational No ANC Most districts had higher proportions of facilities District Name opinion talks provided talks provided Services indicating that they provided educational talks. Districts with significant proportions of facilities indicating that they do not provide educational talks during ANC included; Nakasongola (35%), Luwero (32%) Nakaseke (31%), Masindi (30%), Kibaale (29%), Amuria (23%) and Wakiso (22%). AMURIA 77% 23% BUKEDEA 82% 9% 9% BULIISA 10% 90% HOIMA 5% 73% 17% 5% KABERAMAIDO 78.60% 7% 14% KATAKWI 10% 80% 10% KIBAALE 4% 67% 29% KIBOGA 10% 70% 10.00% 10.00% KUMI 7% 93% LUWERO 4% 64% 32% MASINDI 6% 61% 30% 3% MPIGI 7% 73% 11% 9% MUKONO 6% 71% 18% 6% NAKASEKE 8% 62% 31% NAKASONGOLA 5% 55% 35% 5% RAKAI 4% 82% 11% 4% SOROTI 6% 79% 12% 3% WAKISO 7% 67% 22% 4% Total 5% 71% 19% 4% It should be noted however that, it was only a small number of facilities that could prove that they actually undertake educational talks. The few facilities that could prove had plans displayed on notice boards/facility walls to notify participants that there will education talks. Other evidence was found in work plans and timetables of health workers. For the majority of health facilities, although they quickly informed supervisors that they provided general health education talks including malaria, most of them could neither produce a work plan nor a report as evidence to show that these are the topics and these were the participants. A significant number of these facilities indicated that health education is given but not formalized and it s given on individual basis as mothers come one at ago. As a way of responding to these some health facilities indicated that they resorted to organizing educational talks on immunization days when many mothers are expected to attend. Routine formal education talks at the facility were irregular and most facilities pointed towards lack of teaching aides, malaria IEC materials and limited staff. Assessing Malaria Treatment and Control in selected Health Facilities 14

3.2 HEALTH MANAGEMENT INFORMATION SYSTEM 7 The Health Management Information System (HMIS) collects data from all health facilities in the public and not-for profit private sector with respect to curative as well as preventive services. The malaria control strategic plan 2005/6-2009/10 aimed at improving the collection, quality and utilization of routine data to monitor the implementation of malaria related interventions hence SMP supervised the existence of HMIS at facility level. In the support supervision assignment, the team 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. 3.2.1 Existence of up to date HMIS registers. Proportion of facilities with updated HMIS registers District Name No Comment Registers exist & up to-date No registers AMURIA 100% BUKEDEA 100% BULIISA 89% 11.1% HOIMA 5% 95% KABERAMAIDO 7% 93% KATAKWI 100% KIBAALE 29% 71% KIBOGA 10% 90% KUMI 93% 7% LUWERO 17% 81% 2% MASINDI 18% 82% MPIGI 3% 91% 6% MUKONO 3% 97% SOROTI 12% 79% 9% WAKISO 3% 98% Total 9% 89% 2% From the table below majority of districts that were supervised for HMIS indicated that they had well recorded and updated registers. Apart from Kibaale where a significant proportion (29%) of facilities never responded to the question, most facilities had evidence that they where having updated registers. There were insignificant proportions of facilities that were found missing OPD, ANC and inpatients registers. It should however be pointed out that many facilities indicated that they experience regular stock outs of pre-printed registers. Counter books or black books were found to be improvised in facilities as away of adhering to the requirement. A significant proportion of facilities were found to have registers but with anomalies of proper recording. Some registers were found missing some information like patients weight, client numbers, headings, reasons for referral and in some instances health workers were found to be using non conventional abbreviations in recording data rendered such information unusable to the third party. It was also noted that some facilities improvising registers were not distinguishing between severe and uncomplicated malaria. 7 It should be noted that data presented in this section is missing the districts of Nakasongola, Nakaseke and Rakai. In addition to that 9 facilities in Mpigi, 24 facilities in Mukono and 5 facilities in Wakiso are also missing. This was attributed to an error in printing the tools used in gathering information. So the user of this report should put this error into consideration when making decisions regarding these 6 districts on this particular section. Assessing Malaria Treatment and Control in selected Health Facilities 15

3.2.2 Completing HMIS Reports Appropriately Proportion of facilities with completed HMIS summary reports in the last three months HMIS 105-OPD form HMIS 106-Quarterly Summary HMIS 108 In-patients summary District Month 1 Month 2 Month 3 Month 1 Month 2 Month 3 Month 1 Month 2 Month 3 AMURIA 15% 8% 8% 8% 8% 8% BUKEDEA BULIISA 56% 56% 56% 11% 11% 11% 33% 33% 33% HOIMA 56% 56% 56% 15% 12% 12% 12% 12% 13% KABERAMAIDO 29% 29% 29% 14% 14% 14% 21% 21% 21% KATAKWI 20% 20% 10% 10% 10% 10% KIBAALE 83% 83% 79% 25% 21% 21% 42% 42% 42% KIBOGA 35% 35% 35% 10% 5% 5% 20% 20% 25% KUMI 13% 13% 13% 13% 13% 13% 13% 13% 13% LUWERO 28% 26% 25% 8% 8% 8% 9% 9% 9% MASINDI 91% 91% 88% 31% 31% 31% 41% 41% 41% MPIGI 40% 37% 37% 3% 3% 3% 3% 3% 3% MUKONO 23% 19% 19% 10% 10% 10% 16% 13% 13% SOROTI 24% 24% 24% 9% 9% 9% 9% 9% 9% WAKISO 30% 30% 30% 30% 30% 30% 30% 30% 26% Majority (73%) of facilities in all districts that reported that they kept up-to-date registers were found to be compiling monthly HMIS summary reports. It was mainly Bukedea with a highest proportion of facilities that were less effective in completing monthly reports appropriately. From the table above OPD forms were filled more compared to the inpatients forms and quarterly summary. With exception of Masindi and Kibaale districts which were found at least consistently filling summary reports appropriately for OPD all districts need to vitalize summary reports especially Bukedea district, Kumi, Kaberamaido, Katakwi and Amuria It should be noted that a significant proportion of facilities that had updated registers were hesitant to comment about summary reports. This implies that they also do not fill them hence it points to weaknesses in the general utilization of information gathered in the registers. In addition there was no evidence of report submission to the district or even a feedback from the district about the shared data. There was no evidence to show that the reports are utilized in decision making regarding health unit management and health service delivery. Of the 383 facilities that SMP supervised their HMIS in the quarter; 42% had recorded their data wrongly, 27% missed the comparison, it was only 31% of the facilities with properly recorded data and only 13% with exact data 8. 8 Wrongly recorded HMIS data had the difference on the HMIS report and the register being greater than +-5, while properly recorded data had the difference equals or with in +/-5. Exact data was data where there was no difference between HMIS report and the registers. Assessing Malaria Treatment and Control in selected Health Facilities 16

3.2.3 Availability of trained HMIS officers Proportion of facilities with HMIS Officers No HMIS is District Name comment available No HMIS officer HMIS officer? Proportion of facilities whose HMIS officer is trained HMIS officer was HMIS officer not No Comment trained trained AMURIA 17% 67% 17% Yes 13% 63% 25% BUKEDEA 46% 55% Yes 60% 40% BULIISA 22% 78% Yes 100% HOIMA 81% 20% Yes 70% 30% KABERAMAIDO 7% 29% 64% Yes 100% KATAKWI 60% 40% Yes 100% KIBAALE 67% 33% Yes 69% 31% KIBOGA 32% 68% Yes 100% KUMI 73% 27% Yes 9% 91% LUWERO 8% 45% 47% Yes 13% 79% 8% MASINDI 6% 42% 52% Yes 7% 64% 29% MPIGI 3% 38% 59% Yes 83% 17% MUKONO 69% 31% Yes 9% 55% 36% SOROTI 56% 44% Yes 11% 90% WAKISO 68% 33% Yes 11% 56% 32% Total 3% 55% 42% Total 6% 73% 19% From the table above, Hoima district (81%) had the highest proportion of facilities with HMIS officers at facility; however 30% of them indicated that they were not trained. Kumi had 73% of her facilities having HMIS officers and majority (91%) of them had received training. Bukedea district only had 46% of her facilities indicating that they have an HMIS officer and unfortunately only 60% of them had received training, the 40% indicated that they had not received training. Although Buliisa (22%), Kaberamaido (29%), and Kiboga (32%) had fewer facilities indicating that they had a HMIS officer, all the few that existed were found trained. It should be noted that Masindi (52%), Mukono (31%) Kibaale (33%) and Wakiso (33%) were among the districts that high proportions of their facilities lacking HMIS officers but at the same times they had higher proportions of untrained HMIS officers. Assessing Malaria Treatment and Control in selected Health Facilities 17

3.2.4 Availability of data management computer Proportion of facilities that had a computer for Data management District No Comment Computer Available No Computer AMURIA 8% 92% BUKEDEA 9% 91% BULIISA 22% 78% HOIMA 20% 81% KABERAMAIDO 14% 86% KATAKWI 20% 80% KIBAALE 25% 75% KIBOGA 50% 50% KUMI 27% 73% LUWERO 8% 25% 68% MASINDI 6% 12% 82% MPIGI 6% 20% 74% MUKONO 3% 26% 71% SOROTI 3% 27% 71% WAKISO 23% 78% Total 3% 23% 75% Modern day data management requires electronic gadgets that are used in storing huge some of data. A computer is one of them. From the table below Very few facilities indicated that they have a computer at the facility dedicated to management of health information. Its only Kiboga district (50%) where half of her health facilities accessed a computer for data management. Other districts Like Kumi (27%), Luwero (25%), Mukono (26%), Soroti (27%), and Wakiso (23%) had only a quarter or less of their facilities having a data management computer. It s important to note that some facilities that indicated to have a computer in many instances their computers where found either un-utilized or non functional. This was either because they lacked servicing or because they are not connected to electricity or solar power supply. In some facilities there was no person trained to use them since some of them are donations. Assessing Malaria Treatment and Control in selected Health Facilities 18

3.2.5 Availability of Health Unit Management Committees Proportion of facilities that had a health unit management committee Proportion of facilities with a functional HUMC District Name No Comment HUMC exist No HUMC HUMC? No comment HUMC meet HUMC don t Meet AMURIA 8% 92% Yes 58% 42% BUKEDEA 18% 64% 18% Yes 57% 43% BULIISA 100% Yes 11% 67% 22% HOIMA 85% 15% Yes 9% 69% 23% KABERAMAIDO 14% 79% 7% Yes 18% 64% 18% KATAKWI 100% Yes 10% 50% 40% KIBAALE 4% 83% 13% Yes 15% 50% 35% KIBOGA 90% 10% Yes 11% 67% 17% KUMI 100% Yes 87% 13% LUWERO 13% 59% 28% Yes 19% 77% 3% MASINDI 94% 6% Yes 7% 84% 10% MPIGI 9% 86% 6% Yes 10% 87% 3% MUKONO 3% 90% 7% Yes 7% 79% 14% SOROTI 85% 15% Yes 10% 90% WAKISO 8% 70% 23% Yes 7% 75% 18% Total 5% 82% 13% Total 10% 72% 17% From the table above it can be seen that most (82%) facilities where found to have HMUC in all districts. All facilities in Buliisa, Katakwi and Kumi indicated that they had these committees. Luwero district (28%) had the highest proportion of facilities without HUMC, followed by Wakiso (23%) and Bukedea (18%). Bukedea (43%), Amuria (42%), Katakwi (40%) and Kibaale (35%) were among the districts with high proportions of facilities that indicated that they have a HUMC but don t meet regularly. Facilities indicated that they face challenges with holding meeting because of limited funds and lack of commitment from members hence they end up taking long without holding them. Some facilities hold meetings once a year and others twice a year instead of the recommended quarterly basis. Although many facilities indicated that they hold quarterly meetings, in some facilities supervisors failed to find evidence in form of minutes or reports of the held meetings. There also a general lack of HUMC guidelines for use at the facility. Majority of facilities (53%) indicated that they do not conduct Self Assessments worst among them being Kibaale and Bukedea where only 8% and 18% respectively reported that they hardly do self assessments. Assessing Malaria Treatment and Control in selected Health Facilities 19

3.3 CASE MANAGEMENT According to the Malaria operation plan, Key objectives of the Malaria Control strategic plan for 2005-2010 included; Ensuring universal access to ACTs including patients accessing treatment through the private sector, enhancing the prompt treatment of children under five within 24 hours of fever onset through the provision of home-based management of malaria fever using ACT, Reducing the case fatality of severe malaria by establishing a system to provide highly effective pre-referral treatment and improve the management capacity for severe malaria at health facilities and hospitals. It also aimed at increasing the proportion of malaria cases confirmed by high quality clinical and parasitological diagnosis guided by feasibility and cost effectiveness. 3.3.1 Availability of trained Staff to Manage Malaria Proportion of facilities with a given number of trained staff in uncomplicated malaria Trained No twothree Seven District Staff? Comment One four-six -10 Ten+ Proportion of facilities with a given number of trained staff in severe malaria No twothree Seven- Comment One four-six ten Ten+ AMURIA Yes 40% 40% 20% 20% 20% 40% 10% 10% BUKEDEA Yes 20% 50% 20% 10% 20% 40% 20% 10% 10% BULIISA Yes 67% 11% 22% 33% 22% 22% 11% 11% HOIMA Yes 26% 11% 37% 26% 11% 14% 37% 34% 3% KABERAMAIDO Yes 9% 9% 36% 9% 9% 9% 9% 55% 9% 27% KATAKWI Yes 50% 38% 13% 38% 38% 13% 13% KIBAALE Yes 55% 20% 15% 5% 5% 15% 15% 25% 25% 5% 15% KIBOGA Yes 47% 6% 24% 12% 12% 38% 6% 44% 6% 6% KUMI Yes 20% 7% 7% 47% 13% 7% 20% 13% 20% 33% 7% 7% LUWERO Yes 32% 35% 19% 11% 3% 24% 43% 19% 11% 3% MASINDI Yes 48% 13% 19% 10% 6% 3% 10% 26% 29% 29% 6% MPIGI Yes 11% 40% 20% 20% 9% 14% 26% 23% 29% 9% MUKONO Yes 74% 16% 7% 2% 27% 30% 9% 32% 2% NAKASEKE Yes 11% 22% 33% 22% 11% 11% 11% 22% 22% 22% 11% NAKASONGOLA Yes 14% 14% 36% 29% 7% 14% 36% 29% 14% 7% RAKAI Yes 60% 5% 20% 10% 5% 24% 14% 19% 33% 10% SOROTI Yes 17% 25% 42% 17% 4% 8% 8% 25% 38% 17% 4% WAKISO Yes 36% 9% 21% 27% 3% 3% 42% 9% 18% 18% 12% 79% (381) of the facilities supervised indicated that they had at least a staff trained in management of malaria cases. It was 12% of facilities that indicated that they had no trained staff. The table above represents data on the number of staff in uncomplicated malaria and severe malaria. Most facilities had between 1and 6 staff members trained. Assessing Malaria Treatment and Control in selected Health Facilities 20

3.3.2 Utilization of treatment guidelines in treatment of malaria Proportion of facilities with health workers treating according National Malaria treatment guidelines No Guidelines Guidelines District Name Comment followed Not followed Proportion of facilities with Malaria guidelines in the OPD and IPW No Guidelines No guidelines in Comment in OPD &IPW OPD & IPW AMURIA 69% 31% 77% 23% BUKEDEA 55% 46% 73% 27% BULIISA 90% 10% 90% 10% HOIMA 5% 81% 15% 2% 78% 20% KABERAMAIDO 64% 36% 79% 21% KATAKWI 70% 30% 80% 20% KIBAALE 71% 29% 4% 46% 50% KIBOGA 80% 20% 15% 60% 25% KUMI 100% 93% 7% LUWERO 17% 62% 21% 4% 60% 36% MASINDI 9% 73% 18% 67% 33% MPIGI 9% 59% 32% 2% 48% 50% MUKONO 84% 16% 4% 67% 29% NAKASEKE 8% 69% 23% 46% 54% NAKASONGOLA 10% 65% 25% 55% 45% RAKAI 11% 70% 19% 4% 70% 26% SOROTI 91% 9% 6% 59% 35% WAKISO 4% 89% 7% 4% 80% 16% Total 5% 75% 20% 3% 66% 31% In June 2005, after a study on the malaria treatment policy took a decision to change the policy on malaria treatment from Chloroquine + Sulfadoxine/Pyrimethamine combination to Artemisininbased Combination Therapies (ACTs). Artemether/Lumefantrine is henceforth the first line treatment for uncomplicated malaria and Artesunate + Amodiaquine the alternative. Parenteral quinine is the recommended treatment for severe and complicated malaria and Sulfadoxine/Pyrimethamine is the recommended medicine for Intermittent Preventive Treatment (IPT) during pregnancy the policy reads. Guidelines in line with the new policy were developed and were expected to be distributed to most of the health facilities. From the table above most facilities in all the districts were found to be using the clinical and treatment guidelines. It should be pointed out that Bukedea (46%), Kaberamaido (36%), Mpigi (32%), Amuria (31%), Katakwi (30%) and Kibaale (29%) districts had significant proportions of facilities indicating that they hardly follow the guidelines. This was partly attributed to limited supply of first line drugs hence they often get out of stock leaving HW with no alternative. 50% of the facilities in Nakaseke and Kibaale districts, followed by 36% and 35% of Luwero and Soroti respectively were among the districts with high proportions of facilities having no clinical and treatment guidelines in the OPD and IPW. Some facilities were found with 2003 guidelines which are outdated. Assessing Malaria Treatment and Control in selected Health Facilities 21

3.3.3 Malaria Treatment based on Laboratory Diagnosis Proportion of facilities that treated malaria based on lab diagnosis District Name No Response Lab Diagnosis based Not Lab diagnosis based AMURIA 31% 69% BUKEDEA 91% 9% BULIISA 50% 50% HOIMA 49% 51% KABERAMAIDO 71% 29% KATAKWI 70% 30% KIBAALE 50% 50% KIBOGA 55% 45% KUMI 87% 13% LUWERO 6% 45% 49% MASINDI 3% 49% 49% MPIGI 41% 59% MUKONO 62% 38% NAKASEKE 46% 54% NAKASONGOLA 50% 50% RAKAI 63% 37% SOROTI 59% 41% WAKISO 58% 42% Total 1% 55% 44% The Malaria treatment policy advocates for no more presumptive treatment of malaria by Cleary stating that; The diagnosis of malaria will largely be dependent on history and physical examination. Blood slide microscopy was to remain the gold standard for malaria laboratory diagnosis. Rapid diagnostic tests (RDTs) were to be used in special situations such as malaria epidemics and mass population displacements 9. Apart from Kumi and Bukedea district the rest of the districts had considerable proportions of their facilities indicating that they do not use laboratory diagnosis in management of malaria cases which is adjacent to the malaria treatment policy 2005. Amuria (69%), Nakaseke (54%) Hoima (51%) Buliisa (50%), Kibaale (50%), Luwere (49%) were among the districts with majority of their health facilities indicating that malaria treatment is not laboratory based. Some of the above facilities indicated that they were lacking functional laboratories to help in the diagnosis of Malaria. Other facilities indicated that they rely on clinical treatment which mainly uses signs and symptoms. And in some facilities were laboratories were existent faced challenges of stock out of reagents and inability/reluctance of patients to meet the laboratory costs hence a hardship in replenishment of laboratory supplies. Almost all facilities supervised indicated that their facilities are open all the time and that health workers are on duty 24 hours a day and 7 days a week. Supervisors later on discovered that it was hard for health workers supervised to inform the team that some days the facility is closed and staff off duty. A more triangulated approach about consistent functionality of the facility and availability of health workers may be thought about in the next quarter supervision. 9 National Policy on Malaria Treatment 2005 Assessing Malaria Treatment and Control in selected Health Facilities 22

3.3.4 Referral of Emergency Cases Proportion of Facilities with a referral system for emergency cases District Name No Response Referral system Available No Referral System AMURIA 69% 31% BUKEDEA 36% 64% BULIISA 30% 70% HOIMA 5% 63% 32% KABERAMAIDO 71% 29% KATAKWI 50% 50% KIBAALE 4% 46% 50% KIBOGA 10% 55% 35% KUMI 87% 13% LUWERO 2% 62% 36% MASINDI 3% 49% 49% MPIGI 11% 41% 48% MUKONO 38% 62% NAKASEKE 54% 46% NAKASONGOLA 5% 50% 45% RAKAI 4% 74% 22% SOROTI 3% 41% 56% WAKISO 7% 69% 24% Total 4% 54% 41% It is a general rule in the health service provision for HWs to provide some type of assistance for transporting a sick person to a referral facility, such as communicating to the next level, providing ambulance, arranging community transport and or/funds for public means. From the table below Buliisa (70%), followed by Bukedea, Mukono (62%), Soroti (56%) Katakwi (50%) and Kibaale(50%) districts exhibited the higher proportions of their facilities indicating that they did not have a systematic and consistent referral mechanism for emergency cases. Other districts with significant number of their facilities indicating that they did not have a referral system included; Masindi (49%), Mpigi (48%), Nakaseke (46%), Nakasongola (45%), Luweero (36%) Kiboga (35%), Hoima (32%) and Amuria (31%). Facilities that indicated that they have a referral system were found to be located within smaller distances to the HSD or the district hospital where they easily can an ambulance. Some facilities especially HCIVs had ambulances only that most of them would demand for fuel from patients in case of an emergency. Some like in Masindi had broken down and required repair In most facilities supervised, it was incumbent on the patient or care takers to find transport in case of emergency situations. Among the private means mentioned during the activity included Taxis and Bodabodas. Many facilities did not have referral forms neither referral maps, caretakers just need to take heed of an instruction to take the patient to a given higher level facility without any kind of support. Assessing Malaria Treatment and Control in selected Health Facilities 23

3.3.5 Facility Clinical Audit Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. The clinical audit process seeks to identify areas for health service improvement, develop & carry out action plans to rectify or improve service provision and then to re-audit to ensure that these changes have an effect. Proportion of facilities with a trained staff in clinical audit Proportion of facilities with a trained staff that ever conducted a clinical audit District Name No Response Staff trained No staff trained Trained? No Response Clinical audit Done No Clinical audit done AMURIA 62% 39% Yes 25% 75% BUKEDEA 9% 64% 27% Yes 100% BULIISA 40% 60% Yes 75% 25% HOIMA 7% 27% 66% Yes 64% 36% KABERAMAIDO 79% 21% Yes 9% 73% 18% KATAKWI 80% 20% Yes 13% 88% KIBAALE 4% 29% 67% Yes 57% 43% KIBOGA 5% 20% 75% Yes 75% 25% KUMI 87% 13% Yes 85% 15% LUWERO 6% 21% 74% Yes 55% 46% MASINDI 39% 61% Yes 15% 85% MPIGI 5% 25% 71% Yes 9% 36% 46% MUKONO 24% 76% Yes 62% 39% NAKASEKE 39% 62% Yes 40% 60% NAKASONGOLA 35% 65% Yes 14% 29% 57% RAKAI 4% 44% 52% Yes 8% 33% 50% SOROTI 50% 50% Yes 6% 35% 59% WAKISO 4.40% 26.70% 68.90% Yes 8% 42% 50% Total 2.90% 36.10% 60.60% 4% 47% 48% From the table above Kumi (87%), Katakwi (80%), Kaberamaido (79%), Bukedea (64%), Amuria (62%) and Soroti (50%) districts had the highest proportion of their facilities indicating that they had a trained staff in clinical audit. However apart from Kumi (85%) and Kaberamaido (73%) majority of health facilities in these districts had never done a clinical audit. On the other hand, districts like Buliisa (75%), Kiboga (75%) and Mukono (62%) which had lower proportions of their facilities having trained staff in clinical audit were among the districts which had more facilities indicating to have done clinical audit. There was no evidence to show that audit was done since most facilities had no action plans. Assessing Malaria Treatment and Control in selected Health Facilities 24

3.3.6 Monthly Malaria Case Management Proportion of facilities that conduct monthly Malaria Case Management District Name No Response Does Case Management No Case Management AMURIA 15% 85% BUKEDEA 18% 82% BULIISA 40% 60% HOIMA 10% 20% 71% KABERAMAIDO 14% 36% 50% KATAKWI 40% 60% KIBAALE 8% 29% 63% KIBOGA 20% 15% 65% KUMI 7% 47% 47% LUWERO 11% 42% 47% MASINDI 6% 24% 70% MPIGI 11% 39% 52% MUKONO 56% 26% 18% NAKASEKE 23% 77% NAKASONGOLA 75% 10% 15% RAKAI 15% 52% 33% SOROTI 12% 29% 59% WAKISO 7% 64% 29% Total 18% 33% 50% From the table above, it can be seen that with exception of Wakiso (64%) and Rakai (52%) districts most districts had majority of their facilities indicating that they do no carry out monthly malaria case management. Most facilities indicated that although they carry out monthly CMEs, they had not been particular or specific on malaria. Other facilities indicated that they are not consistently doing CMEs on a monthly basis but rather on a quarterly basis. It s important to note that it was had for supervisors to verify previous activities in CME because most facilities hardly had any report and or action plans to help in decision making or reporting to the district. Assessing Malaria Treatment and Control in selected Health Facilities 25

3.4 LABARATORY MANAGEMENT Improving laboratory services and promoting accurate diagnosis of malaria at community level saves lives and prevent wastage of valuable resources. Increasing levels of resistance to cheap, first-line antimalarials means that many health workers now promote new, more expensive treatment in the form of Artemisinin-based Combination Therapies (ACTs). The importance of accurate diagnosis of all the major diseases cannot be underestimated, and efficient laboratory testing is vital to identifying and treating lifethreatening illnesses. Laboratory services in many rural areas are often run down and yet they are critical for public health, disease control and surveillance as well as guiding patient diagnosis and care. Poor quality laboratory services have the greatest negative impact on poor and vulnerable people because these people carry the largest burden of ill health. The effective diagnosis of malaria and other life-threatening illnesses at both community and laboratory level helps in reducing this burden. There is indirect evidence to suggest that the mismanagement of malaria and other fevers contributes to a vicious cycle of deepening poverty and increasing ill health in Uganda. 3.4.1 Availability of Functional Laboratory at the Facility According to the national health system, all HCIIIs, HIVs and hospitals are expected to be running a functional laboratory or designate a place for carrying out laboratory tests. From the data set all hospitals supervised in all districts had functional laboratories. Majority of HCIVs with exception of 2 facilities in Wakiso had Labaratories. Kibaale (8/24) had the highest number of HCIIIs, followed by Mpigi (6/44) and Wakiso (6/45). Other districts had 1 or 2 HCIII only indicating that they miss a functional laboratory. Most facilities that were found with a functional laboratory had testing protocol available at the lab. Its important to point out that, Mukono (45%), Mpigi (30%), Luwero (29%), Hoima 27%), Kaberamaido (25%) and Nakasongola (25%) were among the districts with significant proportions of their facilities found without testing protocols. Through out all districts there were a few pockets of health centers with laboratories that had faulty equipment and missing/off duty personnel hence not being fully utilized. Assessing Malaria Treatment and Control in selected Health Facilities 26

3.4.2 Availability of Skilled Human Resources District AMURIA BUKEDEA BULIISA HOIMA KABERAMAIDO KATAKWI KIBAALE KIBOGA Functional Lab? Proportion of facilities with skilled staff in laboratory Management No Skilled staff Staff not Functional Response available Available District Lab? No Response Skilled staff available Staff not Available Yes 100% KUMI Yes 100% No 100% Yes 4% 89% 7% LUWERO Yes 89% 11% No 100% No 100% MASINDI Yes 100% Yes 14% 86% Yes 4% 87% 9% MPIGI No 50% 50% No 14% 86% Yes 4% 89% 8% Yes 13% 84% 3% MUKONO No 14% 14% 72% No 29% 29% 43% Yes 100% Yes 100% NAKASEKE No 33% 33% 33% No 100% Yes 100% Yes 8% 83% 8% NAKASONGOLA No 100% No 90% Yes 100% Yes 100% RAKAI No 100% No 100% Yes 8% 75% 17% Yes 12% 84% 4% SOROTI No 100% No 33% 66% Yes 100% WAKISO No 9% 36% 54% All facilities that indicated that had functional laboratories were found to have skilled personnel, with capacity to make all diagnoses required. It was Kiboga district, Bukedea, Hoima, Luwero, Mpigi, Nakasongola and Soroti with 1 or 2 facilities indicating that they did not have a skilled personel. It should be noted however that some of the facilities that did not have laboratory facilities indicated that they have personnel with skills in the subject. These facilities were from Amuria, Bukedea, Kaberamaido, Buliisa, Mukono and Wakiso districts. The biggest proportion of facilities in all districts indicated that they had not had their technicians to train specifically in Microscopy/RDT either as assistants or as technicians. However there were considerable proportions of facilities that indicated that they had 1-3 staff members who had accessed the required training as assistants and technicians. However this was mostly true with HCIII and above in the health system. Assessing Malaria Treatment and Control in selected Health Facilities 27

3.4.3 Techniques used in Diagnosis of Malaria Techniques used to diagnose malaria District Microscopy RDT QBC AMURIA 83% 25% BUKEDEA 73% 18% BULIISA 60% 20% 10% HOIMA 49% 5% KABERAMAIDO 71% 7% KATAKWI 40% 20% 10% KIBAALE 54% 13% 4% KIBOGA 55% 5% KUMI 80% 27% LUWERO 49% 11% 4% MASINDI 61% 3% MPIGI 46% 7% MUKONO 67% 11% 2% NAKASEKE 62% 15% NAKASONGOLA 50% 10% RAKAI 74% 4% SOROTI 74% 3% WAKISO 62% 20% 2% Total 60% 10% 2% Diagnosis of malaria involves identification of malaria parasites or its antigens/products in the blood of the patient. The diagnosis of malaria is confirmed by blood tests and can be divided into microscopic and nonmicroscopic tests. Microscopy: For nearly a hundred years, the direct microscopic visualization of the parasite on the thick and/or thin blood smears has been the accepted method for the diagnosis of malaria in most settings, from the clinical laboratory to the field surveys. The careful examination of a wellprepared and well-stained blood film currently remains the "gold standard" for malaria diagnosis. Microscopy was found to be the most widely used technique in diagnosing malaria in all districts. Most facilities supervised were found to be using a binocular type of microscope, with monocular types reported in a few facilities in Masindi, Bukedea and Kibaale. Rapid Diagnostic Tests: These tests are based on the capture of the parasite antigens from the peripheral blood using either monoclonal or polyclonal antibodies against the parasite antigen targets. Currently, immunochromatographic tests can target the histidine-rich protein 2 of P. falciparum, a pan-malarial Plasmodium aldolase, and the parasite specific lactate dehydrogenase. These RDTs do not require a laboratory, electricity, or any special equipment. A good number of facilities in Luwero, Kumi, Katakwi and Amuria indicated that they sometimes use RDTs. Some facilities recommended the method for being helpful in rural areas and during emergency cases however they indicated dissatisfaction with the inability of the method to quantify the number of malaria parasites, and that sometimes the strips fail to react or they react after a long period. Quantitative Buffy Coat (QBC) tests: The QBC Test, involves staining of the centrifuged and compressed red cell layer with acridine orange and its examination under UV light source. It is fast, easy and claimed to be more sensitive than the traditional thick smear examination. The method was reported to be used by a few facilities in Buliisa, Katakwi, Luwero and Kibaale but still not as the main method for malaria diagnosis. Assessing Malaria Treatment and Control in selected Health Facilities 28

3.4.4 Maintenance of Laboratory Equipment Microscopes; Depending on their use, microscopes should receive routine service once, twice, or even four times a year. Microscopes need; complete cleaning of all optical surfaces, lubrication of all moving mechanisms, adjustments and realignments and thorough cleaning of all external surfaces. Repairs and replacement of Power Cords, Outlets and Voltage many times are required. Since most users are not trained in handling and maintenance of these delicate machines breakdowns are expected since. Apart from Luwero, Bukedea and Buliisa, every district had four or more facilities reporting to have a faulty microscope. Although some were found to have broken down, there is a problem with maintenance of these machines. Facilities in Amuria had taken more than a year when the microscope ran down, in Hoima about 4 microscopes had spent over 2 years, Kibaale had 1 facility with a microscope which has been for 6 years and other 2 for 3 years and the same story goes in almost all districts. There seemed to be no plan for maintenance plans apart from when JMS, Malaria Consortium or Baylor and other NGOS/programs offer support. Otherwise most facilities pointed to regional hospital equipment mechanics that were found to be very irregular and less prompt. 3.4.5 Preparation of Stains used in Laboratory Most facilities in all districts indicated that stains come when they are commercially prepared from Joint medical stores or National Medical Stores supplied by the districts. However many facilities with exception of those from Luwero district indicated that stains is prepared by Laboratory staff at the facility. Most facilities were found using the positive and negative standard control to quality assure stains especially in Amuria, Hoima, Kumi and in Kiboga they indicated that they use the unknown slides to quality assure the stains. Other facilities indicated that they keep a sample and take it to next level facility say at the district for quality assurance. It is important to point out that, guidelines on quality assurance of stains and slides needs to be made known and displayed to ensure quality for the benefit of patients. Otherwise, whereas some districts send their malaria focal person to monitor the quality of slides in facilities, other facilities rely on keeping the positive slides to use them as a control measure for others. A common guideline known to all facilities and laboratory assistants need to be promulgated if not formulated. Assessing Malaria Treatment and Control in selected Health Facilities 29

3.4.6 Management of Laboratory Data Proportion of facilities with a functional laboratory that enters lab data correctly District Name Functional Lab? No Response Data is recorded correctly Data is not recorded correctly AMURIA Yes 90% 10% BUKEDEA Yes 33% 56% 11% BULIISA Yes 86% 14% HOIMA Yes 15% 65% 20% KABERAMAIDO Yes 100% KATAKWI Yes 25% 75% KIBAALE Yes 93% 7% KIBOGA Yes 8% 75% 17% KUMI Yes 100% LUWERO Yes 18% 68% 15% MASINDI Yes 5% 77% 19% MPIGI Yes 9% 91% MUKONO Yes 11% 79% 11% NAKASEKE Yes 75% 25% NAKASONGOLA Yes 33% 67% RAKAI Yes 10% 91% SOROTI Yes 8% 88% 4% WAKISO Yes 3% 90% 6% Data management practices aims at strengthening practices of documentation, analysis, utilization and sharing of laboratory data generated at facility level: this may involve; Storage and retrieval of patient files, Compilation, analysis and utilization of medical data in Malaria treatment, periodic summary reports to districts and Synthesis of interventions that have led to improvement and those that have not. From the table above its evident that most facilities indicated that they correctly record the medical records in the laboratory registers however there was little evidence for analysis and summary reports for utilization at the facility. This was is mainly attributed to limited access to electronic data management practices, which may easily analyse an present reports as opposed to the currently used manual methods of data capture. Assessing Malaria Treatment and Control in selected Health Facilities 30

3.4.7 Availability of Staff Trained in Logistics Management District Functional Lab? No Response Trained staff available No staff trained Not Applicable AMURIA Yes 60% 40% No 100% BUKEDEA Yes 22% 22% 56% No 100% BULIISA Yes 14% 29% 57% HOIMA Yes 15% 39% 47% No 14% 14% 71% KABERAMAIDO Yes 13% 38% 50% No 33% 67% KATAKWI Yes 75% 25% No 100% KIBAALE Yes 57% 43% No 13% 50% 38% KIBOGA Yes 25% 58% 17% No 67% 33% KUMI Yes 17% 50% 33% LUWERO Yes 32% 50% 18% No 33% 67% MASINDI Yes 14% 32% 55% MPIGI Yes 22% 44% 34% No 14% 57% 29% MUKONO Yes 34% 47% 18% No 57% 43% NAKASEKE Yes 25% 50% 25% No 50% 50% NAKASONGOLA Yes 17% 33% 50% No 33% 67% RAKAI Yes 29% 29% 43% No 100% SOROTI Yes 12% 48% 40% No 33% 67% WAKISO Yes 24% 41% 31% 3% No 9% 9% 82% The table shows information of health facilities that indicated that their staff had received training in logistics management. From the data set a cross tabulation of facilities and their responses on whether they had a functional laboratory against their opinion on having a trained staff was done. Bukedea (22%) Rakai (29%)and Buliisa(29%), had the lowest proportion of facilities with trained staff in logistics management. Masindi and Nakasongola followed with only 32% and 33% of facilities with trained staff in Logistics Management. Assessing Malaria Treatment and Control in selected Health Facilities 31

3.5 DRUG VERIFICATION Proper inventory management of malaria drugs is essential in the malaria control program. All health facilities are required to have stock cards to assist staff in monitoring the supply of selected essential malaria treatment supplies. In this assessment quantities on Stock cards were compared with actual physical count at facility stores. Proportion of facilities with updated stock cards District No Response Stock cards available No updated stock cards AMURIA 23% 62% 15% BUKEDEA 9% 18% 73% BULIISA 100% HOIMA 17% 83% KABERAMAIDO 15% 77% 8% KATAKWI 20% 80% KIBAALE 8% 75% 17% KIBOGA 91% 9% KUMI 7% 93% LUWERO 32% 53% 15% MASINDI 27% 70% 3% MPIGI 31% 67% 2% MUKONO 9% 89% 2% NAKASEKE 39% 46% 15% NAKASONGOLA 15% 80% 5% RAKAI 23% 77% SOROTI 18% 71% 12% WAKISO 2% 87% 11% Total 18% 74% 8% Availability updated stock cards; with exception of Bukedea, most facilities in all districts indicated that they had updated stock cards. Nakaseke district also had only 46% of the facilities in the district reporting to have updated stock cards, a significant number 31% would hardly respond to the query. Stock out cases of Malaria drugs; most HCII and HCIII indicated that they rarely consistently get supply of essential drugs. Sometimes they may get supplies after a month and when they receive supplies they are always inadequate. We experienced Stock Out before, we received drugs in august and ran up to middle of September and at the moment they are out of stock Again Lamented the in charge of Ngariam HCIII in Katakwi District. Whereas some facilities where complaining about stock out of coartem, SP and IV quinine some facilities had them in stock for the last three months. Assessing Malaria Treatment and Control in selected Health Facilities 32

3.6 IEC VERIFICATION Effective communication is the basis of behavior change for all stakeholders, their families, community leaders, program managers and service providers. Mobilizing the communities, local, regional and national as well as political and religious leaders to play an active role in malaria control and ensuring proper understanding of the core interventions by the population and promoting positive change of behaviors is the major purpose of advocacy, IEC & social mobilization malaria control strategy. 3.6.1Availability of Malaria Specific Health Education Talks Proportion of facilities that gave malaria education talks to patients District No Comment Talks available No Talks AMURIA 69% 31% BUKEDEA 9% 55% 36% BULIISA 100% HOIMA 7% 63% 29% KABERAMAIDO 100% KATAKWI 10% 70% 20% KIBAALE 67% 33% KIBOGA 10% 70% 20% KUMI 100% LUWERO 13% 49% 37% MASINDI 67% 33% MPIGI 86% 14% MUKONO 82% 18% NAKASEKE 62% 39% NAKASONGOLA 68% 32% RAKAI 4% 85% 12% SOROTI 3% 82% 15% WAKISO 4% 89% 6% Total 4% 75% 22% probably this is part of the reasons to keep malaria education informal. Although significant proportions of facilities especially in Nakaseke (39%), Luwero (37%), Bukedea (36%), Kibaale (33%), Masindi (33%), Nakasongola (32%) and Amuria (31%) indicated that they do not provide educational talks to their clients, majority of facilities in all districts indicated that educational talks about malaria are provided. It should however be noted that in almost all the facilities that provided educational talks, there were no clear planning for educational activities. Health workers indicated that they find challenges with mobilizing people hence they conduct them once in-a-while. In Soroti district most facilities only offered malaria educational talks in OPD and ANC and during community meetings. In Nakaseke district there are no formal educational talks but patients are advised on key strategies to fight malaria and it s a one on one basis. Availability of teaching aides: with exception of Kumi district where 87% of facilities indicated that they had job aides to help in implementation of health education, significant proportions of facilities in most districts did not have malaria teaching aides Availability of a health educator/assistant attached to the facility: Facilities in Buliisa indicated that the health assistant is available and visits the facilities however in other districts most facilities indicated that health assistants are attached to their facilities but they are very irregular and has made limited contributions in malaria ED. Assessing Malaria Treatment and Control in selected Health Facilities 33

3.6.2 Community Awareness activities about Malaria Health facilities are expected to conduct community awareness activities with the aim of informing families on malaria prevention and protection through supporting community initiatives such as Information Education & Communication and Behaviour Change Communication. With exception of Bukedea and Katakwi districts Community awareness activities in use of LLNS, sanitation, IPTp, Malaria treatment and treatment seeking behavior was largely proportionately low in all districts. Hoima district and Nakasongola had no single facility reporting to carry community awareness activities. Many facilities especially in Wakiso, Rakai, Nakaseke, Kibaale and Soroti indicated that the work of community sensitization requires resources because it requires mobilisation of the communities hence making it a little had for health facilities to organize regular sensitization meetings. Such facilities indicated that community awareness activities are now limited to activities of the health assistant with VHTs and during community outreaches. There were only few facilities in all districts that were found using health facility data in planning community awareness activities. This was attributed to the less importance of health facility data in making decisions in regard to client service in all districts. Data collected at health facilities is corrected because it s mandatory and is prepared for the district and MOH. It was only Katakwi and Kumi districts with majority of their facilities indicating that they use IEC materials during community sensitization. In all other districts it was only a few facilities where malaria related materials for the community are available especially with the health assistant. Higher proportions of health facilities that indicated that they carry out health education and had no reports are in the data set. It was only Kumi (54%) with majority facilities indicating that they shared health education reports with the district and at the facility other districts had negligible proportions of facilities conducting health education and sharing reports with the DHE/DHI. Assessing Malaria Treatment and Control in selected Health Facilities 34